DISCURSIVE PAPER

Translating research findings to clinical nursing practice

Kate Curtis, Margaret Fry, Ramon Z Shaban and Julie Considine

Aims and objectives. To describe the importance of, and methods for, successfully
conducting and translating research into clinical practice. What does this paper contribute
Background. There is universal acknowledgement that the clinical care provided to to the wider global clinical
individuals should be informed on the best available evidence. Knowledge and evi- community?
dence derived from robust scholarly methods should drive our clinical practice, deci- • Practical, evidence-informed expla-
sions and change to improve the way we deliver care. Translating research evidence nation and suggestion for knowl-
to clinical practice is essential to safe, transparent, effective and efficient healthcare edge dissemination and translation
to clinical nursing practice.
provision and meeting the expectations of patients, families and society. Despite its
• Methods to build knowledge
importance, translating research into clinical practice is challenging. There are more translation into study design and
nurses in the frontline of health care than any other healthcare profession. As such, conduct.
nurse-led research is increasingly recognised as a critical pathway to practical and • Knowledge translation is not a
effective ways of improving patient outcomes. However, there are well-established linear procedure and involves
barriers to the conduct and translation of research evidence into practice. many processes, systems and
interactions of the researcher and
Design. This clinical practice discussion paper interprets the knowledge transla-
knowledge users.
tion literature for clinicians interested in translating research into practice. • Implementing evidence by trans-
Methods. This paper is informed by the scientific literature around knowledge lating knowledge needs planning
translation, implementation science and clinician behaviour change, and presented and strategy that address the com-
from the nurse clinician perspective. We provide practical, evidence-informed sug- plexity of healthcare systems.
gestions to overcome the barriers and facilitate enablers of knowledge translation.
Examples of nurse-led research incorporating the principles of knowledge transla-
tion in their study design that have resulted in improvements in patient outcomes
are presented in conjunction with supporting evidence.
Conclusions. Translation should be considered in research design, including the
end users and an evaluation of the research implementation. The success of
research implementation in health care is dependent on clinician/consumer beha-
viour change and it is critical that implementation strategy includes this.

Authors: Kate Curtis, PhD, Ms, RN, Professor, Sydney Nursing School, Research Centre, Eastern Health, Deakin University Nursing, Box Hill,
University of Sydney, Camperdown, NSW; Trauma Service, St George Vic, Australia
Hospital, Kogarah, NSW; St George and Sutherland Clinical School, Correspondence: Kate Curtis, Professor, Sydney Nursing School,
University of New South Wales, St George Hospital, Kogarah, NSW; The University of Sydney, 88 Mallet St, Camperdown, NSW 2050,
Margaret Fry, PhD, MEd, RN, Professor, Northern Sydney Local Australia. Telephone: +61 2 9351 0604.
Health District, Royal North Shore Hospital Campus, St Leonards, E-mail: [email protected]
NSW; Faculty of Health, University of Technology Sydney, Ultimo, Twitter: @redtraumakate, @MargFry, @ramonshaban, @Julie_
NSW; Ramon Z Shaban, PhD, RN, FACN, Professor, School of Nurs- Considine
ing and Midwifery, Menzies Health Institute Queensland, Griffith
This is an open access article under the terms of the Creative Com-
University, Nathan, Qld; Department of Infection Control and Infec-
mons Attribution-NonCommercial-NoDerivs License, which per-
tious Diseases, Gold Coast University Hospital, Gold Coast Hospital
mits use and distribution in any medium, provided the original
and Health Service, Southport, Qld; Julie Considine, PhD, RN, FACN,
work is properly cited, the use is non-commercial and no modifica-
Professor, Centre for Quality and Patient Safety Research, School of
tions or adaptations are made.
Nursing and Midwifery, Deakin University, Burwood, Vic; Midwifery

© 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.
862 Journal of Clinical Nursing, 26, 862–872, doi: 10.1111/jocn.13586
Discursive paper Translating research to clinical nursing practice

Relevance to practice. Translating best research evidence can make for a more
transparent and sustainable healthcare service, to which nurses are central.

Key words: behaviour change, clinical practice, evidence based, evidence informed,
implementation science, knowledge translation, nursing, research, trauma

Accepted for publication: 11 September 2016

improvements in patient outcomes are provided. These

Background and aim
examples are supported by a discussion of the supporting
The importance of robust scholarly research for quality, theories and evidence to maximise the opportunities and
safe, effective and efficient care of patients and their fami- traction of the uptake of the evidence into practice.
lies is well established (Australian Commission on Safety
and Quality in Health Care 2009). Although research evi-
Discussion
dence is being produced at an increasing rate, change in
clinical practice to reflect this evidence has lagged behind
Disseminating research knowledge
(Kitson 2008, Benner et al. 2010). For example, in Aus-
tralia, clinician compliance with providing appropriate care Central to nurse-led research and knowledge translation is
for 22 conditions in large nationwide cross-sectional study dissemination. A research study is not complete until the
ranged from 32–86% (Runciman et al. 2012). In the United study findings have been disseminated via presentations at
States, it is reported that <20% of what physicians do has professional forums and published in a peer-reviewed jour-
solid research to support it (Kumar & Nash 2011). With nal and where appropriate recommendations regarding how
more nurses in the frontline of health care than any other the research findings could be translated into clinical prac-
healthcare profession, nurse-led research is increasingly tice are made. Research involves considerable intellectual,
recognised as a critical pathway to practical, effective and time and financial commitments by researchers, participants
cost-effective ways of reducing hospital errors, cutting and funding organisations. It is often conducted using pub-
down on unnecessary costs and improving patient outcomes lic funds under the guise of the common good. Conse-
(World Health Organization 2012). This practice paper quently, researchers are obliged and required to share the
aims to describe the importance of, and considerations for findings of their project with others, regardless of the
nurses to successfully disseminate and translate research results. Moreover, the World Health Organization (WHO),
into clinical practice. in its position on Interventional Clinical Trial Results,
states that it is unethical to conduct human research with-
out publication and dissemination of the results of that
Design and method
research, as withholding results may subject future volun-
This is a practice paper that interprets the knowledge trans- teers to unnecessary risk (Matosin et al. 2014). While there
lation literature for clinicians interested in conducting trans- is a clear bias towards publication of positive response
lational research and translating robust research evidence (Matosin et al. 2014), it is equally important to publish
into clinical practice. The discussion is informed by the sci- studies with negative or equivocal results for this reason.
entific literature around knowledge translation, implementa- Furthermore, the WHO states that clinical trial results be
tion science and clinician behaviour change, and presented submitted for publication in a peer-reviewed journal within
from the nurse clinician perspective. We discuss the impor- 12 months of study completion (Moorthy et al. 2015). For-
tance of disseminating research and explain the definition tunately, there are many opportunities for sharing new
and role of knowledge translation within the knowledge-to- knowledge, not only by writing for journals or books, but
action cycle. This is followed by practical, evidence- also by using social media, speaking at conferences and
informed suggestions to overcome the barriers and facilitate other events about the research outcomes. When planning
enablers of knowledge translation. Examples of nurse-led research, it is critical to consider prospectively how findings
research incorporating the principles of knowledge transla- will be disseminated and to be cognisant of this throughout
tion in their study design that have resulted in the research process.

© 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.
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K Curtis et al.

Successful dissemination and uptake of research evidence across nine different countries identified 29 different terms
requires identifying the appropriate audience and tailoring referring to knowledge translation (Graham et al. 2005). For
messages via appropriate mediums. When analysing study example, similar processes are called research utilisation in
data and interpreting the results, researchers must address the UK and Europe, research dissemination, diffusion or
the study aims and answer the research question(s) in view knowledge uptake in the USA, and knowledge translation
of the background research problem and its significance. and knowledge-to-action in Australia and Canada (Strauss &
The conduct of the research should also consider how the Corbin 1990, Graham et al. 2006). The Canadian Institute
study findings should or could influence clinical practice, of Heath Research (CIHR) definition of knowledge transla-
education, policy or future research. Such recommendations tion is widely accepted and commonly cited in healthcare lit-
should inform dissemination activities. Targeted dissemina- erature (Graham et al. 2006, Lang et al. 2007, Bjørk et al.
tion activities can include summaries for stakeholders, edu- 2013; Box 1). Knowledge translation is not simply a linear
cational sessions with clinicians and/or policymakers, procedure but involves many processes, systems and interac-
development and implementation of clinical guidelines and tions of the researcher and knowledge users. The level at
media engagement (Canadian Institutes of Health Research which these interactions take place varies depending on the
(CIHR) 2014; Table 1). At the heart of dissemination of situation and application of knowledge.
research findings is knowledge translation.

Can all research evidence be translated?

What is knowledge translation?
While all research should be disseminated, not all research
Knowledge translation is the process through which research is readily translatable. The design, applicability and
knowledge is created, circulated and adopted into clinical strength of the research should be assessed, and the evi-
practice. Synonymous terms are used by researchers around dence for translation determined to be relevant and
the world. A study involving 33 research funding agencies sound. This process is rarely simple, and the increasing
volume of research evidence being produced, access to
Table 1 Choosing dissemination forums for research findings new evidence, the skills to appraise the quality of the evi-
Study site: Provide summary of results to key stakeholders at dence, time to locate and read evidence, and the capacity
hospital level (such as nursing and midwifery executive, quality to apply evidence (Gravel et al. 2006) are some of the
unit or nursing education), at unit level for distribution to clinical major barriers to dissemination and translation. Strategies
staff, present research findings at meetings or education sessions.
to promote the use of research in practice by clinicians
Conference: Choose best audience for the work, how to get funding
to go to a conference (chose early bird rate, scholarships, industry continue to be devised as the complexity of the applica-
sponsorship, special purpose funds, build into research grant). tion of evidence into practice has been recognised. One
Journal: Choose best audience for the work, review table of strategy now commonly used is knowledge distillation,
contents for best fit, seek advice, resources for writing for that is the synthesis of findings from the most rigorous
publication. research available on a specific topic into systematic
Social media: For example, TwitterTM, LinkedInTM.
reviews and guidelines (Straus et al. 2009). The synthesis
Media: Local newspaper, media release, hospital public relations,
professional newsletters or magazines, research information can then be presented to clinicians as practice guidelines
dissemination organisations. or fact sheets (see, for instance, www.nhmrc.gov.au/guide-
Nursing organisations: Specific to the type of research, for example lines/titles_guidelines.htm or www.clinicalguidelines.gov.au
the College of Emergency Nursing Australasia or the Society of for two Australian organisations providing practice
Trauma Nurses.
guidelines, https://www.nice.org.uk/guidance in the UK,

Box 1. Definition of Knowledge Translation

‘knowledge translation (KT) is defined as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-
sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the
health care system.
This process takes place within a complex system of interactions between researchers and knowledge users which may vary in intensity,
complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge
user’ (Canadian Institutes of Health Research (CIHR) 2014).

© 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.
864 Journal of Clinical Nursing, 26, 862–872
Discursive paper Translating research to clinical nursing practice

Figure 1 Knowledge-to-action cycle (Graham et al. 2006).

http://www.ilcor.org/home/ for resuscitation, https:// context; (3) assess barriers to using the knowledge; (4) select,
www.cma.ca/En/Pages/clinical-practice-guidelines.aspx in tailor and implement interventions; (5) monitor knowledge
Canada). While sourcing sufficient evidence to base prac- use; (6) evaluate outcomes; and (7) sustain knowledge use.
tice on is an ongoing challenge, so too is identifying
established evidence and translating it into practice (Titler
Getting traction in knowledge translation
2008). The lapse between the publication of evidence and
its implementation into practice is referred to as an evi- Despite the importance of research knowledge translation,
dence–practice gap (National Institute of Clinical Studies barriers to understanding, conducting, and evaluating evi-
2003). Addressing this gap requires knowledge translation. dence impede nurses’ uptake of research at an individual,
unit and organisational level (Leasure et al. 2008). This was
confirmed in a survey conducted by the Emergency Nurses
Knowledge-to-action cycle
Association (ENA) in the United States (Chan et al. 2011).
Knowledge translation forms part of the knowledge-to- Nine hundred and seventy-eight ENA members completed a
action cycle (Fig. 1) (Graham et al. 2006). The knowledge- survey which assessed nurse’s involvement and uptake in
to-action cycle details the sequence and steps involved in research and perceived barriers to research. At an individual
achieving the transfer of research knowledge into clinical level, it was found that nurses lacked knowledge about
practice consisting of two phases. The initial creation phase appraising research preventing them from implementing
consists of synthesising knowledge as part of producing new research knowledge in their clinical practice. At a unit level,
tools, such as clinical guidelines in response to an identified barriers included lack of assistance from managers and col-
clinical problem. This step ensures knowledge is founded on leagues in beginning a project or having the authority to
the best available evidence prior to progressing to the action implement change. Insufficient time provided by the organi-
component, which is the process of implementing and evalu- sation was also found to be an impeding factor failing to pro-
ating new knowledge in clinical practice (Graham et al. vide nurses with the support and time required to conduct
2006). The action cycle comprises seven phases: (1) identify research and change practice (Chan et al. 2011). Other stud-
problem and relevant research; (2) adapt research to local ies have also identified that the attitudes and beliefs of nurses

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K Curtis et al.

as obstacles to research being translated into nursing practice Table 2 Key principles to building knowledge translation into
(MacDonald 2002, Brown & McCormack 2005, Davies research design
et al. 2007, Newhouse 2007). The process through which 1. Begin and plan with the end in mind
individual attitudes and beliefs are formed, interest of admin- 2. Produce evidence that is useful, not just interesting
3. Resource knowledge translation and exchange
istrators at a unit and organisational level must be addressed
4. Seek outcomes that will last
to promote research translation into clinical practice.
5. Involve end users throughout (Brand & Silburn 2014)

Enablers to knowledge translation

Table 3 Nurse-led translational research example 1: Improving the
There are many well-documented enablers of successful
emotional well-being of major trauma patients (Wiseman et al.
knowledge translation. Translation of findings should be 2015, 2016)
considered in initial study design and should be a major con-
Aims: To determine the incidence and predictors of depression,
sideration when developing the study aim(s). When planning anxiety and stress (precursors to PTSD) in major trauma patients
research, by prospectively thinking about how findings will to inform an evidence-informed programme for early intervention.
be translated to clinical practice, key considerations may be Background: Traumatic injury is a leading cause of psychological
what clinicians will need to change their behaviour and what and physical disability across all age groups, responsible for
10
7% of the global burden of disease. Trauma patients report a
resources the organisation will require to permanently main-
substantial reduction in health-related quality of life compared to
tain (sustain) the intervention. Further, it is essential to con- other patients. Despite the known associations between injury,
sider the ongoing monitoring and evaluation of the depression, anxiety, ASD and PTSD, prior to this project there
intervention to enable refinement and determination of was no known established routine screening tool for mental
impact (be that negative or positive). This process will ensure health outcomes in any Australian trauma centre. Further, there
that data will be collected as part of the research to inform was no established referral process for those who do report
symptoms of negative emotional responses after injury.
the implementation of the research findings if appropriate,
Methods: A 14-month mixed methods study was conducted with
for example times of day where problems occur or staff opin- 201 major trauma patients. Levels of depression, anxiety and/or
ion about the proposed intervention. If applying for funding stress symptoms were measured at baseline, three and six months
to conduct research, it is important to budget for implemen- using the DASS-21. Patients reporting high levels were
tation and evaluation of the proposed work. interviewed about their experiences and needs. Descriptive
statistics and thematic analysis results were integrated. Then, in
The success of any implementing practice change is heavily
collaboration with multiple disciplines (allied health, mental
reliant on senior clinician support (Bennetts et al. 2012), those health, trauma, GPs, nursing) and consumers, a sustainable, cost
that will be impacted by the intervention and those that will neutral screening, referral and improved discharge process for
be required to act on the intervention (the end users). It is criti- patients was implemented.
cal to involve end users throughout the research process. In Results: In total, 54% of patients experienced high levels of
our complex and multidisciplinary healthcare system, aside depression, anxiety and/or stress symptoms in the six months
following injury. Key qualitative findings were the extreme
from our patients, who are at the centre of care, those
negative emotional responses experienced many months after the
impacted are likely to include multiple services and medical injury, reluctance to seek emotional support and a lack of
specialties from outside of the instigating department. This emotional support provision by the health service. Since 2014,
could include the hospital switch board, pathology, radiology, more than 2000 trauma patients have been telephoned within a
allied health, as well as hospital executive. Some suggestions week of their discharge from hospital by the hospital trauma
nurses to enquire as to their physical and emotional well-being
for this multidisciplinary type implementation are establish-
and provide guidance. A total of 122 patients have been screened
ment of a working party of key stakeholders to develop a con- for symptoms of DAS when they return to the trauma clinic for
sensus plan to streamline successful implementation. This review. Patients reporting symptoms are referred to their GP,
process is likely to be facilitated if the instigator is an clinical psychologists and if actively suicidal to the site acute
employee or has close links with staff at the target site. The mental health team. Guidance is provided to all patients on
key principles around incorporating translation into research discharge on what to expect emotionally following injury and
where they can seek help should they experience this. This process
design are summarised in Table 2 and an example in Table 3.
is being monitored.
Conclusions: Translation of findings resulted in implementation of
an intervention that for the first time in Australia provides a clear
Barriers to knowledge translation
process for the screening and referral of the injured patient in
There are also many well-documented barriers to research need of mental health support.
translation. Multiple factors influence the uptake of

© 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.
866 Journal of Clinical Nursing, 26, 862–872
Discursive paper Translating research to clinical nursing practice

research into practice. It is challenging to introduce and investigate and address major contextual factors (e.g. social,
sustain evidence and evidence-informed protocols in the behavioural, economic, management) that hinder successful
context of competing priorities in health care. Despite high- implementation, test new approaches and determine causal
level recommendations to improve implementation of evi- relationships (Fogarty International Center 2013). The Con-
dence-based practice, implementation is variable. Numerous solidated Framework for Implementation Research (CFIR)
organisational and individual factors impact implementa- published in 2009 provides a pragmatic structure to pro-
tion and uptake, including clinician behaviour, lack of time, mote verification about what works where and why across
difficulties in developing evidence-based or informed guide- multiple contexts and includes five major domains: inter-
lines, a lack of continuing education and an unsupportive vention characteristics, outer setting, inner setting, charac-
organisational culture (Haynes & Haines 1998, Wallis teristics of the individuals involved and the process of
2012), the availability and dissemination of evidence, indi- implementation (Damschroder et al. 2009). This work pro-
vidual motivation and the culture of specific healthcare vides a foundation for researchers implementing and evalu-
practices (McKenna et al. 2004). Central to successful ating knowledge translation to build the implementation
implementation of research evidence into clinical practice is knowledge base across multiple settings (Damschroder
changing human behaviour. Any attempt to improve the et al. 2009). As with all research, and to truly validate the
quality of care for patients by translating research must CFIR and other research frameworks, descriptions must be
incorporate a clear understanding of the associated barriers precise enough to enable measurement and reproducibility
to, and facilitators of, behaviour change. Understanding (Proctor et al. 2013). When publishing research, researchers
these is also fundamental to the development of a feasible, should clearly explain how they justified the selection of
successful and sustainable implementation strategy. specific framework constructs, integrated the framework
throughout the research process (in study design, data col-
lection, and analysis) and link determinants of implementa-
Theories to inform knowledge translation
tion to outcomes to contribute to this emerging field of
A variety of models and theories have been developed in research (Kirk et al. 2016).
attempt to conceptualise the multifaceted process of knowl-
edge translation. The transformation learning theory devel-
Planning for implementation
oped by Mezirow (Mezirow 1978, 2000, 2004) assists the
process of knowledge translation through acknowledging Implementing evidence by translating knowledge needs plan-
the role and impact of attitudes and beliefs, which are con- ning and strategy that address the complexity of healthcare
stantly cited as barriers to research utilisation (MacDonald systems, individual practitioners, managers (Titler 2008) and
2002, Brown & McCormack 2005, Davies et al. 2007, strong organisational support and patronage (Bate et al.
Newhouse 2007). To successfully engage clinicians and 2008). There are multiple models available on which to
change their behaviours based on sound research knowl- develop and plan an implementation strategy (Schaffer et al.
edge, their attitudes and beliefs towards the proposed new 2013). Perhaps the most well known in health is the Promot-
knowledge must be learned, shaped and transformed (Mat- ing Action on Research Implementation in Health Services
thew-Maich et al. 2010). The clinicians existing thoughts Framework, or PARIHS Framework (Rycroft-Malone 2004),
and stances must be unlearned, and the new way of which is a conceptual framework that suggests fundamental
approach adopted. One such way to achieve this is to use and interrelating elements that influence effective implemen-
tools to design implementation interventions using the theo- tation of interventions. There is a need for this and other
retical domains framework (French et al. 2012) or the implementation models to undergo more robust evaluation
behaviour change wheel (Michie et al. 2011) discussed of their effectiveness in use in implementation projects (Hel-
below. Further, knowledge translation requires design and frich et al. 2010, Proctor et al. 2013).
implementation of interventions. Using a systematic four-step approach as the principal
framework to inform intervention development process is
ideal. The four steps consist of questions to direct the
Implementation science
choice of the most appropriate components of an imple-
Implementation is a science and can be encompassed within mentation intervention (French et al. 2012) and can be iter-
the normalisation process theory, which characterises atively adjusted and refined to suit other contexts. For
implementation as a social process of collective action example, the following steps recommended by French et al.
(May 2013). The intent of implementation science is to (2012) in conjunction with the theoretical domains

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K Curtis et al.

framework (Cane et al. 2012) have been evaluated as effec- the most likelihood of sustainable success are generally
tive. It is also practical and pragmatic: multimodal. To decide how to best to implement change
1 Who needs to do what, differently? depends on what you are trying to change. Changing beha-
2 Using a theoretical framework, which barriers and viour is not simple, but is most effective if interventions are
enablers need to be addressed? based on the principles of behaviour change, and knowing
3 Which intervention components (behaviour change tech- what it is exactly that you need to change. Three validated
niques and mode(s) of delivery) could overcome the mod- tools to use either in isolation or together are the theoreti-
ifiable barriers and enhance the enablers? cal domains framework (Cane et al. 2012), the behaviour
4 And how can behaviour change be measured and under- change wheel (Michie et al. 2011) and the behaviour
stood? change technique taxonomy (BCTT; Michie et al. 2013),
There are myriad templates available online to then guide which are the specific behaviour change techniques to use
the finer details of implementation plans, which all have in interventions focused on behaviour change.
common components. Many health services have a health Once it is determined who is going to need to change
redesign or implementation unit which may assist in the their behaviours, the theoretical domains framework (Cane
process, beginning by outlining the project purpose and jus- et al. 2012) helps you to consider each of possible influ-
tification (i.e. what will be used to introduce the plan to ences on behaviour in 14 domains including ‘knowledge’,
others). Many of these actions will have been made much ‘skills’, ‘beliefs about capabilities’, ‘optimism’, ‘beliefs about
smoother if the key stakeholders have been engaged in the consequences’, ‘reinforcement’, ‘intentions’, attention and
process. It is also important to conduct a stakeholder needs decision processes’, ‘environmental context and resources’,
analysis to identify the key stakeholders and their expecta- ‘social influences’ and ‘behavioural regulation’. For exam-
tions and needs with respect to the project outcomes. The ple, to determine what may need to be addressed to change
responsibilities for each person should then be established, clinician behaviour, a staff survey could be conducted with
alongside a communication strategy, and decisions on the questions mapped to each of the domains. For example,
interventions to be used to implement your evidence and ‘Do you think that the X protocol improves patient care?’
timeline (Centre for Healthcare Redesign 2014). would be mapped to ‘beliefs about consequences’. If the
majority of staff do not think that the protocol will deliver
improved care, they may not make it a priority to change
Implementation interventions to translate knowledge
their behaviour, and you now know that this is an area that
There is a vast array of intervention techniques available to you need to address. But how to do it?
translate research-based evidence into practice, for example The behaviour change wheel and the BCTT are linked to
visual cues (such as signs in the clinical area), audit, educa- the theoretical domains framework and will guide choice of
tional seminars, prompts, clinical guidelines, protocol and interventions and techniques. For example, to address
leadership involvement (Wuchner 2014). Interventions with beliefs about consequence, the interventions known to do

Table 4 Nurse-led translational research example 2 – Changing State-wide Stroke Practice: The QASC Implementation Project (Middleton
et al. 2011, 2015)
Background: The Quality in Acute Stroke Care (QASC) Trial (Middleton et al.) determined that a multidisciplinary supported, nurse-
initiated, evidence-based intervention involving supported implementation of clinical protocols to manage fever, hyperglycaemia and
swallowing (FeSS protocols) following stroke decreased death and dependency by 16% (p = 0
002); reduced temperatures (p = 0
001) and
glucose levels (p = 0
02); and improved swallowing management (p = <0
001). Yet, upscale and spread of even proven interventions on a
state-wide level is challenging.
Aim: To implement the FeSS protocols from the QASC Trial in all 36 stroke services in NSW, Australia.
Method: The 14-month translational project replicated the intervention from the original QASC Trial. The investigators conducted barrier and
enabler assessments and an educational workshop, engaged local opinion leaders, used reminders and provided ongoing site champion support.
Participating sites audited 40 pre- and 40 postimplementation medical records using the National Stroke Foundation clinical audit web-based tool.
Results: All (n = 36, 100%) sites participated in the medical record audit (100% response rate) providing data for a total of 2144 patients
(pre-implementation: n = 1062; postimplementation: n = 1082). Significantly increased proportions of patients received care according to
the fever (pre: 69%; post: 78%; p = 0
0031), hyperglycaemia (pre: 23%; post: 34%; p = 0
0085) and swallowing (pre: 42%; post: 51%;
p = 0
0331) protocols postimplementation.
Conclusion: These results provide rare evidence of successful research translation of Class 1 Level B evidence across an entire state in a
short time frame and in the real world of clinical practice.

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Discursive paper Translating research to clinical nursing practice

Table 5 Key knowledge translation terms

Evidence-practice gap: The lapse between the publication of evidence and its implementation into practice (National Institute of Clinical
Studies 2003).
Evidence informed: The term ‘evidence informed’ versus the term evidence based is slightly different and oft a topic of debate. The
difference between EB and EI is that EB is grounded in the demonstrated positive outcomes discovered through scientific research or
rigorous evaluation. EI on the other hand, are guided by research, evaluation and clinical expertise (Sawatzky-Dickson 2007, Canadian
Nurses Association 2010). Evidence informed is the term used by WHO http://www.who.int/evidence/about/en/. Until the evaluation of
guidelines implemented as a result of evidence occurs, evidence informed is the most appropriate term to use.
Basic research: ‘is performed without thought of practical ends. It results in general knowledge and an understanding of nature and its laws.
This general knowledge provides the means of answering a large number of important practical problems, though it may not give a
complete specific answer to any one of them. The function of applied research is to provide such complete answers’ (Bush 1945).
Clinical research: ‘Patient-oriented research. Research conducted with human subjects (or on material of human origin such as tissues,
specimens and cognitive phenomena) for which an investigator (or colleague) directly interacts with human subjects. Patient-oriented
research includes: (1) mechanisms of human disease, (2) therapeutic interventions, (3) clinical trials, or (4) development of new
technologies. Epidemiologic and behavioral studies, outcomes and health services research’ (National Institutes of Health 2001)
Translational research: ‘Translational research fosters the multidirectional integration of basic research, patient-oriented research, and population-
based research, with the long-term aim of improving the health of the public. T1 research expedites the movement between basic research and
patient-oriented research that leads to new or improved scientific understanding or standards of care. T2 research facilitates the movement
between patient-oriented research and population-based research that leads to better patient outcomes, the implementation of best practices, and
improved health status in communities. T3 research promotes interaction between laboratory-based research and population-based research to
stimulate a robust scientific understanding of human health and disease’ T4 Translation into the public sector (Rubio et al. 2010).
Dissemination: ‘A planned process that involves consideration of target audiences and the settings in which research findings are to be
received and, where appropriate, communicating and interacting with wider policy and health service audiences in ways that will facilitate
research uptake in decision-making processes and practice’ (Wilson et al. 2010).
Stakeholders: ‘persons or groups that have a vested interest in a clinical decision and the evidence that supports that decision. Stakeholders
may be patients, caregivers, clinicians, researchers, advocacy groups, professional societies, businesses, policymakers, or others. Each group
has a unique and valuable perspective’ (Agency for Healthcare Research and Quality 2014).
End users: ‘The ultimate consumer of a product, especially the one for whom the product has been designed’ (The American Heritage
Dictionary 2013).
Implementation science: ‘the scientific study of methods to promote the systematic uptake of research findings and other evidence-based
practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care’ (Eccles & Mittman 2006).
Behaviour Change interventions: ‘coordinated sets of activities designed to change specified behaviour patterns. In general, these behaviour
patterns are measured in terms of the prevalence or incidence of particular behaviours in specified populations (e.g., delivery of smoking
cessation advice by general practitioners). Interventions are used to promote uptake and optimal use of effective clinical services, and to
promote healthy lifestyles’ (Michie et al. 2011).

this are education, modelling and persuasion. There are evidence is applied in a given context, the resulting change
multiple ways to educate, model and persuade. The BCTT should be evaluated in terms of the outcomes, considering
provides a range to choose which would be suitable for the patients, consumers, clinicians and the organisation. It is
target site, staff and context. For example, a technique crucial to build implementation evaluation into study
known to be effective in persuasion is having a senior, well- design by ensuring collection of data that will be able to be
respected clinician repeatedly model the behaviour you used to determine how well the intervention has been
want the rest of the team to do. Using behaviour change adopted, For example, Do all staff comply with the intro-
techniques outlined in the BCTT also adds strength to your duced protocol all the time? If they do (or do not), Why
work because it means your work will be observable (peo- and what difference does this make? An example of this is
ple will know what you have done) and replicable. demonstrated in Table 4. A summary of key knowledge
translation terms is provided in Table 5.

Implementation evaluation
Conclusion
Research utilisation implies not only the implementation of
evidence into practice, but also the evaluation of conse- Translating best research evidence can make for a more
quent changes in practice (Jones 2000). It is no longer transparent and sustainable healthcare service, to which
acceptable to implement a change in clinical care and not nurses are central. More importantly, the translation of evi-
evaluate the impact of that change. That is, if the research dence can bring about cultural, behavioural and practice

© 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.
Journal of Clinical Nursing, 26, 862–872 869
K Curtis et al.

change reducing the research–practice gap. Through the Contributions

translation of evidence, patient safety and care responses
KC led the development, writing and preparation of the
can be recalibrated to optimise outcomes for patients and
manuscript. MF, RS and JC contributed, critically reviewed
staff. Strong evidence must be translated into practice.
and prepared the manuscript for publication.
Translation should be considered in research design, includ-
ing the end users and an evaluation of the research imple-
mentation. The success of research implementation in Funding
health care is dependent on clinician or consumer beha-
Professor Curtis was supported by an NHMRC Translation
viour change and it is critical that implementation strategy
of Research into Practice Fellowship (GNT 1067639).
includes this.

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