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Evidence Based Practice in School Nursing: A
Study of School Nurses in Central and Eastern
North Carolina
Lisa M. Barnes
Gardner-Webb University
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Evidence Based Practice in School Nursing:
A Study of School Nurses in Central and Eastern North Carolina
by
Lisa M. Barnes
A thesis submitted to the faculty of
Gardner-Webb University School of Nursing
in partial fulfillment of the requirements for the
Degree of Master of Science in Nursing
Boiling Springs
2011-2012
Submitted by: Approved by:
______________________ _______________________
Lisa M. Barnes, BSN, NCSN, RN Mary Alice Hodge PhD, RN
______________________ ________________________
Date Date
ii
Abstract
The purpose of the study, Evidence Based Practice Use: A Study of School
Nurses in Central and Eastern North Carolina, is to gain insight of the barriers and
facilitators of evidence based research in the school setting. The unique and
autonomous nature of school nursing makes evidence base practice and research
utilization especially important to achieve optimal outcomes in this setting that is
often isolated from other health care providers. A descriptive cross sectional
survey design using the BARRIER scale was used in this quantitative study (Funk
et al., 1991). Using the BARRIER scale by Sandra Funk, school nurses from
Central and Eastern North Carolina public school systems (N=50) were asked to
rate their barriers to research utilization. Roger’s Diffusion of Innovation Theory
(1995) was used as the theoretical framework to guide this study. The findings
revealed that the perceived greatest barrier was insufficient time on the job to read
research. According to the reported perceived level of awareness, perception of
the importance, and current reported skill level, the data suggests the school
nurses in the sample had reached Roger’s Diffusion of Innovation theory’s (1995)
levels of awareness, persuasion, and decision, however characteristics of the
organization (setting) is a reported barrier to implementation of research
utilization.
iii
Table of Contents
Chapter I
Introduction ..............................................................................................................1
Statement of Problem ...................................................................................1
Background and Need ..................................................................................1
Purpose of Study ..........................................................................................2
Significance..................................................................................................2
Research Questions ......................................................................................3
Hypotheses ...................................................................................................4
Definition of Terms......................................................................................4
Summary .....................................................................................................8
Chapter II
Review of Literature ................................................................................................9
Introduction ..................................................................................................9
Literature Review.........................................................................................9
Summary ....................................................................................................22
Chapter III
Methodology ..........................................................................................................23
Research Design.........................................................................................23
Context .......................................................................................................24
Sample Population .....................................................................................24
Informed Consent.......................................................................................25
Data Collection Method .........................................................................................25
iv
Data Analysis .............................................................................................26
Summary ....................................................................................................27
Chapter IV
Results ....................................................................................................................28
Demographic Characteristics .....................................................................28
Current Awareness .....................................................................................29
Facilitators to Research Utilization ............................................................31
Barriers to Research Utililzation ................................................................31
Barriers to Research Resource Information ...............................................34
Perception of Importance to Research Utilization .....................................35
Perception of skills .....................................................................................36
Chapter V
Discussion ..............................................................................................................37
Awareness of Research Utilization ...........................................................37
Facilitators to Research Utilization ............................................................38
Barriers to Research Utilization .................................................................38
Perception of Importance ...........................................................................38
Skill Level Barrier......................................................................................39
Significance of Findings ............................................................................39
Implications of Nursing Practice ...............................................................39
Limitations of Study ..................................................................................40
Recommendations for Further Research ....................................................40
Importance of the Findings for Nursing.....................................................40
v
References ..............................................................................................................41
vi
List of Tables
Table 1 Demographic Statistics Frequencies and Percentages .......................................29
Table 2 Awareness, Responses to the BARRIER scale item: “The nurse is unaware of the
research” and “There is no documented need to change practice” . ...............................30
Table 3 Responses to the BARRIERS scale facilitator open ended question (N=50), .....31
Table 4 Rank Order of To Moderate or To Great Extent Barriers to Research Utilization
as Perceived by Central and Eastern Region School Nurses (N=50) from Barrier Scale
Questions 1 to 29 ...............................................................................................................32
Table 5 Rank Order of To Moderate or To Great Extent Barriers of Research Resource
Information as Perceived by Central and Eastern Region School Nurses (N=50). ..........34
Table 6 Perception of Skill Barriers from to moderate extent to great extent (N=50) ....36
vii
List of Figures
Figure 1. Rogers Theory of Innovation: Five Diffusion Elements………………………..7
1
Chapter I
Introduction
Statement of Problem
The purpose of the study, Evidence Based Practice Use: A Study of School
Nurses in Central and Eastern North Carolina is to gain insight of the barriers and
facilitators of evidence based research in the school setting. Evidence based practice is
essential to providing optimal nursing care. Patients have the right to receive a level of
care that is based on the best evidence. The achievement of providing evidence based
practice has become the focus and goal of the nursing profession (Gerrish et al., 2007).
Research has shown that there is a varying practice of registered nurses using
findings from research in clinical practice (Bostrom, Ehrenberg, Gustavsson, & Wallin,
2009). School nursing is an area of nursing where evidence based practice is important,
but little is known about the current use or needs of incorporating evidence based
research to guide their practice. The unique and autonomous nature of school nursing
makes evidence base practice and research utilization especially important to achieve
optimal outcomes in this setting that is often isolated from other health care providers.
The previous focus of evidence based practice has been concentrated in the efforts of
implementation in primary and acute clinical settings, even though efforts are also greatly
needed for school nurses in the school setting (Adams, 2009).
Background and Need
Evidence based practice (EBP) emerged from evidence based medicine
concurrently as research utilization was developed through nursing (Adams & McCarthy,
2005). Evidence based medicine is “conscientious, explicit, and judicious use of current
2
best evidence in making decisions about the care of individual patients” (Sakett,
Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71). Practicing evidence based
medicine means integrating clinical expertise with the best available researched clinical
evidence (Sakett et al., 1996). Research utilization is the “process of reviewing and
critiquing scientific research and using the findings to guide practice” (Adams &
McCarthy, 2005, p.259). Research has shown that evidence based practice use has the
potential to eliminate insufficient practices and can provide resources to improve nursing
outcomes (Adams, 2009). The use of evidence based practice is important for school
nurses to utilize in the school setting. Evidence has shown that the use of EBP can
benefit students’ health, reduce absenteeism, and improve educational outcomes (Adams,
2009).
Purpose of Study
The purpose of this study was to gain insight into the current, attitudes, skills,
barriers, and facilitators of implementing EBP among school nurses. This study was
performed to increase the understanding and awareness of the need to use EBP, provide
data of the current facilitators to EBP use practices being utilized that guide school
nurse’s practice, and to identify barriers associated with research utilization in the school
setting.
Significance
Evidence based practice is essential in the school setting. It is estimated that over
a half a billion dollars per year is spent on medical follow-ups, treatments, and
unnecessary exclusions from school for practices that do not follow EBP guidelines
(Adams, 2009). School nurses are often the only health resource in the school systems.
3
School nurses are employed to be a reliable health resource that assist in reducing health
related absenteeism and help students achieve the most optimal health environment
possible at school. A school nurse that effectively uses EBP can have a great impact on
both the staff and the student’s lives. Chronic diseases and conditions are increasing in
school age children and also play a role in the need for evidence-based practice in the
school setting (Erickson, Splett, Mullett & Heiman, 2006). School systems are faced with
the challenge of meeting the federal and state laws and regulations (Erickson et al.,
2006). “ The Individuals with Disabilities Act (IDEA) of 2004 and the Rehabilitation Act
of 1973, Section 504, require districts to provide services and accommodations for
students with chronic conditions” (Erickson et al., 2006, p. 311). Children are surviving
and living with more chronic conditions due to the advancement of technology and
medical care and therefore their health care needs at school are becoming more advanced
(Erickson et al., 2006). Asthma is a common major chronic illness in school age children
(Adams, 2009). Asthma, that is not adequately controlled, is found to cause over 14
million missed school days per year (Adams, 2009). School aged children with chronic
illnesses need to have a medical resource and care, which is based on EBP, at school that
will allow them to participate in the daily school activities to reach their academic goals.
Research Questions
This research study was proposed and designed to answer questions regarding
EBP with the school nurses in this sample. Research questions to be answered in this
study are: (a) What is the school nurses’ current awareness of research? (b) What are the
most reported facilitators and barriers to research utilization in the school setting? (c)
What are the reported barriers of research resource information for school nurses to guide
4
their practice? (d) What is the school nurses’ perception of the importance of using
current research to guide their practice? (e) What are the reported skill level barriers
reported to research utilization?
Hypotheses
Knowing the facilitators and barriers to research utilization in the school setting
will allow insight into how school nurses can be supported in implementing EBP to guide
their practice. School nurses that report being aware of research, perceive EBP as
important, deny EBP skill level barriers, report limited barriers to current sources of
information, and other barriers will report lower barriers and a higher level of facilitators
to research utilization and EBP use to guide their practice. Furthermore, the demographic
information of the participant’s education level, years of experience as a registered nurse
and school nurse, and district size of the schools served also has the potential to affect
EBP use. This study will provide valuable information of EBP facilitators and barriers to
research utilization and to identify the needs associated with implementing EBP in the
school setting.
Definition of Terms
This proposed study seeks to gain understanding of the facilitators and barriers to
evidence based practice use by exploring the perceived facilitators and barriers of school
nurses and research utilization Defining and understanding what is being asked helped
guide this research study in answering the desired research questions.
5
Evidence based practice. Evidence based practice is using the best available
evidence from research, along with previous nursing experience and patient and family
preferences to guide nursing practice (Adams & McCarthy, 2005).
Awareness of EBP. The nurse reports being aware of research as a barrier from
no extent to great extent (Funk, Champagne, Wiese, & Tornquist, 1991)
Attitude toward the importance of EBP. Self-reported perception of the school
nurse’s value of research for practice, benefits of changing practice, benefits to self,
documented need for practice change, and the willingness to change or try new ideas as a
barrier to EBP reported from to no extent to great extent (Funk et al., 1991).
Current facilitators and barriers of research utilization. Self-reported factors
by the school nurses that are facilitators and barriers to research utilization that are
included by the school nurse and addressed on the BARRIERS scale statements from no
extent to great extent (Funk et al., 1991).
Barriers of information sources. Research and Presentation of research barriers
as presented on the BARRIERS scale that are reported as barriers from to no extent to
great extent (Funk et al., 1991).
Skill level of EBP use. Self-reported perceived skill level of understanding
research statistical analysis and being capable of evaluating the quality of research as a
barrier of EBP use as reported from to no extent to great extent (Funk et al., 1991).
Theoretical framework. Rogers Diffusion of Innovation (1995) theory was
chosen to guide this study on the current use and perceived needs of incorporating EBP
with nurses in the school setting. Roger’s Diffusion of Innovation theory states that
diffusion of an innovation is implemented by a social system (e.g. school nurses) in the
6
five-step process of awareness, persuasion, decision, implementation, and evaluation
(Adams, 2009). The autonomous and often isolated setting of school nursing practice
suggests that these members of this social system may face this five-step diffusion
process of this innovation change on their own (Adams, 2009). Roger’s theory (1995)
also states that communication with a person that has already adopted the innovation (e.g.
having access of an advanced practice nurse who is knowledgeable) is an important
factor of the adoption of the innovation (Lundbald, 2003). It is important to know the
current stage of EBP diffusion in the school setting. Knowing the social system’s (e.g.
school nurses) demographics and researching the variables of the diffusion of EBP (e.g.
the current reported facilitators to use, information sources, the perceived importance, the
perceived skill level, perceived barriers and needs) use will provide insight on how to
increase the diffusion of the innovation of EBP. Inquiring the social system’s current
knowledge, perception, facilitators and barriers to utilizing research will show the ability
of achieving the steps of awareness, persuasion, and decisions. Assessing the self-
reported skill level will also allow an understanding into the implementation and
evaluation of the innovation of EBP with this social system.
7
ROGER’S THEORY OF INNOVATION (1995)
Figure 1. Rogers Theory of Innovation: Five diffusion elements.
Awareness
Persuasion
Decision
Implementation
and Evaluation
Implementatio
n- Current
Practice
Support and
Practice Needs
Research Utilization/Evidence
Based Practice
Current
Reported
Knowledge of
Research
Attitude
toward
Research
Utilization
and Change
Perceived
Skill Level,
Facilitators
and Barriers
Evaluation-
Access to
Knowledge
able
Advance
Practice
Nurses and
Technology
8
Summary
Incorporating research utilization and evidence-based practice to guide nursing
practice is essential in ensuring that patients receive optimal nursing care. The
autonomous and often isolated setting of school nursing practice makes practicing
evidence based nursing care especially important. Research has shown that the use of
EBP can eliminate insufficient nursing practices and improve nursing outcomes (Adams,
2009). Roger’s Diffusion of Innovation (1995) was described to guide this study to gain
insight in the current use and perceived needs of incorporating EBP use with school
nurses in the school setting. EBP in the school setting provides the student the care
needed to obtain optimal health, reduce absenteeism, and allow students to reach their
educational goals, while validating the nursing care that is given by the school nurse. This
study will provide valuable information on the facilitators of school nurses EBP use
guide their practice, and to identify the barriers associated with providing EBP in the
school setting.
9
Chapter II
Review of Literature
Introduction
The use of evidence-based practice (EBP) has been determined to be essential to
providing quality healthcare (Koehn & Lehman, 2007). Support, training, and leadership
are important aspects in increasing EBP in nursing (Adams, 2009). It is important that
nurses, such as school nurses, who often work independently in rural areas away from
colleagues, use EBP to guide their practice (Adams, 2009). A literature review was
preformed of fifteen studies to examine Registered Nurses’ perception, use, and barriers
to the use of evidence-based practice. The information obtained in this literature review
will to help understand the current trends and barriers of incorporating evidence-based
practice in nursing.
Literature Review
A descriptive cross-sectional survey study that used Roger’s Diffusion of
Innovation Theory conducted by Adams (2009) examined the use of evidence-based
practice in school nursing. A descriptive cross-sectional survey was placed at the
National School Nurse Conference registration desk. A convenience sample of 247
Registered Nurse School Nurses returned the survey that was used to for this study.
Measurement of evidence-based practice was obtained by using the school nurse
evidence-based practice survey. Adams (2009) reported that the results of the study
showed that the recommended use of evidence-based practice was inconsistent. Although
the participants reported they felt evidence-based practice was important and were
willing to try new ideas, the respondents showed varying degrees of adherence to
10
recommended practice. The study findings showed the need for additional strategies that
addressed the unique needs of school nurses. These results were reported to help develop
strategies to increase the use of evidence-based practice in the school setting.
Koehn and Lehman (2007) investigated registered nurses perceptions, attitudes,
knowledge, and skills of evidence-based practice use. A descriptive, cross sectional
survey design that used a psychometrically validated measurement of evidence-based
practice based on a Likert scale from 1-7 was used. A sample group of 422 nurses in a
large Midwestern Urban Medical Center in the United States were given a clinical
effectiveness and evidence-based practice questionnaire. The results found that the
participants overall scored themselves as moderate on knowledge/skills and attitudes
toward evidence-based practice, however an inconsistency was found that only 52% of
the participants reported that they read or subscribed to a nursing journal. Koehn and
Lehman (2007) reported that a reasonable conclusion would be that if the nurse was
incorporating the best evidence in their practice, they would be reading or subscribing to
a professional nursing journal. The findings of this study indicated that further research of
developing an educational plan to assist nurses with the process of evidence-based
practice and skills are needed. Koehn and Lehman (2007) also reported that the findings
of the study also showed that a minimal variation of the study might indicate the need for
a better instrument to be used in the research of use, knowledge/skills and attitudes
towards evidence-based practice.
Significant Registered Nurse clinical differences of evidence-based practice use
were found in the third study reviewed. A study by Bostrom et al. (2009) examined the
problem of whether or not newly graduated nurses are actually applying evidence-based
11
practice in their practice. This study used 987 relatively newly graduated Swedish RNs
from the nursing students that were enrolled in nursing programs in 2002. The
participants were given a six-item questionnaire using a 4-point response that measured
the respondent’s extent of applying components of evidence-based practice. The results
showed that 1/5 of the RN’s were reported to formulate questions for seeking research-
based knowledge and searching databases. Bostrom et al. (2009) reported that over 50%
of the RN’s were found to use other sources of information to identify relevant research
knowledge and approximately one third of the RN’s were found to appraise articles
contents and participated in evaluating changing clinical practice. Great variations in the
RNs accomplishment of the different components of evidence-based practice were found.
These findings showed that the implementation of EBP is complex process and further
research should focus on the components of evidence-base practice and the factors
relating to education and organization.
Carlson and Plonczynski (2008) performed an analysis study of the use of the
BARRIERS scale to identify the perceived barriers to research utilization, the extent of
the nurses’ perceived barriers to research utilization, and the most frequently cited
barriers that have changed over the past 15 years. Cooper’s (1989) guide for integrated
literature reviews was used to guide this research study. A systematic search was
conducted using MEDLINE, Dissertation Abstracts International (DAI) and Academic
Abstracts that identified relevant nursing literature from the development of the
BARRIERS scale in 1991-2006. Key words that were used in the search were
BARRIERS scale, research utilization, and evidence-based practice. Studies were
included if they were reported in English, used the entire BARRIERS scale, and reported
12
data on the responses of nurses separately from other categories of respondents. Forty-
five studies met the inclusion criteria and were used in the analysis. The research results
found that two studies suggested that interventions were successful in decreasing nurses’
perceptions of barriers to using research in practice, but did not indicate an increase in the
use of evidence-based practice. The results of this study also showed that no evidence
was found that an identified barrier to nurse’s use of research has influenced nursing
practice; and the extent of the perceived barriers and the most frequently reported barriers
cited by nurses has been consistent over time. The findings of this research analysis
showed that using the BARRIERS scale to identify the nurse’s research use barriers has
not shown to increase research utilization.
A study by Gerrish et al. (2007) developed and tested a tool for assessing a range
of factors influencing the development of evidence-based practice among clinical nurses.
This study sought a need for a measurement tool that included a broader definition of
evidence that incorporated other ways of knowing that forms nursing practice. The
Development of Evidence-Based Practice (DEBP) tool was said to be different from the
original barriers scale by changing to a more personal ‘I’ or ‘my’ to ensure that
respondents reported on their own experience rather than by nurses in general. The tool
included a range of factors that included different types of evidence used to guide
practice, barriers to evidence-based practice, and needed skills for evidence-base practice.
Two studies were conducted to measure the new broader based DEBP questionnaire.
Study one’s sample surveyed consisted of 598 nurses that worked at two hospitals in one
strategic health authority in Northern England. All nurses at the two hospitals were
offered to participate, except for two already participating in an evidence-based practice
13
survey. Study two consisted of 689 community nurses from a random sample of 1600
nurses in 12 primary care organizations in two strategic health authorities in Southern
England and Northern England. Study two received a slightly expanded version of the
questionnaire. An adequate sample of 1287 total was achieved in this study to test the
tool. The study provided evidence of the validation of the DEBP questionnaire for
investigating associated factors of evidence-based practice in nurses in England. The
research findings showed that the development of new measuring tools for the range of
factors in evidence-based practice was validated. The testing and development of the
DEBP questionnaire suggested that this instrument is a valid and reliable method,
although further testing is needed to establish its validity and reliability. This study
showed the importance in providing a measuring tool that would reflect the experience of
the sample group being studied.
A study’s aim to explore the individual nurses’ interpretation and understanding
of evidence-based practice was conducted by Rolfe, Segrott, and Jordan (2008). A cross
sectional survey, followed by semi-structured interview and focus group was offered to
all qualified nurses in one UK National Health Service (NHS) Trust. The survey
questions using a Likert-type scale, which allowed natural responses, avoided binary
responses, and were based on, current literature relating to interpretations of evidence-
based practice was used. The questionnaire was pre-tested, reviewed and revised before
the study. The questionnaires were placed along with pre-paid envelopes to be sealed and
returned. Limitations of the study were reported to be due to a poor response rate of 218
out of 2438. Although there was a poor response rate, the researchers reported that
interesting information was obtained from the respondents. The results of the study
14
showed the participants did not respond to the message that evidence-based practice
empowers individual practitioners to make informed judgments based on research. The
respondents reported being influenced by national and local guidelines, their own
experience, and the patient’s preferences to guide their practice. The findings of this
study indicated that practicing nurses do not always follow the guidelines of evidence-
based practice and that nurse leaders need to synthesize the published research and
experimental knowledge of evidence-based practice.
Using a descriptive cross sectional study, researchers Brown, Wickline, Ecoff,
and Glaser (2008) conducted a study to describe nurses’ practices, knowledge & attitudes
relating to evidence based practice and relations to perceived barriers. A convenience
sample of 458 nurses was drawn from all nurses from an academic medical center in
California. Two questionnaires that were reported to be reliable and valid were used to
explore respondents’ practice, attitudes, knowledge, and perceived barriers associated
with evidence-based practice use. The research study was measured by the BARRIERS
to research utilization scale and the Evidence-Based Practice Questionnaire (EBPQ). The
data analysis was conducted by SPSS. The results of the study showed that attitudes
toward EBP obtained the highest mean score, followed by knowledge, then practice.
Brown et al. (2008) found the strongest correlations for the EBPQ factors were found to
be between the practice of EBP and knowledge. The higher the knowledge scores, the
higher the practice score of EBP was found. A negative relationship was found between
the research message & knowledge/skills. Attitudes to EBP were found to be more
positive than their associated knowledge and implementation of EBP organization.
Innovation was found to be the highest subscale of barriers. Organization barriers were
15
reported to be lack of time, lack of autonomy to change practice, and lack of support by
staff . The findings of this study included that further research is needed to evaluate the
ability of educating the interventions of EBP.
The aim of a study that was performed by Johansson, Fogelberg-Dahm, and
Wadensten, (2010) was to describe evidence-based practice use among head nurses and
to explore whether or not their number of years of duty was associated with their
evidence-based practice activities. The study further evaluated the effects of education on
evidence-based practice, as well as their perceived support from immediate supervisors.
All head nurses (N =168) from two hospitals were asked to participate. Of the 168 that
were asked to participate, 99 (59%) completed the survey. The research questions of this
study included questions of, the head nurses attitudes toward evidence-based practice, the
extent that the head nurses engaged in evidence-based practice, the extent that research
utilization is promoted among staff members, the extent that the ward is involved in
systematic development work, the number of years since their nursing degree or years as
the head nurse associated with EBP, the effects of head nurses education that included a
EBP course on the EBP activities, and what are the effects of the perceived support from
their immediate supervisors on EBP. The web-based head nurses EBP Questionnaire
(Evi Pra Q) that was specifically developed for this investigation and was inspired by the
research utilization questionnaire (RUQ) was used. The Evi Pra Q was comprised of 26
items in which the majority of statements were to be responded to using an 11 point scale
from
0 = strongly disagrees to 10 = agrees completely. The results were reported to show that
the majority of head nurses expressed a positive attitude toward EBP, but disagreed that
16
they had time to read research reports. The majority of head nurses were also reported
that they disagreed that it is possible to conduct research during working hours, however,
they did report being engaged in the evaluation of care. Additional results include that six
of the nurses reported never searching scientific databases, nine reported it being more
than two years since performing a database search, three reported it being one to two
years, twenty three reported it being in the past six to twelve months, and thirty-eight
reported it being in the last six months that they performed a database search. The more
experienced head nurses were found to have the greater possibilities of research
utilization. The study also showed that having had involvement in an education that
included scientific methodology reporting a supportive supervisor also was shown to
positively affect EBP . Johansson (2010) concluded that research utilization and the
development of EBP use are issues that are complex and require both organizational and
educational efforts.
Oermann et al. (2007) stated that findings from research must find its way into
clinical practice. Researchers, Oermann et al. (2007), preformed a research study to
describe the available research in clinical nursing journals and evaluate the
communication and practice knowledge of this research by analyzing research citations.
A descriptive study of 20 randomly selected nursing journals was performed. A total of
768 articles and 18,901 citations were examined. The results determined that the
knowledge used to develop the clinical publications came from both research and clinical
practice sources. Oermann et al. (2007) further reported that the citation analysis
confirmed the relationship between research and practice knowledge in nursing. The
findings of this study showed that nursing journals are important in disseminating
17
research findings and the dissemination of the research allows the researchers to critique
and replicate the research. This research study further showed that nurses need to be
aware of current research to incorporate the use of EBP in their practice and research
studies need to be in clinical nursing journals, online resources, and other ways that can
provide easy access.
Brown et al. (2010) performed a study to determine the relationships between the
perceived barriers of research use to the implementation of EBP use among hospital
nurses and to further investigate the barriers as a predictor of EBP use. A cross sectional
study was obtained by using both a computerized EBP questionnaire and the BARRIERS
survey. The BARRIERS scale measured the nurses’ perceived barriers to research
utilization and this study was reported to be guided by Roger’s Diffusion of Innovation
Theory. A convenience sample (N =1301) of nurses from four Southern California
hospitals was used. A hierarchical multiple regression analysis was performed for the
three dependent variables of practice, attitude, and knowledge/skills of EBP along with
BARRIERS subscales that were used as predictor variables. The correlational analysis
results of the study showed that the perceived barriers of the sample group to research use
predicted only 2-7, 2-4, and 4-5 % of practice attitude and knowledge/skills associated
with evidence-based practice. The results concluded that barriers to research use had
minimal influence over the EBP implementation for most of the hospital nurses in the
sample. Brown et al. (2010) further concluded that the barriers to research that were
measured on the BARRIERS scale had minimal influence on most of the hospitals nurses
in the sample and may be due to research being far from their busy daily schedules in
their hospital nursing practice; they may not have had strong opinions when answering
18
the survey; and the results may have been affected due to missing data and the no opinion
option on the survey scale.
Veeraman (2007) performed a study on the use of research findings in nursing
practice. The study’s aim was to examine the extent in which research findings are used
in nurse’s practice and to identify barriers and highlight the strategies that facilitate the
EBP process. A sample of ten nurses took part in this interview phase of the study. A
literature review performed identified possible barriers to the nurse’s research finding use
as being lack of awareness, lack of knowledge of the research process, insufficient time
to read and interpret research findings, and a shortage to colleagues with expertise to
discuss the research findings.
The findings from the interviews performed showed that all of the participants
stated they used research findings in their practices and gave examples but not all of the
time (Veeraman, 2007). The extent to which research findings were used varied among
the participants. The barriers listed from the interviews were that time was not allowed
during work hours to go to the library or read research papers; they felt pressured at
work, they were reported to be tired, and did not want to think about work when they
were off work. Participants also stated that there should be allotted protected time at work
for research, they had lack of knowledge on how to search and evaluate the research,
there needs to be research education supplied and nearly all stated there were lack of
resources. The strategies that were offered from the participants to facilitate research use
was to have an effective leader, be provided research education, have access to research
at work, and to also have the ability to share information with colleagues at work
Veeraman (2007) concluded the study showed that clinical leaders should demonstrate a
19
commitment to research and to assure that the necessary resources, funds, and time were
available for research utilization. However, with the current economic conditions, health
care professionals may have to take it upon themselves to maintain and improve the
professional skills.
An analysis of EBP research was performed by Mantzoukas (2008). A literature
search of evidence-based practice, research evidence, evidence for practice, qualitative
research, reflective practice, reflection and evidence was performed using the Cumulative
Index for Nursing and Allied Health Literature (CINAHL), Medline and Ovid electronic
databases. Randomized controlled trials (RCT) was promoted as the hierarchy of
evidence, however it was found to have the potential to impede the use of most effective
treatment due to practical, political, epistemological contradictions and limitations.
Mantzoukas (2008) concluded that however evidence based practice or performing best
practice was necessary in nursing, but the hierarchy of evidence (RCT) may hinder its
implementation. Reflective practice and EBP have similar goals and to implement the
best evidence in practice the hierarchy of evidence may need to be abandoned and
reflection added as a core component of EBP. However, Mantzoukas (2008) points out
that EBP is needed to prevent habitual practice and to provide a means to make effective
clinical decisions and to affectively justify these decisions.
Thompson, Estabrooks, Scott-Findlay, Moore, and Wallin (2007) performed a
systematic review that included eight thousand screened titles, three random controlled
trials (RCT) and one controlled before and after study (CBA) of the research use of
nurses. The review was conducted using the databases of Medline, CINAHL, Healthstar,
Education Resource Information Center (ERIC), Cochran Central Register of Controlled
20
Trials and Psych Info. Thompson et al. (2007) further reported using grey literature,
ancestry searching, key informants, and manual searching of journals. All of the studies
reviewed were in English and the inclusion criteria of the studies were reported to be
eligible if it was, a random controlled trial or a controlled before and after design, the
authors evaluated interventions that were aimed at increasing research use or EBP, the
participants in the study were nurses, and the outcomes of the study directly captured
research use. Thompson et al. (2007) evaluated the RCT studies for the analysis of
power, baseline measure, concealment of allocation, blinded or objective outcome
assessments, protection against contamination, reliable outcomes, and follow up
completeness. The CBA studies were assessed for items related to unit of analysis, power
base line measure, the comparability of groups, whether the study was blinded or
objective outcome assessment and the protection against contamination of studies follow
up. Thompson et al. (2007) reported to find that the overall quality of the studies were
low and before they could state the effectiveness of interventions that could increase
research use in nursing practice, study designs and implementation will need to be
improved. Thompson et al. (2007) further reports the need for studies to include primary
outcomes to help determine the effectiveness of an intervention. The need to develop
sufficient evidence that supports a relationship between interventions that are specific and
research use, then it can be explored whether or not there is a relationship between
effective research use interventions and behavioral changes in the nurses research
utilization that influence patient outcomes. Thompson et al. (2007) concluded that there is
still little known about how to increase nurses research and increasing research utilization
in nurses will require methodical and conceptual advancement.
21
Reasons, strategies and the benefits of providing research and evidence-based
(EBP) education to direct care nurses was described by Staffileno and Carlson (2010).
The results of the direct care nurses that attended an institutional staff development to
increase knowledge about research and best practices were evaluated. Staffileno and
Carlson (2010) reported that the direct care nurses in the study expressed insufficient
time, lack of education and a lack of mentoring from an Advanced Practice Nurse or
Research Nurse with EBP research. EBP is essential with today’s complex health care
needs and higher health care costs, which mandates that nurses provide quality. The staff
development program provided interactive sessions of the research process and concepts,
brown-bag sessions, Journal clubs, and individual work with the direct care nurses.
Staffileno and Carlson (2010) found that providing direct care nurses with additional
education and support empowered them and allowed them to integrate research findings
into their daily practice. The nurses who participated in the program were reported to
have gained confidence and the desire to learn about EBP and research as well as
demonstrate a higher level of critical thinking. Staffileno and Carlson (2010) further
reported a transition of the direct care nurses from a traditional-based care to an evidence-
based care that is recommended in today’s standards of nursing practice.
Squires et al. (2011) performed a systematic review of 55 articles that assessed the
professional nurses’ use of research in their clinical practice. English and Scandinavian
language studies were included. Of the 55 studies reviewed, 51 were cross
sectional/survey studies and four were quasi-experimental studies. Squires et al. (2011)
reported that the use of many different measures of research prevented them from
performing a meta-analysis and the findings from the review were presented in a
22
narrative form. The review results of the 55 articles were reported to show that the extent
in which nurses reported to use research in their clinical practice was moderately high.
However, caution must be taken when interpreting the findings due to different
instruments and concept utilization of research being used. The limitations of this study
were reported to be deliberately omitting “evidence-based practice” and “decision
making” from the search, due to evidence-based practice referring to a range of sources
of evidence in addition to researched evidence that included patient preference, clinician
expertise, and resources. Research use was referred to be specifically the use of research
in practice. The finding of moderately high use in this study may not have been found if
the omitted search studies from the terms “evidence-based practice” and “decision
making” were included.
Summary
The literature review of these 15 research studies used a variety of nursing
backgrounds and experience. Different research tools and methods were also found to be
used to study the current use, knowledge, attitudes, and perceived barriers to evidence-
based practice. The literature review showed that inconsistencies were found in the use of
evidence-based practice. One research study was found to examine the use of evidence-
based practice nationally in school nursing. A gap in the literature showed a need to
examine the use, barriers, and needs of independent nurses, such as school nurses, of
incorporating evidence-based research to guide their practice. This literature review
confirms the need for research studies of the current trends and unique needs of school
nurses incorporating evidence-based practice in the school setting.
23
Chapter III
Methodology
This chapter will describe the research design, survey instrument, sample
population, and process that were used to conduct the research. The purpose of this study
was to address the current perception, awareness, facilitators, resource information
barriers, and skills, of providing EBP in the school setting. School Nurses work isolated
from their peers and are often the only healthcare resource available in the school setting.
Little is often known about the practices and needs of the School Nurses in other school
systems due to the isolated environment of this specialty. Providing current evidence-
based practice (EBP) is an essential need for the school nurse to ensure that optimal
health care is given. The results of this study can provide valuable information on the
facilitators of school nurses EBP use guide their practice, and identified barriers
associated with providing EBP in the school setting.
Research Design
A descriptive cross-sectional survey design using the BARRIER scale was used in
this quantitative study (Funk et al., 1991). According to Burns and Grove (2009), cross-
sectional designs are used to examine a sample “in various stages of development, trends,
patterns, and changes simultaneously with the intent to describe changes in the
phenomenon across stages” (p. 241). Descriptive research provides an accurate look into
the characteristics of a group and the sample population’s perception (Burns & Grove,
2009). Moving through stages is a process that progresses and selecting subjects that are
at different stages in the evidence based practice use process can provide information
about the process as a whole (Burns & Grove, 2009). This research design allowed this
24
researcher to affectively examine the facilitators and barriers to progress the different
innovation of evidence based practice use among the sample of school nurses. Permission
to use the BARRIERS scale was obtained by signing and returning the permission form
provided online by Sandra Funk, PhD. Funk et al.’s (1991) BARRIER scale included a
29 item scale measuring research utilization where responses are rated from 1-5 (1-to no
extent, 2- to little extent, 3- to moderate extent, 4- to great extent, and 5- no opinion), as
well as six additional open ended questions on barriers and facilitators to research
utilization.
Context
Prior to conducting the survey interviews, permission was obtained from the
Internal Review Board (IRB) for Gardner-Webb University. This study took place in one
county school system in addition to a sample of available school nurses from other
surrounding county public school systems in Central and Eastern North Carolina. The
BARRIER scale by Funk et al. (1991) was used to identify the context variables of the
school nurses’ current practice facilitators and barriers, knowledge, and attitudes of
evidence based practice use. An initial pilot study of the school nurses within this county
school system was conducted prior to the including the additional county school systems.
The school nurses in the pilot study was administered the demographic and BARRIERS
scale survey to evaluate the clarity and effectiveness of the research tool.
Sample Population
Inclusion criteria was all available registered nurses who read, write, and speak
English and are employed as school nurses in public school systems located in Central
and Eastern North Carolina. The length of employment will not be considered as an
25
inclusion criterion due to including a sample of school nurses with various experience as
a school nurse will be a valuable variable with the use of evidence based practice.
Informed Consent
Prior to surveying the School Nurses, who agreed to participate in the study,
informed consent was obtained. The informed consent form included details of the
purpose of the study and the rights for participating in proposed research study. Each
participant had the opportunity to read and have explained the information on the consent
form. At any time during the study the participant had the right to decline to participate in
the study. A copy of the consent form was given to all participants at the time of the
survey. The form was provided to the participant with contact numbers of the primary
investigator (PI) and the Internal Review Board (IRB) at Gardner-Webb University. The
detailed consent further provided information concerning the potential risks and benefits
of the study. Consent from all of the participants confirmed by them responding to the
data collection.
Data Collection Method
The survey questionnaires were distributed to the school nurse participants in
person, and via email depending upon the preference of the school nurses of the school
system and or the location of the school system. Prior to the distribution of the surveys,
introduction telephone conferences or emails took place with the available school
system’s school nurses to explain the study, request participation, and answer any
questions that may arise. Rogers Diffusion of Innovations Theory (1995) and previous
evidence-based practice studies influenced the selection of the BARRIER scale tool. This
survey questionnaire tool uses a five point Likert scale to provide answers of the school
26
nurses’ current facilitators and barriers to research utilization and evidence-based practice
use. A Likert scale is used to determine the perception or opinion of a subject by linking a
declarative statement with a number on the scale and is the most widely used form of
scaling technique (Burns & Grove, 2009). Rogers Diffusion of Innovation Theory’s five
diffusion elements of (1) Awareness, the innovation characteristics that influence
adoption (reported knowledge and awareness) (2) Persuasion, the process which the
individuals consider adopting the new idea (perception of importance) (3) Decision, the
individuals characteristics and additional factors that make them likely to adopt the
change (perceived skills, facilitators, and barriers) (4) Implementation, society and the
individuals consequences for adopting the innovation (current practice and practice
needs) and (5) Evaluation, the communication channels used for adopting the innovation
(access to knowledgeable advance practice nurses and technology), along with the
components found throughout EBP studies from the literature review, provided guidance
in the selection EBP survey questionnaire (University of Twente, 2010). In addition to
the context variables of the BARRIERS scale, the questionnaire will also consist of
requests for demographic and background information that will provide the researcher
with the school nurse’s education level, national school nurse certification obtainment,
professional organization membership, length of nursing experience as a registered nurse
and school nurse, and population size of school district served.
Data Analysis
Data Analysis is an important step in adequately interpreting the research study
findings and meaning of the results (Burns & Grove, 2009). After the entire survey
questionnaires of the participating sample population were collected a statistical analysis
27
of the data was conducted. The Statistical Package for Social Sciences (SPSS) version 20
for Windows (SPSS Inc. Chicago, IL, USA) was used to obtain the statistical analysis of
this study. The data obtained was carefully reviewed before being entered into SPSS for
data analysis. SPSS allowed the obtainment of descriptive statistics to describe the
frequencies, means and percentages of the reported evidence based practice facilitators
and barriers with the context variables from the completed questionnaire.
Summary
Research studies that examine the facilitators and barriers to evidence base
practice use provide valuable knowledge of the current trends and needs of nurses to
provide optimal care. The methodology of this study was designed to examine the
current awareness, attitude, skills, and reported facilitators and barriers to school nurses
to provide EBP in the school setting. Examination of evidence-based practice among
school nurses is especially needed due to the autonomous nature of the school nurse
practice. A successful research study using the chosen descriptive cross sectional
research design, data collection method, data analysis, and the sample population will
provide valuable information about evidence-based practice with this school nurse
population. The study results will increase the understanding and awareness of the need
to use EBP, and identify the needs associated with providing EBP.
28
Chapter IV
Results
Demographic Characteristics
The data sample included a convenience sample of school nurse participants with
available contact information (n = 50) from Central and Eastern North Carolina, whereas
73 declined and did not return the survey. The school nurse data sample were all female
and consisted of Registered Nurses (RNs) with years of experience ranging from four to
40 years, as well as years of school nursing experience ranging from one to 34 years. The
school nurse sample included the education levels of Associate, Bachelors, and Masters
Degrees. The sample further included both certified and non- certified Nationally
Certified School Nurses, as wells as members and non-members of the National
Association of School Nurses. The school nurse sample was reported to serve small,
medium, and large school districts located both in town/city limits as well in rural areas.
Demographic characteristics were collected of the data sample’s education, professional
achievement, experience, and the school nurse’s work settings that could be associated
with their reported research utilization facilitators and barriers as depicted in Table 1.
29
Table 1
Demographic Statistics Frequencies and Percentages
Gender
Degree
Obtained
Years
As
RN
Years
Experience
As
School
Nurse
National
Certified
School
Nurse
National
Association
Of School
Nurses
Member
Location
Area of
School
School
District
Size
Female-
(100 %)
Male-
(0%)
ADN- 2
(4%)
BSN/BA/BS-
43 (86%)
Graduate-
5 (10%)
Doctorate-
0 (0%)
0-4 yrs. -
1 (2%)
5-10 yrs.
- 4 (8%)
11-15
yrs. -8
(16%)
16-20
yrs. - 8
(16%)
21-25
yrs. - 7
(14%)
>25 yrs.-
21 (42%)
Missing-
1 (2%)
0-4 yrs. -
10 (20%)
5-10 yrs. -
22 (44%)
11-15 yrs. -
10 (20%)
16-20 yrs.-
5 (10%)
21-25 yrs.-
1 (2%)
>25 yrs.-
2 (4%)
Yes- 41
(82%)
No- 9
(18%)
Yes- 17
(34%)
No- 9
(18%)
Missing-2
(4%)
Rural-
33
(66%)
In
Town/
City
Limits-
17
(34%)
Small
(<1000
students)-
5 (10%)
Medium-
(1000-
4000
students)-
20 (40%)
Large-
(>4000
students)-
25 (50%)
Current Awareness
Table 2 depicts the statistical descriptive data of frequencies, percentages, means
and standard deviations of the reported barrier levels data to the nurse being unaware of
the research.
30
Table 2
Awareness, Responses to the BARRIER scale item: “The nurse is unaware of the
research” and “There is no documented need to change practice” (Funk et al. 1991).
Barrier Level
Frequency
Percentage
Mean
SD
The nurse is unaware
of the research-
To no extent, to little
extent (combined)
To moderate extent,
to great extent
(combined)
No opinion
There is no
documented need to
change practice
To no extent, to little
extent (combined)
To moderate extent,
to great extent
(combined)
No opinion
26
20
8
23
12
15
52%
40%
8%
46%
24%
30%
1.32
1.07
.621
.695
31
Facilitators to Research Utilization
The BARRIERS scale addressed the facilitators to research by including an open
ended question requesting the participants write in what is perceived as facilitators to
research as depicted in Table 3.
Table 3
Responses to the BARRIERS scale facilitator open ended question (N=50),
“What are the things you think facilitate research utilization?” (Funk et al. 1991).
Reported Facilitator
Frequency
Percentage
Missing or No opinion
Resources
Collaboration with
Colleagues
Computer Programs
Knowledge
Administrative Support
43
2
1
1
1
1
86%
4%
2%
2%
2%
2%
Barriers to Research Utilization
Participants of the study were asked to rate each of the 29 items on a scale
according to the extent that the item was perceived as a barrier. To a moderate extent and
to a great extent responses were combined, as in previous studies, to better understand the
results given (Parahoo, 2000). Table 4 shows how the barrier items were ranked with the
32
combined categories, to moderate extent and to a great extent, for all 29 barrier items
addressed in the BARRIER scale.
Table 4
Rank Order of To Moderate or To Great Extent Barriers to Research Utilization as
Perceived by Central and Eastern Region School Nurses (N=50) from Barrier Scale
Questions 1 to 29
Rank
Order
Barrier
%
Rating
Type
Mean
SD
Missing
or No
Opinion
1
2
3
4
5
6
7
8
9
10
11
12
13
The nurse does not have
time to read research
The nurse feels results are not
generalizable to own setting
Research reports/articles
are not readily available
The amount of research
is overwhelming
The nurse does not feel
she/he has enough
authority to change
patient care procedures
The facilities are inadequate
for implementation
Physicians will not cooperate
with implementation
The nurse is unaware of
research
Other staff are not supportive
of implementation
Administrators will not allow
implementation
Implications for practice
are not made clear
The nurse is isolated
from knowledgeable
colleagues with whom
to discuss the research
The research is not
56%
46%
44%
44%
42%
42%
42%
40%
40%
40%
38%
38%
38%
S
S
P
R
S
S
S
N
S
S
P
N
P
1.54
1.38
1.34
1.37
1.47
1.24
1.22
1.32
1.36
1.34
1.38
1.44
1.33
.542
.716
.658
.725
.505
.744
.823
.621
.650
.680
.490
.502
.591
1
11
5
13
5
9
16
4
10
16
0
7
3
33
Rank
Order
Barrier
%
Rating
Type
Mean
SD
Missing
or No
Opinion
14
15
16
17
18
19
20
21
22
23
relevant to the nurse’s
practice
There is insufficient time
on the job to implement
new ideas
Statistical analyses are not
understandable
The nurse does not feel
capable of evaluating the
quality of research
The nurse sees little benefit
for self
The relevant literature is
not compiled in one
place
The nurse feels benefits
of changing practice will
be minimal
There is not a
documented need to
change practice
The nurse is uncertain
whether to believe the
results of the research
Research reports/articles
are not published fast
enough
The research has not
been replicated
38%
38%
38%
28%
28%
26%
24%
22%
22%
20%
S
P
N
N
P
N
N
R
R
R
1.36
1.30
1.34
1.27
1.00
1.18
1.07
1.08
.89
.78
.613
.614
.645
.539
.798
.560
.695
.607
.784
.764
9
4
10
5
19
4
15
8
22
21
24
25
26
27
The research is not reported
clearly or readably
The nurse is unwilling to
change/try new ideas
The conclusions drawn from
the research are not justified
The literature reports
conflicting results
18%
12%
12%
12%
P
N
R
R
1.09
1.09
.98
.89
.570
.421
.556
.618
12
8
14
17
34
Rank
Order
Barrier
%
Rating
Type
Mean
SD
Missing
or No
Opinion
28
29
The nurse does not see the
value of research for practice
The research has
methodological inadequacies
10%
10%
N
R
1.04
.78
.424
.636
8
20
S=Setting, N=Nurse, P=Presentation of the Research, R=Research
Barriers to Research Resource Information
Table 5
Rank Order of To Moderate or To Great Extent Barriers of Research Resource
Information as Perceived by Central and Eastern Region School Nurses (N=50).
Rank
Order
Barrier
%
Rating
Type
Mean
SD
Missing
or
No
Opinion
1
2
3
4
5
6
7
8
9
10
Research reports/articles are
not readily available
The amount of research is
overwhelming
Implications for practice are
not made clear
The research is not relevant to
the nurse’s practice
Statistical analyses are not
understandable
The relevant literature is not
compiled in one place
The nurse is uncertain whether
to believe the results of the
research
Research reports/articles are
not published fast enough
The research has not been
replicated
44%
44%
38%
38%
38%
28%
22%
22%
20%
18%
P
R
P
P
P
P
R
R
R
P
1.34
1.34
1.38
1.33
1.30
1.00
1.08
.89
.78
1.09
.658
.725
.490
.591
.614
.798
.607
.784
.764
.570
5
13
0
3
4
19
8
22
21
12
35
Rank
Order
Barrier
%
Rating
Type
Mean
SD
Missing
or
No
Opinion
11
12
13
The research is not reported
clearly and readably
The conclusions drawn from
research are not justified
The literature reports
conflicting results
The research has
methodological inadequacies
12%
12%
10%
R
R
R
.98
.89
.78
.556
.618
.636
14
17
20
P=Presentation of the Research, R=Research
Perception of Importance to Research Utilization
The nurses in the sample’s perception of the importance of research utilization
were analyzed by including the frequency of four of the factor 1 responses on the
BARRIER scale. Factor 1 on the BARRIER scale includes the nurse’s research values,
skills, and awareness, however only the items that addressed the nurse’s research values
were included in Table 5 (Funk et al.,1991).
36
Table 5
Perception of Importance to Research Utilization Barriers from to no extent to little
extent (N=50)
Rank
Order
Barrier
Type
%
Ranking
Mean
SD
Missing or
No
Opinion
1
2
3
4
The nurse does not see the
value of research for practice
The nurse is unwilling to
change/try new ideas
The nurse does not see the
value of research for practice
The nurse sees little benefit
for self
N
N
N
N
74%
72%
66%
58%
1.04
1.09
1.18
1.27
.424
.421
.560
.539
8
2
4
2
Perception of Skills
Table 6
Perception of Skill Barriers from to moderate extent to great extent (N=50)
Rank
Order
Barrier
Type
%
Ranking
Mean
SD
Missing or
No
Opinion
1
2
The nurse is isolated from
knowledgeable colleagues
with whom to discuss the
research
The nurse does not feel
capable of evaluating the
quality of the research
N
N
38%
38%
1.44
1.34
.502
.645
7
10
37
Chapter V
Discussion
The purpose of this study was to address the current perception, awareness,
facilitators, resource information barriers, and skills, of school nurses providing EBP in
the school setting. The demographic data of the school nurses concluded that all of the
school nurses in the sample were female (100%) with the majority (86%) having
achieved the educational level of Baccalaureate degree, whereas the 10% of the nurses
have achieved the level of Graduate degree and the remainder obtaining an Associate
degree (4%). The year of experience as a RN Mean was reported to be 21.45, as well as a
Mean of 9.7 for years of experience as a school nurse. Among these nurses, 82% have
additionally obtained the professional status of national certification as a school nurse
while 34% reported being a member of the National Association of School Nurses
professional organization. The data sample further found the majority of the nurses
served in rurally located schools with a district size >4000 students (see Table 1).
Awareness of Research Utilization
According to the data collected, the majority of the nurses (52%) reported to no
extent or to little extent that being unaware of research was a barrier to research
utilization (see Table 2). In addition, the BARRIER item there is no documented need to
change practice as a barrier contained 15 no opinion responses (30%), however did
contain 23 responses (46%) to no extent or little extent as a barrier to research utilization.
These findings suggest that the majority of the school nurses in the sample are aware of
research and the majority of the responses to there is no documented need to change,
provided are aware of the need of research utilization and have achieved the step of
awareness in Roger’s Diffusion of Innovation Theory (1995).
38
Facilitators to Research Utilization
The BARRIER scale addressed the facilitators to research utilization by asking
the respondents to write in their perceived facilitators in an opened ended question
format. The majority of the school nurses in this sample did not respond or responded no
opinion (86%), however, three of the responses provided could be seen to be related to
the category of setting (see Table 3). The setting facilitator responses included
“resources” (4%), “computer programs” (2%), “collaboration with colleagues” (2%), and
“administrative support” (2%). The final response of “knowledge” (2%) could be related
to the skill of the adopter.
Barriers to Research Utilization
The greatest barrier was found to be that there is not enough time on the job to
read research (56%), followed by the nurse does not feel that the research are not
generalizable to own setting (46%) (see Table 4). Furthermore, 70% of the top ten
reported barriers were characteristics of the organization (setting). The least barrier
reported was the research has methodological inadequacies (10%). Additionally all of the
29 individual barriers were ranked according to the combined categories of to moderate
extent and to great extent and provided in Table 4.
Perception of Importance
When addressing the characteristics of the adopter’s (school nurse’s) value of the
innovation (research utilization), the majority of the school nurses in the sample reported
the nurse does not see the value of research items as the least barrier (74%) (see Table 5).
These findings further suggest that the majority of the school nurses valued the
innovation of research and had achieved the step of persuasion in Roger’s Diffusion of
Innovation Theory (1995).
39
Skill Level Barrier
With the reported perceived skill barrier of the adopter, the items of ‘the nurse
does not feel capable of evaluating the quality of the research’ and ‘the nurse is isolated
from knowledgeable colleagues with whom to discuss the research were both reported at
38% to be barrier at to a moderate extent or to a great extent (See Table 6). The majority
of the school nurses did not report that skill was a barrier to research utilization, which
also suggests the majority of school nurses had achieved the step of decision in Roger’s
Diffusion of Innovation (1995).
Significance of Findings
Funk et al. (1991) note that facilitators to research utilization included increased
administration support and time available at work to utilize research that will allow
evidence to guide practice. This study found that the school nurse’s setting is a perceived
barrier to research utilization. The setting is greatest reported barrier although the
majority of the nurse’s reported increased years of experience as a RN and an educational
degree beyond the entry level of an Associate degree.
Implications for Nursing Practice
This study contributes to the understanding of the barriers to the process of
research utilization that allows evidence to guide the practice of the school nurse in the
school setting. Studies that include nurses practicing in organizational settings outside the
medical setting can provide a greater understanding to the barriers that individual nurses
face with research utilization.
40
Limitations of the Study
The short time span of one week that was requested of the participants to
complete the survey study may have limited the response rate of this study. The
convenience sample of 123 school nurses yielded a response rate of 41% (n = 50) which
may not have been an adequate sample to show the true response rates to the barriers.
The majority of the school nurses (86%) did not respond to the open ended questions
requesting their perception of facilitators of research utilization, the low response rate
(14%) also may have not adequately portray the entire perceived facilitators of research
utilization in the school setting. Including the right of the participant to not respond to
any item that they did not wish to respond to, increased the high rate of missing or no
opinion responses to items.
Recommendations for Further Research
A repeat of this study with school nurses is recommended that allows for a larger
research sample and includes additional research for a better understanding of the current
use of evidence based practices. Further studies that address the organizational (setting)
barriers to research utilization of school nurses and that address the barriers of
administration that compares both nursing and non-nursing administrations.
Importance of the Findings for Nursing
The findings from the survey study suggest that the setting has the potential to be
major barrier to research and research utilization. School Nurses are often the only health
resource in the school setting. A school nurse that effectively uses EBP can have a great
impact on both the staff and the student’s lives. Understanding the barriers that prevent
school nurse from using research to guide their practice will provide a better
understanding of how to support nurses in increasing research utilization.
41
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