Barriers to research utilization: Does diversity play a role

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Barriers to research utilization Does diversity
play a role?

• Victor Agoo, MSN, RN
• Julie A. Hoff, PhD, RN
• Kathy Pischke- Winn, RN, MBA

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Internationally educated Registered Nurses

• U.S. Nursing Shortage
• 2000, ? demand for Internationally educated
  nurses
• ? recruitment of nursing students from minority
  groups
• InternationallyEducated Nursing School Graduates
• Part of the American Nursing workforce since WWII
• 2.2 million RNs 12-15 are international RNs
• Philippines major foreign nurse exporter
• Other Asian Exporters
• India, Korea, Thailand, China, and Japan

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Internationally Educated Registered Nurses

• Most represent an ethnic or racial minority
• 48.9 Asian non-Hispanic
• 31.3 White non-Hispanic
• 6.7 African American non-Hispanic
• 2.1 Hispanic or Latino
• Many speak at least one language other than
  English

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Internationally Educated Registered Nurses

• Initial educational preparation
• 50.2 Philippines
• 48.4 Baccalaureate Degrees
• 41.6 Diploma
• 20.2 Canada
• 8.4 United Kingdom

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Internationally Educated Registered Nurses

• Employment
• Work in hospitals as staff nurses
• California (28.6 percent) ?
• Florida (10.7 percent)
• New York (10.4 percent)
• Texas (7.5 percent)
• New Jersey (6.9 percent)
• Illinois (5.6 percent)

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Cultural Variability

• Social Patterns
• Acquired through socialization within a cultural
  context
• Throughout ones lifetime
• Occurs at unconscious level
• Influences all aspects of life
• Collectivism versus Individualism
• Difference in Social Patterns leads to conflicts
  because of communication style differences
• Low Context versus High Context

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Classification of Cultures by Social Pattern

• Individualism
• AMERICAN
• Motivated by own preferences needs, rights and
  contracts they have with others
• Gives priority to personal goals over goals of
  others
• Premiums placed on individuals needs,
  initiatives, and achievement
• I superseded the We identity
• Australian, Canadian, Northern European,
  American cultures

• Collectivism
• ASIAN
• Motivated by the norms and duties of the
  collective
• Gives priority to the collective over personal
  goals
• Needs of group outrank individual needs
• We comes before I
• African, Arab, Asian, Latin and Southern
  European cultures

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Classification of Cultures by Communication Style

• Low Context Communication
• AMERICAN
• Individualistic cultures
• Dominant communication style is explicit and
  direct
• Dominant in Australian, Canadian, Northern
  European, American cultures

• High Context Communication
• ASIAN
• Collectivistic cultures
• Dominant communication style is indirect and
  implicit
• Depends heavily on context
• Internalized programming
• Dominant in African, Arab, Asian, Latin and
  Southern European cultures

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Concept of Face

• Concept of face is universal
• Rooted in honor and associated with emotions of
  respect, pride, shame, dignity and guilt
• Face is a projected image of ones self in a
  relational situation
• Public self-image in a relationship of at least 2
  parties
• Collective cultures
• Concerns individual as well as family, work unit
  community, and country
• Individualistic cultures
• Concerns the involved individual

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RESPECT
AUTHORITY
AMERICAN DREAM
HIERARCHY
WE
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• Where is everyone today? And why?

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Background

• 2007 UIMC hires new CNO
• Embarks on ANCCs Magnet journey
• Research and Evidence-Based Practice Key to
  success
• Research is the foundation for the empirical
  outcomes component of the 08 Magnet model
• UIMC Workforce Demographic
• Majority of RNs licensed gt 10 yrs
• Generous compensation benefit package

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Background

• UIMCs nursing EBP initiatives
• EBP program developed gt 75 RNs attend
• Literature supports knowledge of barriers
  facilitators to research utilization
• Limited knowledge regarding acceptance of
  research, EBP and research utilization by RNs

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EBP barriers facilitators What do we know?

• Weve studied barriers facilitators long
  enough, there is enough evidence, we know what
  those factors are its time to move along
• Alyce Shultz
• UIC College of Nursing EBP Conference
• May 2009

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Purpose Funks Survey

• To assess UICMC nurses perceived barriers and
  facilitators to research utilization
• What are the perceived barriers to and
  facilitators of research utilization among
  inpatient registered nurses employed in an
  Academic Health Science Center?
• Are the demographic characteristics of inpatient
  registered nurses associated with the perceived
  barriers and facilitators of research
  utilization?

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Theoretical Framework

• ? Diffusion of Innovation Everett Rogers, PhD
• ? Diffusion is a process by which innovation is
  communicated through certain channels over time
  among members of a social system

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Four Factors that Influence Extent of Utilization

• Characteristics of the ADOPTER
• The nurses research values, skills, and
  awareness
• Nurse subscale (8 items)
• Characteristics of the ORGANIZATION
• Setting barriers and limitations
• Setting subscale (8 items)
• Characteristics of the INNOVATION
• Qualities of the research
• Research subscale (6 items)
• Characteristics of the COMMUNICATION
• Presentation and accessibility of the research
• Presentation subscale (6 items)

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Barriers to Research Utilization Scale Scoring

• The Barriers to Research Utilization Scale
  consists of 29 items
• Each item describes a potential barrier to
  research utilization
• Respondents rate the extent to which they think
  each item is a barrier to nurses use of research
  to change or enhance practice on a 4 point Likert
  Scale
• No Opinion alternative is offered

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Barriers to Research Utilization Scale Item
Examples
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Past Studies Using Funks Barrier Scale

• 6 International Studies
• Turkey, Northern Ireland, Korea, Hong Kong,
  Australia and Norway
• 4 Single-Site U.S. Studies
• ? Magnet Community Hospital
• ? Large, Urban Academic Medical Center
• ? Magnet Community Hospital
• 1 Multi-Site U.S. Study

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Comparison of Sub Scale Means among 6 Studies
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Previous Findings using BARRIERS Tool

• Barriers
• Lack of time, RN Authority , unaware of research
  studies
• Facilitators
• Devoted time, Improved staffing ratios,
  Initiation of journal clubs, Support from nursing
  administration, Support from physicians

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Methods

• Cross-sectional, correlational exploratory
  research design
• Surveyed Registered Nurses employed in an
  inpatient setting
• Demographic information
• Professional Information
• Funks Barriers Scale

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Methods

• Identified Funks BARRIERS Survey Instrument
• Created data collection tool for demographics
• Developed cover letter
• IRB Application and Approval
• Distributed surveys
• Created Access? Database
• Entered data into database
• Analyzed data using SPSS?
• Present and publish results

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Methods

• Setting
• Inpatient Nursing Units
• Academic Medical Center
• Sample 698 Surveys Distributed (575 completed)
• Registered Nurses
• APNs
• Nurse Managers
• Analysis
• Microsoft Access? used for data entry
• SPSS ? data analysis
• Frequency and descriptive statistics
• Pearson Correlation
• One-Way ANOVA with post-hoc comparisons

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Results Demographic Characteristics
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Results Demographic Characteristics
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Results Demographic Characteristics
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Barriers to Research Utilization Scale Mean
Scores
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Results by Ethnicity
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Results ANOVA
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Study Limitations

• Cross-sectional study
• Participants were not randomly selected
• Original intent did not include diversity
• Lacked measures of acculturation
• Location of education

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Conclusion

• Barriers and facilitators of research utilization
  may be impacted more by the culture and social
  values of ones homeland than their adopted
  country.
• When empowering nurses through research
  utilization, the role of diversity must be
  recognized and addressed in a culturally
  sensitive manner.

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Recommendations for Future Research

• Improve assessment of diversity
• Acculturation Scales
• Identify where people were education
• Mixed Methods - Focus groups
• Replicate study with multiple organizations
  participating

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Next Steps Report Data, Review Literature
Reassess

• ANCCs Magnet recognition award is steeped in
  Anglo Saxon, Protestant, English values
• Link survey results with march to Magnet, our gap
  analysis, Funks survey data, and more recent
  literature
• Internationally educated nurses adjustment
• More than orientation
• First acute 12 months of employment
• Life-long adjustment to a new culture and
  environment

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Next Steps Report Data, Review Literature
Reassess

• Facilitators for new culture adjustments
• Positive work ethic
• Persistence
• Psychosocial logistical support
• Learning to assume an assertive role
• Continuous learning

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Next StepsEducation for all staff

• Clinical competency areas encountered by at
  internationally educated nurses encounter
• Competency more than NCLEX
• Communication Command of English language, yet
  thinks in native tongue
• Consistency Patient Advocacy, Privacy (HIPPA),
  Speaking Up may be unfamiliar cultural concepts
• Cooperation anxious to please form strong ties
  within group
• Customs RN shortage means fast visa
  turn-around. Belief in Gods will
• Conformity develops survival strategies
  coping mechanisms
• Courage leave family culture promise of
  better economics and life

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Next StepsImplications for Practice

• Develop implement a comprehensive
  evidence-based strategy by addressing
• Barriers facilitators of communication
• Culture-based lifeway conflicts
• Inadequate support towards acculturation,
  orientation practice differences
• Develop an evidence-informed transitional program
  for nurses by
• Address facilitators
• Minimize barriers
• Assessments
• Acculturation Scales
• Identify where people were educated
• Mixed Methods - Focus groups

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Implications for practice Language
Communication

• Competency training
• Idioms, phonetics, accent reduction
  socio-cultural dimensions
• Communication competency directly affects patient
  safety quality of care
• Language skills/Communication
• Most challenging issue facing international nurse
• Hire requirements not enough
• Accented speech
• Telephone communication not picking up on
  non-verbal cues
• Socio-cultural dimensions of communication

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Implications for Practice Comprehensive,
effective transition

• Mentoring system Implement buddy program for
  both emotional clinical support, especially
  during initial adjustment period, and then
  on-going
• Assertiveness training Especially in context of
  patient safety advocacy
• Emotional support Transition/welcome program
  Logistical support lodging, financial immediate
  need
• Assistance with registration licensing
  procedures
• On-going education support to international
  nurse, supervisor and staff

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Implications for Patient SafetyTim Porter
OGrady

• Internationally educated nurses working in
  America have to confront the requisite for a
  level of effective communication that is
  necessary to operate in the best interests of
  patient care and safety. Unlike homeland
  cultures, where passive and subordinating
  behavior is expected and the voice of the doctor
  and the male dominates.

• American healthcare institutions. . . Work in a
  highly technological and complex environment,
  assertive and balanced communication between the
  various disciplines is essential to assure
  patient needs are attended to and safety is
  addressed. Thus the need for equitable and viable
  conversation and communication between the
  disciplines is often coordinated and facilitated
  by nurses.

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Implications for Nurse Leaders and Managers

• Develop unit leaders/managers
• Understand needs of internationally-educated RNs
• Leaders/Managers create a context for
• Safe personal development for international RNs
• Develop clear nursing role expectations
• Patient safety
• Advocacy
• Multi-disciplinary interactions
• Personal development plan for each international
  RN
• Offers support
• Identifies the challenges of new learning
  environment
• Improve expression of their nursing role

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Implications further research

• Potentials for research
• Develop test evidence-informed transition
  programs
• Does a transition program effect retention of
  internationally educated RNs?
• Do support and mentoring programs help
  internationally educated RNs adjust to the work
  environment?
• Communication competency assertiveness training
  does it affect workplace adjustments?

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Implications for Policy

• Professional development promotion inequalities
• Race
• Gender
• Culture
• National origin
• Language and/or accent (including accent)
• Such inequalities are contradictory to social
  justice a fundamental value of the nursing
  profession

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Implications for Policy

• Perceived Injustices
• Lack of promotions
• Racism
• Bullying by staff, peers, supervisors
• Denial of supplement pay for additional
  responsibilities
• Given undesirable work assignments, shifts or
  lower wages
• Discrimination by patients peers

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MAGNET 2008 The 5 Model Components
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Magnet Cultural Diversity and Competencies of
UIMC RNs

• UIMC RN workforce demographics need to address
  facilitators barriers from a culturally
  sensitive perspective
• Diversity/Competency issues cross all 5
  components of the Magnet model
• Transformational Leadership
• Structural Empowerment
• Exemplary Professional Practice
• New Knowledge, Innovations Improvements
• Empirical Outcomes

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Next Steps Fall/Winter, 2009

• Assess data communicate results with nurse
  leaders, managers staff
• Discuss diversity/competency needs of our
  international workforce with staff leadership
• Assess competencies around communication, safety,
  EBP-research
• Address need for manager 11 mentoring with
  international RNs

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Acknowledgements

• UICMC Registered Nurses who completed the survey
• UIC Clinical Research Center Staff who helped
  with the data entry
• This project was supported by the University of
  Illinois at Chicago (UIC) Center for Clinical and
  Translational Science (CCTS), Award Number
  UL1RR029879 from the National Center For Research
  Resources. The content is solely the
  responsibility of the speakers/authors and does
  not necessarily represent the official views of
  the National Center For Research Resources or the
  National Institutes of Health

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Questions and Comments