Iranian nurses' constraint for research utilization

The body of literature is vast. Throughout the last two decades the barriers of research utilization in clinical practice have been repeatedly stressed. There are several reasons why nurses do not use research findings, and multiple studies have revealed barriers of research utilization [9‐12]. One influential study was undertaken by Funk et al (1991, 1995) who developed and validated the BARRIERS Scale [13, 14]. It has been used in several published studies to elicit nurses' perception regarding barriers to research utilization in the UK [10] the USA [9], Ireland [15], Norway [16] Greece [17] and Iran [1]. Most studies have been conducted using survey approaches and rely on self reported utilization behavior [14, 18, 19]. For example Mehrdad et al (2008 a) used a descriptive design to identify barriers and facilitators of research utilization in nursing practice from the Iranian nurses self reports [1].

The value of self-report studies per se may be questioned in relation to the veracity of the results, due to the possibility of inflated reports of research utilization by those responding. This cannot be relied upon to present the most valid outcome [20]. Moreover, these types of studies tend not to concede the interaction of the individual with contextual factors, which may be an important factor in successful implementation [21].

The employment of qualitative research methods will contribute further to our knowledge about barriers of research utilization by nurses by allowing deeper exploration of experiences, perception and issues faced by nurses in the utilization of research in their practice [11]. Such an approach also allows us to draw upon participants' attitudes, experiences, and reactions in a way that would not be feasible using self-report studies [22]. Although the studies are carried out in several countries, the factors inhibiting research utilization have not been well explored in the Iranian national health system and particularly within the discipline of nursing in Iran since the context is different. It is an urgent need to develop nursing knowledge based on the health of the global community. We need to understand constraints of research utilization in several countries. We need to integrate collaborative international research in the ongoing work of scientists in leading nursing academies throughout the world. And we need to pay attention to the freedom of thought and action which is a fundamental value among university members. Therefore, it is time to identify Iranian clinical nurses' views on issues that hinder research utilization in nursing practice.

The local research ethics committee approved the project. Before each interview and focus group discussion, the participants were informed about the purpose of the study, how it would be carried out, and that their participation was voluntary. Participants were advised that they could leave the interviews at any time. Confidentiality would be provided. To ensure confidentiality no names were used. Written informed consent was gained from all participants. All data has remained anonymous.

A number of procedures in data collection and analysis were used to foster 'trustworthiness' [24]. Participants received copies of their interview transcripts for comment and possible revision. No one elected to make changes or to cancel any information. Credibility was established by a team-based approach to analyzing data. Team-based coding, indicating excellent levels of agreement/disagreements in interpretation were resolved through discussion.

Immediately following each single interview and focus group, the researcher made some notes of what she supposed the key issues arising through the debate were.

In this study, the analysis process proceeded as follows: the transcribed interviews and focus groups were initially read and re-read several times expansively to obtain a comprehensive view of the data, understand the main issues and experiences, and get a good sense of the entire discussion in focus group as well.

Texts were then read line by line, separating passages in to sections concerning similar content. The text was divided into smaller units of analysis that could be reviewed. Meaningful statements and paragraphs were identified and underlined as the unit of analysis. A code was assigned to each meaningful statement and paragraph. Codes were freely generated. Codes and the original files were reviewed by the researcher's director for truthfulness and the participants for precision. Codes with similar meanings were grouped together. The various codes were compared on the basis of similarities and differences and grouped into categories.

The transcripts were read again to validate the codes and categories. For the purpose of abstraction, the relationships between categories were identified and six major themes come up. The themes are kept in mind and the researcher returns to the data to ensure if the themes really fit the data and refine the themes. Categories and themes were discussed with the second researcher who is an expert in the research field. The researchers used MAXqda2 software for the analysis process.

Review of literature revealed a knowledge and skill deficit in conduction research and using it [25, 11]. This aspect of the study was explored with the participants of the focus group. They all mentioned that they don't have necessary knowledge and skills toward research utilization. The following explanation was offered by staff nurse: It is not an easy task for us to base the nursing on research findings; we need the appropriate education to recognize the individual stages necessary. I have not been given this appropriate training in either nursing school or in my years of working as a nurse (Participant 14).

All participants in single interviews suggested that some research skills such as data collection and analysis are necessary for the nurses. The majority of participants believed that extensive research skills are required for research utilization.

A number of studies recommended that the level of educational training has a direct impact on nurses' knowledge of research and their attitudes towards it [19, 25]. All of the participants in this study believed that the content of research courses and nursing educational resources are not sufficient for teaching and learning of research utilization. They mentioned that there is not a consistency between conducting research and using the research results. On of the participant indicated that: During my Master of Science training, I only became familiar with research methodology. However I was not taught how to use it in my training (Participant 9).

The participant noted that lack of educational facilities, lack of focus on continuing and in service education in research utilization and poor access to expert collogues are the reasons for insufficient research education in nursing. Participants reported on shortcoming of their organization in providing a suitable educational setting.

In general the participants in both focus group and single interviews concluded that education of research utilization process is one of the basic and important principles for providing research-based care. They also believed efficient research education leads to research-based practice.

Research mindedness was another theme identified from data. Focus groups and single interviews' participants claimed tradition and routine based practice impede provision of research based care and leads to stagnant nursing practice.

Task-centered practice reinforces traditional based practice and this further segregates the nurses from research based practice. As a result nurses don't priorities and focus on acquiring research utilization skills.

Rushing through responsibilities, task-centered practice and conforming to superiors, all leads to nurses caring for the wards more than the patients. The gradual accustoming of nurses to routine and manual task further reinforces the lack of specialized and skilled mentality.

The study considers that the imbalanced emphasis given by nurses to research conduction and research utilization devalues the importance of research transmission. In addition, research is not considered to be a valuable and useful tool in nursing practice.

Despite the emphasis on research as one of the basic and important nursing roles, focus group participants highlighted lack of research role in Iranian nursing care leads to lack of research utilization.

Participants have concluded the nurses who do not consider research roles and do not have research thoughts have not been doing research based practice. Therefore, the traditional-based practice has been sustained strongly. Study participants highlighted the need for creating a research culture in nursing practice as a prerequisite for promoting research-based, clinical practice. Additionally, the creation of an appropriate research context could strengthen research mindedness in nursing administrators and staff. They emphasized the culture of the unit to be focused on research utilization.

Policy-making and planning, evaluation policy, scientific and research-based management patterns are three sub-themes identified from analysis of the up to date data from this theme.

In the participants' point of view, the lack of scientific administration models led to insufficient management. These participants explained that they care for patients based on their administrative interests. Participants' experiences indicated that there is a gap between research-based administration and traditional administration. They also mentioned that administrators do not support evidence based practice. As a result, the participants felt that the necessity of suitable planning and policy making with the purpose of introducing high quality and evidence-based nursing care are important. It is worth mentioning that administrators could develop a scientific curriculum and policy to guide nurses in critical thinking and using research results in their practice.

The gap between research and practice has also become a subject of discussion in nursing. It is believed that the root of many problems in nursing is the wide gap between theory and practice in Iran. Participants also claimed that this ample hole leads to a lack of proper context in research usage.

From analysis of the data from this theme, the subsequent sub-themes were recognized:

Structural/organizational gap

Relationship/affiliation gap

Performance/Behavioral gap

Participants in the focus groups felt less professional relationship between board member and faculties in nursing as two important nursing organizations in Iranian health care system is one of the major reasons for theory-practice gap. They strongly announced that if the professional relationship develops, professional interaction will be improved in nursing.

Examples offered by some participants in the single interviews did point to different performances between academic and staff nurses.

In both focus groups and face to face interviews, participants had a detailed dialogue about poor professional relationships among nurse-researcher and clinical nurses. This matter has been discussed from different perspectives. They believed a lack of consistency between education and practice in nursing discipline is the result of the lack of resources and facilities, motivation, routine and ritual practice and undifferentiated in nursing responsibilities.

In terms of participants' point of view, closing the gap between academic setting and clinical setting is the outcome of sympathy among these professional groups and it is an important context for research utilization.

Like all studies, this work has some limitations. The results have indicated some potential influencing factors that may be worth exploring with a larger, more representative group of nurses. A key consideration in this study is that since this study has been conducted by qualitative approach, it is not possible to generalize these findings to nursing as a whole.

According to the results, nurses received least support in the utilization of research findings from ward managers. They also claimed the infrastructure to support research efforts is not established and emotional-informative, practical support was nurses' need to be research active. From the managerial point of view, the most imperative source of support is the ward manager, so it is quite distressing to notice that many nurses felt that they received only a little support from this person.

Lack of support from head nurses is also an important finding in that the development of nursing is a key element of the head nurse's role, not only in providing support and in encouragement on the ward, but also in an attempt to help the use of research results. Rycroft-Malone et al (2004) proposed that a supportive context or environment and adequate facilitation are needed to achieve research-based practice [28]. Nevertheless, Rogers (1994) found that perceived support, in general, was not associated with research utilization, but that support of the director of nursing, the unit director and the chairperson was significantly correlated with research utilization [29]. In particular, senior staff/policy should make certain that the necessary structural and practical support has been recognized and will be supplied. Thus, nurse administrators and other organizational managers and policymakers need to provide health professionals and, in particular, nurses a supportive professional environment to speed research-based practice movement. The role of administrative support and lack of such support in the utilization of research results has been highlighted in numerous previous studies [30, 31].

Extent of nurses' knowledge, skill and levels of educational training involving research utilization were two themes that extract from data and have a close interrelation with each other.

Majority of participants also recognized that they lacked the skills and knowledge necessary to make use the evidence. In general, the participants viewed their research skills as being basic. They believed that many Iranian nurses lack knowledge of the research process. From the participants" suggestions, it seems that the possession of research knowledge may be an important factor for enhancing their skill to evaluate and use research findings. These findings are supported by previous studies [19, 17].

Knowledge and skill in research use are needed to build nurses' professional portfolios and gain recognition as science-based providers. If nursing care decisions are to be based on science, infrastructure, skills, and abilities are required of nurses to interpret, use, and conduct research. With this knowledge and these skills come power to change practice and benefit patients [32]. Among the reasons, participants claim that they did not have any educational opportunities and time within the workplace to read and discuss research that is relevant to their daily practice. Inadequate educational preparation in research is also supported by other authors [20, 33].

The participants recognized that they needed further education support to improve the quality of nursing care delivered. Authors believe education is seen as one of the main factors underpinning changes and research training is a key way, in which academic departments can increase research capability and capacity [34‐36]. In addition, Iranian educational system for nurses should be reviewed for consideration of course content that focuses on using research in practice. At the individual BSc level, nurses need to prepare themselves with the skills needed to evaluate current findings, establish if they are applicable for their setting, and apply these with confidence. However, training research courses should also be made available to practicing nurses.

Despite providing nurse education in Iran at an academic level, research is often seen as a lower priority in nursing practice and research utilization is not well and used in Iranian nursing practice [8].

Despite providing nursing education in Iran at the academic level, research evidence and its application to improvements in patient care are neither well understood nor applied in the practice setting. Moreover, participants claimed that Iranian nurses have little motivation and interest to use research results and they do not regard using research as part of their job. The majority of Iranian clinical nurses strongly agree with the statements 'research is not relevant to the everyday work in nursing [8]. This necessarily means that they thought it had no worth in the nursing setting. The patients were seen as work units and the aim of care was to get through the work as quick as possible. This was thought to suppress any ideas of creative or innovative practice. The circumstances of nursing in Iran defined by low to medium salaries, lack of organizational advocacy, nurses' professional rights, and control over professional credential. Nursing roles in Iran are also quite focused on practical matters, consisting mainly of the provision of direct care to patients based on traditional approach instead of research-based practice. Additionally, Iranian nurses work under extensive time pressure. The definite shortage of nursing staff creates an environment of very low nursing autonomy; the delivery of patient care usually falls under medical command. The traditional nature of nursing, in contrast to the scientific position of medicine, appears to delay nursing movement in research. It has also emerged in earlier studies.

The lack of a belief in the value of nursing research, traditional and experience - based practice, unfamiliarity with research reports, rushing through responsibilities, task - centered practice and conforming to superiors leads nurses to be mindless of research.

This in turn strengthens experience and routine-based care. According to Hutchinson and Johnston, depending on experience-based practice threatens nursing and conduct of nursing practice in this manner is 'the antithesis of professionalism[11]. The majority of Iranian nurses are still not convinced of the importance of research to nursing practice and to the nursing profession as well [8]. It is also a barrier to autonomy, and a detriment to quality care.

However, participants believed research mindedness creates innovation in nursing practice; they also claimed that constructing a research friendly culture through appropriate infrastructure promoting the use of research in practice. Meijers et al (2006) reported a statistically significant relationship between research climate, an environment where research use is encouraged and recognized, and research utilization [37].

The delivery of research-based practice is a complex issue that involves personal commitment including a positive attitude, and willingness to keep up to date. So it is essential to change cultural attitudes, create a research culture and building an optimal research environment [38‐41, 36] and generally creating an atmosphere that is conducive to research activity [40]. Such strategies are to be effective if coherent visions and missions develop in nursing organization to address successfully the challenges outlined above [34].

The nursing organizational values and priorities have played an important role in affecting the ability to develop research capacity. These organizations should formulate policy focus on implementing research, becoming research-based practice as an central part of the nursing strategic plan [42], teaching research use process as part of core duties in nursing universities and, reshaping teaching curricula [38]. Convergences of policy and professional agendas are also facilitating to develop nursing research use [43]. Yet where nurses perceived that a rule existed, they were more likely to be using research-based caring in practice.

Participants claim that research use is not a personal responsibility and they address relevant barriers related to lack of managerial commitment to getting research into practice. Lack of organization's support had been experienced by some nurses as contributing to thwarting their efforts at practice innovation. Managers are not concerned with developing professional care. Nurses in this and other studies [11, 12] have repeatedly cited a lack of management support as problematic. The healthcare system in Iran does not also provide the incentive for nurses to engage in research or to seek research findings [1]. The findings demonstrate that organizations' political and contextual agenda, organizational structures and procedures have a possible influencing factor on adoption of research findings.

Rogers (1995) claimed that in many cases an individual cannot implement new ideas before the organization has formally adopted them [44]. Moreover, in the current study the nurses reported that research implementation has a strong interdisciplinary component and involves collaboration between individuals and organizations as Parahoo and McCaughen (2001); and Walsh (1997) mentioned in their studies [31, 45]. Those nurses who reported support from their nurse managers were also willing to implement research findings in practice [14, 46].

Participants believed if research use capability is part of the professional expectation for nurses, then nurses must be forced to learn the new skills, and organizations will need to facilitate required knowledge and skills. The provision of well-defined organizational processes and pathways would assist nurses in promoting research-based change in their practice. To affect research-based practice change, providing a framework of support, sympathetic infrastructures, development of a national strategy to use nursing research, adequately clarified expectations along with encouragement seems necessary [47]. Clinical nurses themselves need to dynamically embrace research-based practice and look for opportunities within organizations to become involved in research opportunities to both support their professional paradigm and development patient care.

Organizations need to be open, have decentralized decision-making processes and imbue a management style that is facilitative rather than 'ordering' [21].

In modern health care, much stress is located on 'transformational leadership'. Transformational leaders create a culture that recognizes everybody as a leader of something. Transformational leaders require rationality, motivational skills, empathy and self-confidence in public presentation [48]. Thus, it is implied that the transformational leader can alter the prevailing organizational culture and create a context that is more conducive to the integration of evidence and practice. Interventions related to work patterns; clinical supervision, communication systems, management structure, quality improvement, and staff development are key determinants to achieve research - based practice.

According to the results, the research practice gap is still a major force for research-based practice in Iranian nursing and nursing administrators should consider it. Participants believe Iranian nursing should find a way to close the research practice gap. Participants state that nurses with a PhD are not being adequately involved as research-active practitioners. In Iran, the PhD is rapidly becoming the essential degree for faculty positions in nursing universities. This is certainly occurring in many universities around the developing and developed country [49]. As a result, cooperation between academic and clinical staff is one of the main elements driving the movement for research-based care. Some authors confirm the finding that collaborative exchange between service and academia is essential and there is obviously a real need for increased collaboration between researchers and clinical nurses willing to promote the use of research [42, 50, 51]. The academic staff could act as change agents and play roles of facilitators on nursing research team and assist staff nurses to develop ways to implement the research study findings. Active dialogue between the researcher and the nurse was advisable in order to promote research dissemination. This strategy has been confirm by previously [32, 52]. In addition, lack of synergy between two main groups in nursing lead to weakness profession.

In the Iranian nursing situation, the clinical and academic settings are governed by different administrative structures and different visions for research utilization. It seems that mutual interest of promoting research utilization and establishing committees with leaders of both settings are crucial. Clinicians needed to be equal partners in the research endeavor and faculty had to be willing to be flexible and adaptive to clinical realities [42]. Research utilization is a reflective process found both at the individual and institutional levels and it needed interdisciplinary interaction. Collaboration, interaction and recognizing mutual need could lead to narrow research-practice gap.