Revisiting the Barriers to and Facilitators of Research

Nurse Media Journal of Nursing, 9(1), 2019, 90-102 Available Online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v9i1.20827

Utilization in Nursing: A Systematic Review

Cyruz P. Tuppal1, Paolo D. Vega2, Marina Magnolia G. Ninobla3, Mark Donald

Reñosa4, Abdullah Al-Battashi5, Glenda Arquiza6, Elizabeth P. Baua1

1St. Paul University Philippines System, Tuguegarao City, Cagayan Valley

2Mount Sinai St. Luke’s Hospital, New York, United States of America 3College of Nursing, Muscat Branch, Sultanate of Oman

4Research Institute for Tropical Medicine – Department of Health, Philippines 5Oman Specialty Medical Board, Muscat, Sultanate of Oman

6Philippine Regulation Commission, Manila, Philippines

Corresponding Author: Cyruz P. Tuppal (drcyruztuppal@gmail.com)

Received: 29 October 2019 Revised: 19 May 2019 Accepted: 12 June 2019

ABSTRACT

Background: Nursing profession continues to evolve, expand, and link its practice that

requires evidence to strengthen its body of knowledge, and research utilization (RU) is

pivotal towards this realization.

Purpose: This systematic review aimed to critically identify, select, appraise, and

synthesize research evidence about the barriers to and facilitators of research utilization.

Methods: There were 17,961 papers during the initial database search and 85 papers

from other sources from the electronic databases including Web of Science, CINAHL,

Complete, Scopus, OVID, Medline, PsychInfo, SocIndex, Internurse, British Nursing

Index, ERIC, and PubMed. After further analysis, thirty-six articles were included in the

analysis that explicitly identified and described the barriers to and facilitators of

research utilization in nursing.

Results: Based on the findings, the lack of awareness about research, lack of authority

to change their practice, overwhelming publications, and lack of compiled literature

were the topmost identified barriers to research utilization. On the other hand,

organizational and colleague support, and continuing education as both personal and

professional commitment can further facilitate research utilization.

Conclusion: Despite extensive studies conducted addressing the barriers to research

utilization, the findings suggest a consistent reproach on the capability of nurses to

maximize and utilize research. The same elements that may serve as barriers can

likewise become the impetus in gaining sufficient research utilization among nurses.

Keywords: Barriers; facilitators; nursing; research utilization; systematic review

BACKGROUND

The nursing profession continues to evolve, expand, and link its practice on the

evidence as the groundwork to strengthen its body of knowledge through research.

From the time the National Center for Nursing Research (NCNR) was created, research

has become “a sign of the profession’s status, power, and acknowledged the contribution

to the health of the American public” (D’Antonio, 1997, p. 105). “The NCNR is a

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Nurse Media Journal of Nursing, 9(1), 2019, 91

turning point in the history of nursing research that further broadens the opportunities of

various scientific investigations. During the infancy stage of nursing research, the focus

was nursing concepts, roles, and professional programs” (p. 204). The graduate

programs focused on nursing procedures, war-related and military services, workforce

distribution, costs of services, and nursing education. There was also an apparent

demand during the post-World War II for the standardization of practice, qualification

of nurses, inclusion of mental health services, student, and professional attributes along

with the process of socialization grounded in social sciences.

Gortner (1980) also emphasized the emerging focus on career mobility to advance

practice, opportunities for education, and training for the nurse scientists. Added to this

landmark was the growth of practice-related research during the 1970s, including

disease-specific therapeutic modalities, either actual or potential health needs of the

diverse patient population and nurse-patient relationships. Throughout the 1980s, theory

development was highlighted for nurse scientists “to think, to examine, to analyze, and

to synthesize” elements for the advancement of nursing as a discipline interwoven in

education, research and practice (Harriet, 1980). From then and way forward, the focus

of nursing research becomes multifaceted to address the patient demands, the ever-

changing status of healthcare, demographic shift, radical reforms, and globalization.

Gortner (1980) from his seminal work, noted that nursing would continue to search for

knowledge on health promotion, illness prevention, curative, rehabilitation, and

restoration. The union of nursing and technology serves as an impetus addressing the

biomedical, behavioral, and clinical sciences to advance practice along with the research

utilization (Bostrom & Suter, 1993; Estabrooks, Winther, & Derksen, 2004).

In the recent development, the practice of nursing has presented scientific and

authoritative credence as a discipline. However, as the new millennium unfolds, it also

poses immeasurable threats and research has been considered to be a pivotal instrument

to strengthen the profession’s resilience and adaptability. Nurses need to use research

findings, and through research utilization, the best practices and substantial evidence

will lead to better practice, improve patient outcomes, and inform policymaking bodies.

Moving to a more important realization, nurses should better start addressing those

barriers to and facilitators of research utilization.

PURPOSE

This study employed a systematic review of the literature to identify, select, appraise,

and synthesize research evidence on barriers to and facilitators of research utilization in

nursing.

METHODS

A systematic review was used in this study. Both quantitative and qualitative studies

were aggregated to develop a deeper understanding of barriers to and facilitators of RU.

The authors performed computerized searches from the Web of Science, CINAHL

Complete, Scopus, ERIC, OVID, Medline, PsychInfo, SocIndex, Internurse, British

Nursing Index, and PubMed using the keywords ‘barriers,’ ‘facilitators,’ ‘research

utilization,’ or ‘research utilisation,’ ‘nurse,’ and ‘nursing.’ A supplemental hand

searching that involved a manual page-by-page examination of the entire content of a

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journal issue to avoid bias in a keyword search was also conducted. The retrieved

articles were imported by using a reference manager and were screened based on the

prespecified selection criteria.

Final criteria for single publication were studies with an explicit focus on barriers to and

facilitators of research utilization, reports of empirical data (qualitative and

quantitative); and articles in English published in January 2007 through October 2017.

Newspapers, magazines, images, conference summaries, dissertation, and poetry were

excluded. There were 17,961 papers during the initial database search and 85 papers

from other sources. When limits were applied, there were 3,369 articles, of which

14,182 were removed as duplicates. Three hundred fifty-five (355) were included for

full-text review, 36 articles for final screening, and 36 for final inclusion. Figure 1

shows the PRISMA Flow Chart detailing the results of the search summary.

Figure 1. PRISMA Flow chart detailing of studies through the review

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The authors reviewed the articles in three phases. In Phase 1, all included articles

underwent a double-blind review of whether to reject or accept the articles

(CT/PV/MDR). In Phase 2, all records were reviewed for the full details

(CT/PV/MN/MDR/AA). Many articles contained incomplete information, including the

abstract and title, introduction and aims, data analysis, ethics and bias, findings or

results, transferability/generalizability, and implications and usefulness. In Phase 3, the

scoring for methodological rigor involved the assessment of the articles based on

abstract & title, introduction, and aims, method and data, sampling, data analysis, ethics

and bias, findings/results, transferability/generalizability, implications and usefulness

using a four-point Likert scale (4=good, 3=fair, 2=poor, and 1=very poor) by five

authors independently. Reviewers reached consensus during a disagreement about the

retrieved articles (CT/PV/MN/MDR/AA). The country of origin, study design, sample,

setting, barriers, and facilitators were systematically coded.

RESULTS

Characteristics of studies

Thirty-six studies in this review include seven (7) from the United States of America,

five (5) from Turkey, three (3) from China, two each (2) from the Kingdom of Saudi

Arabia, South Korea, and Iran. Other articles were from Sweden, Hongkong Taiwan,

Bahrain, Austria, Spain, Greece, Jordan, Nepal, Norway, Australia, and Kenya. Thirty

(30) quantitative studies were identified using descriptive, cross-sectional, and

correlational or a combined approach. One (1) quasi-experimental pre-posttest design

was noted. Five (5) qualitative studies, among them three (3) literature reviews, one (1)

systematic review, and one (1) grounded theory approach.

Funk, Champagne, Wiese, and Tornquist (1991) initially developed the 28-item Barriers

to Research Utilization Scale (BRUS), the Conduct and Utilization of Research in

Nursing (CURN) Project Research Utilization Questionnaire. Two studies used this

original version, and others had the modified 29-item with four factors (adopter/nurse,

organization/setting, innovation/research, and communication/presentation). Overall,

BRUS had high reliability, and content validity from various studies across countries

and population from the 1990s to 2000s translated to different languages like Spanish,

Chinese, Korean, Persian, and Turkish.

The sample nurses surveyed from different settings were from tertiary public hospitals,

gerontological nursing homes, university teaching hospital, specialty pediatric hospital,

primary care centers, and traditional Chinese medicine tertiary-level hospital. The

sample size among nurses ranged from 63 to 1,487 while focus group among public

health nurses had sixteen.

Quality scores of articles included

Table 1 shows the results of quality appraisal scores. The included studies were

reviewed and graded based on the abstract & title, introduction and aims, method and

data, sampling, data analysis, ethics and bias, findings/results, transferability/

generalizability, implications, and usefulness. The independent review and appraisal

scores ranged from 92% – 97% (Hawker, Payne, Kerr, Hardey, & Powell, 2002). A

Nurse Media Journal of Nursing, 9(1), 2019, 94

meta-analysis was not appropriate due to the variation of the type of outcome measures.

Hence, content analysis was undertaken.

Barriers to facilitators of research utilization

Table 2 shows the topmost barriers to RU based on the following domains: adopter/

nurse, organization/setting, innovation/research, and presentation communication.

Seven articles found nurses to have a lack of awareness about research (adopter/nurse).

Twenty-one (21) articles indicate a lack of authority to change practice (organization/

setting). Three (3) articles reported overwhelming publications (innovation/research)

and four (4) articles indicated a lack of available relevant literature compilation

(communication/presentation). The topmost facilitators of research utilization

highlighted in this review: organizational support; colleague support and continuing

education as personal and professional commitment.

DISCUSSION

RU has gained much recognition in the past recent years and continued to attract

attention (Estabrooks et al., 2004). From an early commentary, Gift (1994) mentioned

that RU is “the use of research findings as a basis for practice” (p. 306). Estabrooks et

al. (2004) mentioned that as early as the 1970s, research-based projects proliferated due

to the demands of the advancements in nursing practice in the United States, Canada,

and the United Kingdom. Using a bibliometric analysis, Estabrooks et al. (2004) found

RU as a topic existed in 630 articles between 1981 to 2001 in 194 journals. Among

them, there were 350 opinion articles, 65 conceptual articles, 112 clinical research

utilization studies, and 103 research articles. Estabrooks et al. (2004) highlighted three

significant reasons why RU has not been fully implemented including interdisciplinary

collaboration has not yet occurred, less evidence of active programmatic research and

research utilization as a scholarship is more renounced among the developed countries.

The findings in this review revealed that despite the knowledge diffusion and

advancement in technology, and advocacy on research capacity-building in many

organizations, nurses are still caught unaware of the research. Nurses had low direct

participation and involvement in research and did not attend any postgraduate courses

that could reduce barriers. The lack of awareness about research could also be related to

the nurses’ daily work that demands much of their time, and nurses’ attributes for being

task-oriented and role-focused in direct patient care. Moreover, nurses tend to focus on

the role at hand and engage heavily in regular unit roles and responsibilities. In addition

to this focus, specialized nurses are heavily engaging themselves in the technical and

advanced skills performed in specialized units. Other reason could be the nurses’ feeling

of isolation from knowledgeable colleagues (Kocaman et al., 2010). Nurses who feel

that they have been away from studying for a more extended period and are discouraged

perceive that they do not have any research involvement. The so-called theory-practice

gap may have also contributed to the feeling of isolation.

It should be noted that lack of facilities highlighted in some other studies also yields a

lack of awareness among nurses including adequate resources, education and training,

and policies where support from the organization should be prioritized. The lack of

authority to change practice is reported in many studies. This finding echoed the studies

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from Saudi and Bahrain where Omer (2012) surmised, “Saudi hospitals are

administered either under the medical or operational department, a status that reduces

nursing department autonomy” (p. 71). Buhaid, Lau, and O’Connor (2014) mentioned

that empowerment is imperative for nurses despite bureaucratic demands of a

hierarchical organization exist. According to Kang (2015), the conditions of work

empowerment are significant predictors of the three barriers: adopter (nurse),

organization (setting), and communication (research). Nurses feel that they lack

authority to change a practice that is related to factors such as resistance to change,

complacency in the existing routine practices, lack of managerial support, as well as

lack of policies and regulations to support some of these changes. For example, students

are taught in their diploma, bachelors, or post-graduate studies to practice in a specific

manner as per the international standards. However, when these students or graduates

go to clinical settings, they see different practices leading to a theory-practice gap.

When such students or graduates attempt to create changes through RU, there is limited

support in the system that allows them to make the desired changes.

Nurses also reported an overwhelming publication requirement, and institutional

approval is not made readily available. This finding suggests that nurses who would

wish to publish their articles take some time for the review process and publication.

This is particularly evident in bureaucratic organizations where there are rules and

regulations and multiple levels of approvals for moving research work forward. High-

ranking peer-refereed journals have their window review period to ensure conformity to

their guidelines. Nurses should understand the rigorous process of review but should not

be discouraged. Nurses should always have the intrinsic motivation for research

activities and move forward with RU as an integral part of improving their practice and

providing high-quality care for their patients and their communities.

The lack of relevant literature compilation is another barrier. Nurses would appreciate if

there were available and more accessible resources that they could use whenever they

need even for reading or actual research conduct. For instance, the library journal

subscriptions that should be in place and the availability of such resources would

encourage nurses and be an excellent motivator for them in initiating and moving their

research work forward. Schoonover (2009) contends that this barrier is perhaps due to a

lack of knowledge and skills to access and search electronic databases.

Also, the results indicate that organizational support is an essential driver of RU and

consistently mentioned in international literature. Organizational support is critical in

RU, specifically in bureaucratic organizations where approvals and funding are a

lengthy process. The organization can provide funding, infrastructures, and facilities for

research. However, developing countries need to strive in building hybrid facilities for

research. The government-owned universities and healthcare organizations have a

limited budget to make RU as feasible and implementable as possible.

Colleague support is also another driver of RU. Those who have experience can assist

nurses in developing their research skills in various phases (e.g., conceptualization,

empirical, analytical, dissemination, and utilization). Colleague support is an asset to

organizations and an essential method for nurses to commence and initiate the process

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of research. On the one hand, the multidisciplinary collaboration between academic and

service partnerships are in existence to date. The collegial partnerships would yield

mentored participation to motivate nurses, enhance their involvement, and heighten

their commitment.

Moreover, nurses would have inner motivation to conduct research, pursue postgraduate

courses, and eventually utilize their findings to inform practice, and build authority. It is

worth noting that the so-called ‘theory-practice’ is an essential challenge to the initiation

of research and RU. The concept of research is made complicated and confusing by

academics and educators, while educators and academics do not understand the practice

setting. Clinicians perhaps do not understand all aspects of research. Hence, the gap

becomes more prominent.

Another aspect that is important in this context is that research is the least emphasized

aspect of educational preparation due to curriculum constraints, as well as the focus of

the curriculum, is more on the acquisition of knowledge and skills aspects such as

critical thinking, patient history and assessment, and on other management patient

aspects, but not on research. One crucial issue that should be considered within the area

of RU is the role of the nurse that poses a challenge, particularly the specialized nurse or

midwife. The role of the specialized nurse and midwife poses a constraint to their desire

and ability to participate in research activities because of the increased workloads, time

constraints, as well as staff shortages.

Results indicate that there need to be concerted efforts for healthcare professionals,

specifically nurses, to enhance RU in all aspects of their practice and professional

careers. Efforts should be geared for nurses to promote research-based activities. These

include but not limited to critical decision making “clinical challenging,” critiquing and

appraising of the available evidence, capitalizing on available resources, partnerships

between academics and clinicians, collaboration with administrators, and designing

clinical studies. The results of the study deploy a possible avenue to help improve the

present and future patient outcomes. Nurse educators and clinical nurse educators must

fulfill the call to serve as role models and facilitators of evidence-based nursing through

learning activities. Likewise, as nurses are expected to be the primary caregivers be it

inside or outside the confines of the hospital, the identification of favorable and adverse

research utilization imposes a very significant impact for evidence-based nursing care. It

is seemingly apparent that there exists a gap to support the goals for a more scientific

approach to nursing practice when the barriers to research utilization are present within

clinical practice settings. These have made it difficult for nurses to fully absorb the

possible benefits of RU and incorporate these to help advance evidence-based nursing

practice.

CONCLUSION

This review showed that the lack of awareness about research, lack of authority to

change their practice, overwhelming publications, and lack of compiled literature are

the topmost identified barriers to RU. Meanwhile, organizational and colleague support

and continuing education as both personal and professional commitment are found to

facilitate research utilization further. Despite extensive studies conducted addressing the

Nurse Media Journal of Nursing, 9(1), 2019, 97

barriers to RU, the findings suggest a consistent reproach on the capability of nurses to

maximize and utilize research. With the same elements that may serve as barriers to, can

likewise become the impetus in gaining sufficient RU among nurses. The prime movers

identified to encourage RU among nurses can be deduced in the provision of adequate

support, extending from the organizational to collegial and to personal self-motivation

pursuit to excellence, the nursing profession endures to evolve. To fully realize the

implementation of RU in nursing, the barriers, as mentioned in this review, should be

addressed primarily those that limit nurses’ scope of practice.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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Nurse Media Journal of Nursing, 9(1), 2019, 101

Appendixes

Table 1. Quality appraisal scores

Authors Country 1 2 3 4 5 6 7 8 9 Appraised

Studies

Aboshaiqah, Qasim, Al Bashaireh, and Patalagsa (2014) Kingdom of Saudi Arabia 4 4 4 4 4 3 3 4 4 94% Al Khalaileh et al. (2016) Jordan 4 4 3 3 4 4 4 4 4 94%

Athanasakis (2013) Greece 4 4 4 4 4 3 4 4 3 94%

Atkinson, Turkel, and Cashy (2008) USA 4 4 4 4 4 4 4 4 3 97% Austvoll-Dahlgren and Helseth (2012) Norway 4 4 4 4 4 4 4 3 3 94%

Boström, Kajermo, Nordström, and Wallin (2008) Sweden 4 4 4 4 4 4 4 3 4 97% Breimaier, Halfens, and Lohrmann (2011) Austria 4 4 4 4 4 4 3 4 4 97%

Brown et al. (2010) USA 4 4 4 3 4 4 3 4 4 94%

Buhaid et al. (2014) Bahrain 4 4 4 4 4 3 4 4 4 97% Chang, Russell, and Jones (2010) Taiwan 4 4 4 4 4 4 4 3 4 97%

Chau, Lopez, and Thompson (2008) Hongkong 4 4 4 4 4 3 4 4 4 97%

Chen, Shao, Hsiao, and Lee (2013) Taiwan 4 4 4 4 4 3 4 4 4 97% Chien, Bai, Wong, Wang, and Lu (2013) China 4 4 4 4 4 3 4 4 4 97%

Cline, Burger, Amankwah, Goldenberg, and Ghazarian

(2017)

USA 4 4 4 4 4 4 4 3 4 97%

Hendricks and Cope (2017) Australia 4 4 4 3 4 4 4 4 4 97%

Heydari and Emami Zeydi (2014) Iran 4 3 4 4 4 4 4 3 4 94%

Kang (2015) South Korea 4 4 4 4 4 4 3 3 4 94% Kocaman et al. (2010) Turkey 4 4 4 4 4 4 3 4 4 97%

Mehrdad, Salsali, and Kazemnejad (2008) Iran 4 4 4 4 4 3 3 4 4 94%

Morenso-Casbas, Fuentelsaz-Gallego, de Miguel, Gonzalez-Maria, and Clarke (2011)

Spain 4 3 4 4 4 4 4 4 3 94%

Mutisya, Karani, and Kigondu (2015) Kenya 4 4 4 4 4 4 4 4 3 97%

O’Nan (2011) USA 4 4 4 4 4 4 4 3 4 97% Oh (2008) Korea 4 4 4 4 4 4 3 4 4 97%

Omer (2012) KSA 4 3 4 4 3 3 4 4 4 92%

Sanjari, Baradaran, Aalaa, and Mehrdad (2015) Iran 4 4 4 4 4 3 4 4 4 97% Sari, Turgay, Genc, and Bozkurt (2012) Turkey 4 4 4 4 4 4 3 4 4 97%

Schoonover (2009) USA 4 4 4 4 4 4 3 4 3 94%

Solomons and Spross (2011) USA 4 4 4 3 4 4 4 4 4 97% Srijana, Raj Subramaniam, and Paudel (2016) Nepal 4 4 4 4 4 4 3 4 4 97%

Strickland and O’Leary-Kelley (2009) USA 4 4 4 4 4 3 3 4 3 92%

Tan, Sahin, and Ozdemir (2012) Turkey 4 4 4 3 4 4 4 4 4 97% Uysal, Temel, Ardahan, and Ozkahraman (2010) Turkey 4 4 4 4 3 4 4 4 4 97%

Wang, Jiang, Wang, Wang, and Bai (2013) China 4 4 4 4 4 3 4 4 4 97%

Yadav and Fealy (2012) Ireland 4 4 4 4 3 2 4 4 4 92% Yava et al. (2009) Turkey 4 4 4 4 4 4 4 4 3 97%

Zhou et al. (2015) China 4 4 4 4 4 4 3 4 4 97%

Note: 1Abstract & Title, 2Introduction and aims, 3Method and data, 4Sampling, 5Data analysis, 6Ethics and bias, 7Findings/results, 8Transferability/generalizability, 9Implications, and usefulness (4=good, 3=fair, 2=poor, and 1=very poor)

Nurse Media Journal of Nursing, 9(1), 2019, 102

Table 2. Topmost barriers to and facilitators for research utilization

Barriers to Research Utilization Facilitators of Research Utilization

Domain Authors Domain Authors

Adopter/Nurse Characteristics:

Lack of awareness about

research

Athanasakis (2013), Breimaier et al. (2011),

Kang (2015), Kocaman et al. (2010),

Morenso-Casbas et al. (2011), Sari et al.

(2012), Schoonover (2009)

Colleague Support for the

interdisciplinary team and

mentored participation

Chau et al. (2008), Cline et al. (2017), Heydari and

Emami Zeydi (2014), Mehrdad et al. (2008), Yadav

and Fealy (2012)

Continuing education as a

personal and professional

commitment

Buhaid et al. (2014), Chang et al. (2010), Chau et

al. (2008) , Cline et al. (2017), Heydari and Emami

Zeydi (2014), Mehrdad et al. (2008), Srijana et al.

(2016), Yadav and Fealy (2012)

Organization/Setting

Characteristics: Lack of

authority to change practice

Omer (2012), Yava et al. (2009), Schoonover

(2009), Strickland and O’Leary-Kelley (2009),

Buhaid et al. (2014), Wang et al. (2013),

Chang et al. (2010), Atkinson et al. (2008),

Chau et al. (2008), Tan et al. (2012), O’Nan

(2011), Al Khalaileh et al. (2016), Brown et

al. (2010), Cline et al. (2017), Mehrdad et al.

(2008), Morenso-Casbas et al. (2011),

Aboshaiqah et al. (2014), Solomons and

Spross (2011), Heydari and Emami Zeydi

(2014), Sanjari et al. (2015), Oh (2008)

Organizational Support

(funding, infrastructures,

and research facilities)

Chang et al. (2010), Chau et al. (2008), Kang

(2015), Mehrdad et al. (2008), Omer (2012),

Sanjari et al. (2015), Srijana et al. (2016), Tan et al.

(2012), Yava et al. (2009)

Innovation/Research

Characteristics: Overwhelming

publication

Zhou et al. (2015), Srijana et al. (2016), Al

Khalaileh et al. (2016)

Presentation/Communication

Characteristics: Lack of

avilable literature compilation

Sari et al. (2012), Uysal et al. (2010), Yadav

and Fealy (2012), Boström et al. (2008)

Revisiting the Barriers to and Facilitators of Research

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Diet Analysis Project

Revisiting the Barriers to and Facilitators of Research