The objective of this study is to elucidate how healthcare professionals in a hospital setting experienced working with the implementation of research results in practice, and which existing methods they utilized to incorporate research results into daily healthcare action.
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A descriptive qualitative design was chosen, as the aim of the study was to elucidate the experiences of healthcare professionals. A directed content analysis approach guided the analysis [ 32 ]. The participants were healthcare professionals working in two different medical wards in a medium-sized university hospital in Denmark. As there was an overlap between the positions in two instances, twelve interviews were carried out. The wards were selected on the basis of having several researchers employed, as well as their willingness to participate.
The participants were recruited through the heads of departments, who were asked to identify professionals eligible to participate. A calendar invitation was subsequently sent out inviting the professionals to participate, and all agreed.
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Data was collected in the spring of through 12 qualitative, semi-structured interviews. All of the interviews took place in the wards. The theoretical framework consisted of factors enhancing implementation: 1 a package of implementation policies and practices established by an organization, 2 the climate for innovation implementation in the team or organization —i. The opening question of the interviews was always open-ended, asking the participants to talk about their own experiences of working with research implementation in practice.
Consequently, the participants contributed as much detailed information as they wished, and the researchers asked further questions as necessary. One person acted as the main interviewer while the other observed the interview as a whole, ensuring follow-up in accordance with the interview guide. All interviews were recorded and transcribed. A directed and deductive content analysis approach [ 34 ] guided the analysis in order to bring theoretically-derived coding categories into connection with the empirical data. Transcripts were entered into NVivo10 in order to structure the data.
An unconstrained categorization matrix was developed on the basis of the twelve theoretical factors to guide the analysis, as described by Elo et al.
Data was coded according to the categories in the matrix. During the coding process, new categories emerged, such as issues about professionals using their spare time for research and research implementation, and multidisciplinarity among doctors and nurses. The new categories were noted and treated as equally important additions to the initial categories.
This abstraction process was repeated with the higher-order categories, resulting in six main categories, as described in the results section of this article.
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In order to enhance rigor and validity, interviews were initially coded by all authors individually, after which they met and discussed the categorization until consensus was obtained [ 35 ]. The study was submitted to The Committees on Health Research Ethics for the Capital Region of Denmark De Videnskabsetiske komiteer for Region Hovedstaden , who assessed that the study did not require formal approval by the committee.
As only two wards at the hospital served as the empirical basis of the study, the researchers paid special attention to issues of confidentiality and anonymity. Participants were therefore informed that their names would not be mentioned in the study, but were also asked to reflect on the fact that the limited number of participants might make it difficult to maintain total anonymity. With this information in mind, all participants gave their written, informed consent prior to participating.
In this study of the experience of healthcare professionals with existing ways of incorporating research results into healthcare action, six main categories were identified: non-formalized , consensus-oriented , problem-oriented , autonomous, person-driven and knowledge-based. These main categories related in different ways to the varying implementation activities of initiating, deciding on, managing and executing change.
These activities are associated with different stages in the process of implementation, and the main categories are therefore structured around these Fig. The healthcare professionals experienced no formalized procedures or established workflows in relation to initiating the implementation of research results. One nurse explained how the work of initiating implementation was not integrated into the conclusion of a research project:.
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In relation to describing, searching for, remaining updated on, and evaluating the relevance of new research knowledge within various areas, one doctor commented:. It becomes somewhat unsystematic. No well-defined assignments, roles or responsibilities emerged in the experience of translating research results into practical implementation.
One doctor described the uncertainty experienced due to the lack of a more systematic approach to research implementation, and stated that:. Heads of departments and heads of units were not active in initiating the implementation of new research in practice. Their participation was mostly limited to approving, allocating resources or applying for financial support when a healthcare professional wished to initiate the implementation of a research result. Often, highly-motivated persons with specific research interests took the initiative into their own hands to suggest the implementation of certain new research results in practice.
In the nurse group this was often a clinical nurse specialist, whereas in the doctor group any doctor might initiate a potential implementation. One senior physician with special research responsibility described this as being closely related to a high degree of motivation to take action:. I mean — they just do things. This informal practice of individuals independently initiating the implementation of research results was also seen in doctors putting in extra hours after their formal working hours, both to conduct their own research and to acquire the skills necessary to implement a certain new result in practice, such as a surgical technique or a new item of equipment.
In this connection, both research and the implementation of research were to some extent driven by individual interests and motivation that went beyond formal obligations. When deciding on and managing implementation, various patterns were described in relation to doctors and nurses. In the doctor group, the decision to implement a new result was described as a consensus process among the senior physicians; managing implementation, on the other hand, was experienced as being regulated by individual doctors autonomously.
The most specialized physicians within a clinical area selected and presented new research results to their colleagues. These presentations were followed by discussion in the group — sometimes debating the results, and at other times considering whether to implement the results in practice or not. One doctor said:. In this way a consensus decision was arrived at, and the group would then define the principles for implementing new methods of patient treatment.
As one doctor described it:. Once a consensus decision had been taken to implement a new result, the collective coordination ceased, and was replaced by a principle of the individual autonomy of each doctor to manage his or her own decisions in practice. We do not all do things the same way. In this way, any doctor could refrain from implementing a new practice that had been decided on in the group, or act on something that had not been decided in the group, without the need to ask permission.
Due to autonomy, no organized follow-up was conducted from within the ward to manage and monitor the implementation of research results.
Some healthcare professionals said that if there was a follow-up on the implementation of a new research result, it was often in practice conducted by agents from the pharmaceutical industry who wished to establish the application of certain products. The principle of autonomy was also visible in deciding whether to adopt new instructions and guidelines.
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As a head of ward stated:. There may be many other issues to consider. We might be satisfied with the treatment that we already have, and not find the new treatment much better. It might even be more expensive. In the doctor group, therefore, the experience of deciding on and managing the implementation of research results in practice showed both an orientation towards achieving consensus decisions, and at the same time a principle of managing change autonomously in practice.
Fewer persons participated in decision-making and management in the nurse group. One or more clinical nurse specialists and a Nursing Head of Unit jointly planned a process to collect research results and design an intervention to change practice. Most of the time, the proposals came from clinical specialists, with the formal aim of remaining updated on research within the overall professional field. One clinical specialist said:. And on that basis I implemented a new practice. A problem in existing practice inspired clinical nurse specialists to revise that practice, and on that basis seek out existing research results.
Clinical nurse specialists were seen as agents of change with responsibility to manage the implementation of a research result as a revised practice in cooperation with the Nursing Head of Unit. One nurse with special research responsibility described how she worked to spread change in the nursing group by engaging particularly motivated staff members to advocate the new practice and act as change ambassadors in the daily routine:. At the same time, both clinical nurses and Nursing Heads of Unit described instances when the implementation of research results failed because nobody took action on the agreed plan.
Despite the intention to implement the change, the clinical specialists described how they failed to actually turn decisions about changes into revised practice.
One nurse explained:. Both the large flow of patients, the pressure to keep up efficiency figures and the large number of other, unrelated implementation processes going on in connection with quality improvement were seen as barriers to implementing the research-based changes. The overriding focus on production was experienced as being closely related to management focus and behavior:. As well as being the ones with the responsibility for managing changes, nurses with special research responsibility also saw themselves as being very much alone and having trouble making the changes on their own:.
There is not enough resonance. Operationalizing research results into revised action in practice was mainly knowledge-based, in terms of generating information external to the individuals handling the knowledge [ 36 ]. Moving from the decision to executing the changes was mostly experienced as a procedure to create a new instruction or a supplement to an existing one. Information-sharing about decisions took place between a few consultant doctors in the doctor group.
As one doctor said:. Because then you pass it on to others.
When reflecting on how the new information reaches the majority of other healthcare professionals, one Medical Head of Department stated:. They are accessible on our local network. Or on the hospital network. You can read all of them there. At the same time as relying on knowledge-based implementation through mandatory reading of written documents, the large number of written procedures was also experienced as something that hindered healthcare professionals from knowing how to carry out the practice.
Several instructions and guidelines referred to the same practice, and reading all of the instructions simultaneously was experienced as too demanding in a busy schedule, resulting in a failure to read them. Other types of knowledge-based implementation included exchanging and sharing information at meetings, and in newsletters and e-mails. Both doctors and nurses described teaching each other theoretically, sharing knowledge, and in some cases attending formal training, such as conferences or courses.
Nonetheless, these practices were seen as ineffective in implementing research results. As one nurse expressed it:. Applying job training and bedside learning in the implementation of research results was common in the nurse group. As one clinical nurse specialist explained her practice:. On-the-job training was perceived as being a more efficient way of implementing research results, but at the same time much more demanding on resources:.