Barriers for nurses’ participation in and utilisation of clinical research in three hospitals within the Kumasi Metropolis, Ghana (2024)

Abstract

Keywords: Evidence based medicine, nurses´ professional role, delivery of health care, clinical nursing research, Ghana health care sector

Introduction

The need for health care staff to appreciate and engage with scientific evidence cannot be underestimated. Even though it cannot wholly replace the so called “clinical eye”, i.e experience based knowledge gained from working in a clinical setting, tradition and homegrown trial-and-error cannot be the main source of knowledge for 21^stcentury high quality health care [1,2]. Nursing research, which is defined as a systematic inquiry designed to develop knowledge about issues of importance to nurses, including nursing practice, nursing education, and nursing administration [3,4]. It is directed towards promoting professional quality, ie. the credibility, accountability and cost effectiveness of nursing care [2]. The American Association of Colleges of Nursing (AACN) has described nursing research as part of the field “clinical research” which attends to issues such as acute to chronic care experiences throughout life, health promotion and preventive care to end-of-life care; and care for individuals, families and communities in diverse settings [5]. Nursing research thus also promotes evidence based nursing practice and it should therefore be as imperative to nurses as biomedical research is to eg. medical doctors [2, 3]. Medical practice, including nursing, has evolved a great deal since the mid-19^thcentury when Florence Nightingale laid the foundation for professional nursing and the first school of nursing was established [5]. In the aspect of research, nursing practice has been in the focus for a century, yet did more recently become a scientific discipline in its own right. Although advances have been made, the larger portion of nurses with direct research involvement is seen primarily in academia while it is rare for direct care nurses, working outside of university hospitals, to engage in research activities and thus cultivate a culture of research [6-9]. Owing to this, nursing research still, to a large degree, remains a university topic carried out within and by academia. Several studies on the factors that hinder nurses' participation and utilization of research identified lack of time on the job, lack of knowledge, lack of funding, nurses poor attitude/perception towards research and lack of research support services as the key constraints [7,8, 10-14 ]. Some studies within this field have been carried out in Nigeria [13, 14], but little is known about clinical nurses' involvement in research, in Ghana. In addition, despite some efforts by the Nursing and Midwifery Council of Ghana, very little is seen from graduates of the various nursing programs working in clinical settings regarding clinical research. In order to gain a more precise understanding of the situation this study sought to assess the involvement and utilization of clinical research by direct care nurses. The overarching aim of the study is to identify strategies to improve the scientific quality of nursing practice and “consequently” patient care. Specifically, the research question in focus of the study was how many clinical nurses participate and utilize research findings in three hospitals within the Kumasi Metropolis was addressed? Moreover, the question of what barriers and socio-demographic factors influence participation and utilization in clinical research among these nurses were posed.

Methods

A descriptive and analytical cross-sectional quantitative design, with complementary qualitative interviews, was used in carrying out the study among 158 clinical nurses in three hospitals within the Kumasi Metropolis from October 2014 to June 2015. The hospitals Komfo Anokye Teaching Hospital (KATH); directorate of Surgery and directorate of Accident & Emergency Medicine, Kumasi South Government Hospital and the Kwame Nkrumah University of Science and Technology (KNUST) Hospital was selected as these are responsible for teaching and represents the different levels of healthcare delivery in Ghana. Moreover, these hospitals have all the categories of nurses with different levels of educational qualifications hence different experiences and research exposure. The inclusion of these hospitals was done in accordance with purposeful sampling logic, ie. it aimed at generating varied views related to the study title across all the levels of healthcare delivery within the country. However, all involved hospitals are located in one region, out of the ten regions in the country. Inclusion criteria for participants were involvement in clinical practice, a minimum of a diploma nursing qualification and consent to be part of the study. Excluded from the study were part-time nurses, nurses on leave and nurses with a less than six months clinical experience. A convenient sampling method was used to select the participants involved in the study. To determine the sample size for the study, the formula below was used.

z = standard normal deviate; =1.96, p = since no previous study has been conducted in this setting, a pre-study estimate of the proportion of nurses involved in clinical research; = 0.5 (50%), q = 1- p; p= 1-0.5= 0.5, d = amount of error to be allowed; = 0.05 (5%)

Sample size for an infinite population, n₀ = 384 clinical nurses However, due to the limited time and inadequate time for the study, a finite population correction was done using;

Where: n = sample size for the finite population of clinical nurses within the three selected hospitals n₀ = assumed sample size for an infinite population of clinical nurses N = Size of the population of nurses who met the inclusion criteria for the study within the three selected hospitals; N₁ + N₂+ N₃ Sample size for the finite population for the study, n = 214 clinical nurses A total of 214 questionnaires were therefore administered, out of which 158 were completed, representing a 74% response rate. A close-ended questionnaire, with a four category Likert scale, based on the Research Utilization BARRIER Scale was used [15]. However, the items in the questionnaire were modified in order to better fit the study objectives and context. The modification was done in response to a Pre-test carried out at similar hospitals (compared to those who was later included in the study). The questionnaire and the interview guide (see below) were also reviewed by an Msc Nursing graduate, a PhD Nursing student as well as my local collaborator, and the data collection instruments were amended accordingly. The questionnaires were administered to the nurses on their various wards/unit during their usual schedules, after written consent had been obtained. The items on the Research Utilization BARRIER Scale are grouped under four categories: “Characteristics of the Setting”, “Presentation of research”, “Qualities of the Nurse” and “the Characteristics of the Research”. Yet, only “Characteristics of the setting” and “Qualities of the nurse” were considered in this study. In addition, data on sociodemographic factors were obtained. Quantitative data was analyzed using SPSS version 17.0. Both univariate and bivariate analysis were done. Thus to determine the number of nurses who had ever participated in clinical research after school, frequencies and proportions of use was calculated. The same was done in determining those who had ever used recommendation from any research (globally or locally) to change their practice. The barriers to both the participation and use of research findings/recommendations on the job were therefore determined. A chi-square test was used to determine the association between the socio-demographic factors and nurses' participation and utilization of clinical research. Level of significance was also set at a P-value of 5%. As a complement to the questionnaires, interviews with key informants-nurse managers working at three of the included hospitals-were carried out. Answers to each question in the interview guide were written down by the informants as they declined tape recording of the interviews. A thematic analysis was then done, relating the interviews to the research questions.

Ethical considerations: Ethical approval was obtained from the Committee on Human Research, Publication and Ethics (CHRPE), School of Medical Sciences, KNUST. However, administrative approvals were obtained from the administrations of the three selected hospitals. Data collection process began after approval had been granted by the Committee on Human Research, Publication and Ethics (CHRPE).

Results

Distribution of participants by demographic factors: As presented in Table 1, out of the 158 nurses, 92 (58.2%) were females. With regards to their educational qualification, 92 (58.2%) were diploma holders, yet only 1 (0.6%) had a master's degree and the remaining had a first degree in nursing. The mean age and years of practice among the participants were 29.02 ± 2.34 and 3.23 ± 1.76 years respectively.

Proportion of nurses who have ever participated clinical research: Out of the 158 participants, 57 (36.1%) had been involved in nursing research (after graduating from nursing school), while 101 (63.9%) had not. Out of the 57 nurses who had ever participated in a clinical research (after school), only 3 (1.9%) were Principal investigators of those studies carried out while 43 (27.2%) were study participants and 11 (7.0%) were data collectors. The level of participation by the nurses in clinical research differed greatly among the various hospitals. While 30 (70.2%), of the 57 who had ever participated in research, were from KATH (Surgery and A&E), only 17 (29.8%) were from the Kumasi South and 10 (17.5%) from KNUST Hospitals.

Discussion

Proportion of nurses who have ever participated and used clinical research: The study shows that less than half (36.1%) of the nurses who participated in the study had ever been involved in a nursing research. It also shows that nurses, when they do participate, the absolute majority of them do it as study participants, ie. not as active researchers. A cause, or effect, of this was that only a few perceived research as part of the nursing role. These findings are consistent with similar studies in China [16] and Nigeria [13, 14]. This is troublesome, as nursing research forms the key foundation for nursing practice and a minimal research participation by nurses therefore risks affecting patient care adversely. The result regarding nurses ever using a research finding to change their practice showed that only 40 (25.3%) of the 158 participants had done so, after nursing school. This too corresponds with similar studies in Nigeria [14]. However, in another Nigerian study, that included nursing tutors from the university, a higher proportion of nurses (61.7%) had utilized research in practice [13]. Findings from this study, focusing primarily on direct care nurse, imply that majority of its participants keep working in accordance with yesterdays' instruction. The paradigm of EBNP can therefore not be said to be championed by these nurses.

Barriers and socio-demographic factors influencing nurses participation in and utilisation of clinical research in practice: The study revealed that insufficient time for nurses to read articles was associated with nurses' participation in research as it recorded a P-value of 0.04 at a 95% confidence interval. As studies from both Zimbabwe [17] and Singapore [18] show similar results, inadequate time may be a characteristic of nurses' work situation. Moreover, nurses' perception about research as not a nursing role was expressed in the qualitative interviews and also found to be statistically significant with a P-value of 0.04. This finding implies that many nurses interpret research to not be part of their professional profile, which could influence their motivation to read research articles even if time was available. In order to foster nurses' research participation and utilization, both measures are probably needed on both individual and institutional level. Based on the above findings, the null hypothesis of no statistical difference between characteristics of the nurse and participation in research was therefore rejected. As could be expected, educational qualification of nurses was found to be associated with participation in clinical research indicating that the higher the educational level the more the nurse is research-conscious. Similarly, studies in Nigeria identified that a significant relationship existed between nurses' educational qualification and their involvement in research after nursing education [13,19].

Barriers and socio-demographic factors influencing utilization of research findings by nurses: Findings from the study revealed that lack of cooperation from physicians and colleagues, perceived minimal benefit of research to clinical practice and nurses' lack of motivation for change were found to be statistically significant with P-values of 0.003, 0.01 and 0.02 respectively. As nurses, in this study, noted minimal experience from engaging in research and lack of institutional as well as collegial support for doing so, their low motivation for integrating research into practice is quite understandable. A similar studies [19,20] also documented that despite the fact that majority of the nurses had formal training in research methods, close to half held a unconvinced attitude towards the benefits of utilization of research in clinical practice. From the findings of this study, we therefore reject the null hypothesis of no statistical difference between characteristics of the setting and utilization of research. The qualitative interviews strengthens the tendency in the survey, as the key-informants too described nurses' unfamiliarity with principals for evidence based clinical practice as a barrier for their active engagement in implementing research findings. For nursing practice to be evidenced-based, nursing schools and regulatory bodies therefore need to design measures that continuously support the scientific and professional development of nurses' in clinical care.

Conclusion

The study revealed that only 57 (36.1%) and 40 (25.3%) had ever participated and used research findings to change their practice after school respectively. Among the nurses who had ever participated in research, the majority did so as study participants and very few were principal investigators. Moreover, it was also found that insufficient time on the job to read research articles, perception about research as not part of the nursing role were associated with nurses participation in research. Among the socio-demographic factors considered for this study, nurses' educational qualification was found to be associated with participation in clinical research. Interviews with key-informants confirmed that inadequate time, lack of funding and nurses poor perception about research were barriers to research participation among nurses. Lack of cooperation from physicians and colleagues, perceived minimal benefit of research to practice and lack of motivation for change were factors associated with utilization of research in practice. However, none of the socio-demographic factors considered for the study was associated with utilization of research. The qualitative interviews also indicated a lack of appreciation for research among nurses as a barrier influencing their utilization of research.

Competing interests

Authors declare no competing interests.

Acknowledgments

Our profound gratitude goes to the Intra-ACP Academic Mobility Scholarship team (European Union and University of Buea) for the sponsorship and collaboration during the entire postgraduate education by the student. We also extend appreciation to the department of nursing, faculty of health sciences, University of Buea for the quality tuition and guidance. Lastly, we are thankful to the nurse managers and nurses at the three selected hospitals (Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology Hospital and Kumasi South Hospital) used for the study for their cooperation during the data collection.

Authors’ contributions

Isaac Nkrumah designed the study and was involved in all aspects of the study. Samuel Nambile Cumber guided the study, edited and supervised the study at each stage until submission for publication. Isaac Nkrumah, Gunilla Priebe, Samuel Nambile Cumber contributed to scientifically reviewing the manuscript for intellectual inputs and review. All authors reviewed the final manuscript and agreed for submission.

References