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Using Roger’s Model of the Diffusion of Innovations to test Research Utilization of
Cancer-related Fatigue Evidence by Oncology Nurses.
By
Lawrence J. Wilcox
Major Professor: Dr. Jean K. Brown
A dissertation submitted to
the Faculty of the Graduate School of the
University at Buffalo,
State University of New York
in partial fulfillment of the requirements for the
degree of
Doctor of Nursing Science
Department of Nursing
UMI Number: 3356130
Copyright 2009 by
Wilcox, Lawrence J.
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ACKNOWLEDGEMENTS
I want to thank all of the members of my dissertation committee. Each of them has
proven to skillful mentors who have provided thoughtful guidance. My dissertation Chair, Dr.
Jean Brown has been recognized nationally as a mentor to graduate students. I can testify
firsthand of her devotion to the professional development of nursing scientists and improving the
professional standing of the nursing profession. I have been inspired by your knowledge,
patience and encouragement. Your value to the nursing profession cannot be calculated, for
without your mentorship, I and many others would follow a more difficult path in their efforts.
For the future you set the bar high, if I am able to accomplish a fraction of your accomplishments
I will feel a sense of accomplishment, but continue with a dedication to further develop myself
professionally. Dr. Bill Wu is the consummate statistician, unparalleled in his statistical
knowledge, patient when explaining even the simplest of concepts. His love of his work and
thoughtful guidance demonstrate the important contributions he makes to further the
development of future scientists. Several times I would stop by unannounced, without an
appointment, and he was always willing to listen and suggest options or advice I never would
have thought of. His open door policy for me was always refreshing for it revealed his support
for my efforts and progress. To Dr. Kay Sackett, I was distressed at your departure from the
University at Buffalo. You were more than a mentor, you were someone I looked up to, but
more importantly could easily talk to. You not only offered encouragement you also offered
practical advice, when I would become frustrated, you focused my efforts. To Dr. Christine
Nelson and Dr. Nancy Wilk, I would be remiss failing to acknowledge your contributions to my
efforts. The program of doctoral education is a road that is less travelled, and it can be a lonely
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one. Few of my friends, co-workers, or family can really understand the inherent challenges
faced with a demanding program. As fellow students you, more than anyone else understand the
challenges, frustrations, intimidations and questions that are routinely faced by doctoral students.
Our frequent discussions allowed inevitability, calmness, as we progressed forward. Without
the “we’re in it together attitude” the two of you displayed and encouraged, success may not
have been achievable. I was thrilled with your successful defenses and wish both of you well
and again thank you. To my wife Anna goes all my unconditional love. Through 34 years of
marriage you have always stood by my side. I can truly say that without you I would not have
accomplished this life goal. To my sons Michael and Christopher I do this work for you. You
must always strive for something better, anyone can be comfortable, but the challenge is to
standout in what you do. I have always been proud of your accomplishments and hope that I
have been a good role model and father.
iii
Abstract
This manuscript style dissertation, which is entitled Using Roger’s Model of the
Diffusion of Innovations to test Research Utilization of Cancer-related Evidence by Oncology
Nurses, presents three interconnected manuscripts. Manuscript I discusses the systematic review
of the literature related to barriers to research utilization that have been demonstrated in the
nursing literature. Manuscript II presents the psychometric analysis of the Cancer-related
Knowledge and Use Instrument that was specifically developed to measure whether nurses have
obtained knowledge regarding CRF symptom management innovations that has been published
in the literature and use it in their practice. Manuscript III presents the methods, specific aims,
hypotheses, and findings of the study. The purpose of this investigation is to describe factors
associated with research utilization among nurses specializing in oncology and to describe the
diffusion of evidence-based innovations related to cancer-related fatigue (CRF) symptom
management among these nurses. The study had two primary aims: 1) Describe barriers and
facilitators of research utilization among nurses specializing in oncology; and 2) Describe the
diffusion of evidence-based innovations for CRF symptom management. Roger’s Theory of
Innovation Diffusion (1995) provided the theoretical framework for the evaluation of barriers.
The Oncology Nursing Society “Putting Evidence into Practice” guidelines (Mitchell, Beck,
Hood, Moore & Tanner, 2007) and the NCCN Cancer-related fatigue and anemia: Treatment
guidelines for patients, Version III (2005) provided the foundation for the development of the
CRF Knowledge and Use instrument. Participants for this study were selected from a random
sample of the ONS membership. The study achieved a 14% response rate (N=608). Data
analysis was conducted with SPSS version 16.0 of the eight research questions that were
developed for the study. Findings revealed that: 1) the top three barriers based on ranking of
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mean scores were, there is insufficient time on the job to implement new ideas (mean 3.10,
SD=1.00), the research has not been replicated (M=3.08), SD=1.46), the nurse does not have
time to read research (M=3.05, SD=0.96) and the research has methodological inadequacies
(means 3.05, 1.56); 2) top ranked sources used to update participants’ clinical practices included
the Clinical Journal of Oncology Nursing (66%), other information sources (66%), and the ONS
website (63%). The least utilized information source was the Cochrane Database (9%); 3) the
relationship between CRF knowledge and use scores with organizations that provided a research
facilitator or those nurses who reported having a research mentor found no significance; 4) there
were not significant relationship between demographic or professional characteristics on
knowledge or use of CRF innovations; 5) 13% of participants viewed the impact of regulatory
bodies on the use of current research findings positively, while 46% viewed the effect as
negative and 40% perceived no effect. The study found a significant relationship between
knowledge and those participants who viewed the impact of regulatory bodies negatively; 6)
59% of participants had the knowledge of CRF symptom management innovations that were
disseminated in ONS PEP and NCCN guidelines. Of that group, 76% used those innovations in
their clinical practice. 45% of all study participants knew and used those innovations in practice;
7) the Oncology Nursing Forum and the NCCN guidelines significantly predicted the knowledge
score of participants R2 = .034 , F= 1.728, ONF beta .097 p = .034, NCCN beta .132, p = .002
These values when all info sources ran, I can get better values when I regress each info source
individually on knowledge or use? ) and the NCCN guidelines significantly predicted the score
for use of innovations to manage CRF symptoms R2 = .059, F = 3.121, beta .163, p = <.001,
same thing as above here; 8) there was no relationship between knowledge or use scores and the
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four subscales of the Barriers Scale that measure constructs of Roger’s model of the diffusion of
innovations.
vi
Table of Contents
Acknowledgement…………………………………………………………………………...…...ii
Dissertation abstract…………………………………………………………………………..….iv
Manuscript
1 Innovation Diffusion and Barriers to the Translation of Research findings

into Nursing Practice: A systematic review.
Introduction to Manuscript I………………………………...…….1
Abstract………………………………………………...…….........3
Introduction…………………………………………...….………..5
Background………..……………………………………….……...5
Purpose of the paper.……………………………….……………...7
Systematic Review……………………………….………………..8
Theoretical Framework..……………………….…………….........8
Analysis of the Literature…...…………………………………….9
Stage 1. Knowledge Acquisition…………………………10
Stage 2. Persuasion ..…………………………………….12
Stage 3. Decision…..………………….……………...…13
Stage 4. Implementation……….……….……………….15
Stage 5. Confirmation…………..……………………….15
Discussion………………………………………………….…….16
Conclusions………………...…………………………….………18
References….…………………………………………………….19
vii
Table 1. Barrier Studies Analysis Rubric...…………....………...27
Table 2. Studies identified at Stage 1 – Knowledge………….…28
Table 3. Studies identified at Stage 2 – Persuasion…………..…31
Table 4. Studies identified at Stage 3 – Decision……………….32
Table 5. Studies identified at Stage 4 – Implementation………..34
II. Development of an Instrument to measure RN’s Knowledge and Use of

Research Evidence: The Cancer-Related Fatigue Knowledge & Use
Instrument.
Introduction to Manuscript II………………………………….…35
Abstract…………………………………………………………..37
Introduction………………………………………………………39
Purpose of the study……………………………………………...40
Methods…………………………………………………………..40
Design and setting………………………………………....40
Samples……………………………… ……………………41
Instrument development and testing procedures…………..41
Analysis……………………………………………………42
Results……………………………………………………..42
Discussion………………………………………………………..43
Conclusions………………………………………………………43
References…………………………………………...…………...45
Table 1. Selected CRF knowledge and use items for the
CRF knowledge and use instrument………………...…………...46
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Table 2. Item and overall test-retest correlations…………...…47
III. Knowledge and Use of Cancer-related fatigue research evidence by ONS RN’s
Introduction to Manuscript III……………………………..…..49
Abstract………………………………………………..……….52
Introduction…………………………………………………….54
Background…………………………………………………….54
Barriers to research utilization….…...…….…………....55
Knowledge and use of research innovations……….......57
Research gaps…………………………………………..58
Strategies for reducing the research gap…………….…58
Summary……………………………………………….59
Conceptual Framework……………………………..………….59
Purpose/Objectives………………………………….…………60
Aim 1: Describe barriers and facilitators of
research utilization among nurses specializing in
oncology……………………………………………….60
Aim 2. Describe the diffusion of evidence-based
innovations for CRF symptom management……….…61
Methods………………………………………………………62
Design and setting……………………………………..62
Sample…………………………………………………62
Measures……….……………………………….………63
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Procedures……………………………………..……….64
Analysis…………………………………………..…….64
Results………………………………………………………….65
Barriers and facilitators of research utilization
among nurses specializing in oncology………………..65
Information sources that oncology nurses use to
update their clinical practices…………………………..66
Facilitating research translation with a mentor or
facilitator………………………………………….……66
Demographic or professional characteristics
related to oncology nurses perceptions of barriers
to research use………………………………………….66
Perceptions of the effect of regulatory bodies
on research translation…………………………………67
Knowledge and Use of CRF symptom
management innovations……………………………67
Information sources predictive of utilization
of CRF symptom management innovations……………68
Extent to which Roger’s predicted diffusion
of CRF symptom management evidence knowledge
and use…………………………………………………68
Discussion……………………………………………………...68
Implications……………………………………………….……73
x
Research………………………………………………..73
Clinical…………………………………………………74
References………………………….…………………………..75
Table 1. Demographic and Professional Characteristics of
the sample…….………………………………………………...79
Table 2. Barriers scale items means and standard deviations…82
Table 3. Individual information sources as reported by
study participants………………………………………………83
Table 4. CRF Knowledge and Use………………….…………84
Table 5. Pearson correlationis for all information sources….…85
IV. Dissertation Synthesis and Discussion…………………………86
Appendices
A Institutional Review Board Approval………………………….89
B Cover letters – implied consent………………………………...94
C Reminder Postcard……………………………………………..96
D CRF Knowledge and Use Instrument……………..……………98
E Demographic and Professional Characteristics items...………102
F Barriers Scale…………………………………………………108
G Permission to use Copyrighted Material……………………...…112
xi
Introduction to Manuscript I
The purpose of Manuscript I, Innovation Diffusion and Barriers to the Translation of
Research findings into Nursing Practice: A systematic review, was to systematically review and
examine the scientific investigations into this field of nursing research. The review incorporated
Roger’s Theory of the Diffusion of Innovations and aimed to demonstrate from the literature the
state of the science regarding barriers to research utilization and knowledge diffusion.
Knowledge diffusion and ultimately nursing practice based on the research evidence is a critical
goal of the nursing profession. This systematic review provided an opportunity to examine the
barriers to research utilization, while at the same time providing the profession with knowledge
of where nurses are in the innovation diffusion process.
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Running head: INNOVATION DIFFUSION AND BARRIERS TO TRANSLATION
Innovation Diffusion and Barriers
to the Translation of Research findings into Nursing Practice:
A systematic review.
Lawrence J. Wilcox
University at Buffalo
Jean K. Brown
University of Buffalo
Yow-Wu Wu
Kay Sackett
Wake Forest University
Baptist Medical Center
2
Abstract
Introduction
Translation of research tested innovations to nursing practice continues to present a
major challenge to the profession.
Background
Studies evaluating barriers to the translation of research findings into practice
consistently demonstrated significant barriers to innovation diffusion into clinical nursing
practice.
Purpose of the paper
Evaluate through a systematic review, the progress made over several decades in the
translation of research findings into practice in the context of Roger's Theory of Innovation
Diffusion. This theory served as the theoretical framework for the Barriers Scale that has been
used extensively to evaluate the barriers to research translation.
Systematic Review
A review of research studies that investigated research utilization and related barriers was
conducted using several databases. Reference lists of selected articles were further evaluated to
enhance search results. Studies were limited to those in the English language.
Results of the Search
3
Multiple studies were identified that have utilized Roger's theory. Study findings were
evaluated according to the stages identified in Roger's theory. From this evaluation it can be
determined that most nurses remain at the first stage of knowledge diffusion, which is
knowledge acquisition.
Conclusion
Studies consistently demonstrated that there has been little change in the barriers to
adoption of new evidence-based innovations in clinical nursing practice. Future research should
focus on the diffusion of evidence-based innovations, diffusion and the role of perceived barriers
in the diffusion process.
4
Innovation Diffusion and Barriers to the Translation of Research findings into Nursing
Practice: A systematic review.
Introduction
The translation of research-tested innovations to nursing practice continues to be a major
challenge facing the nursing profession with many experts debating the severity of the research
to practice gap. This gap, which represents the time from dissemination of research findings
until their adoption into clinical practice, can take several years or decades with many arguing
adoption does not occur at all. The Institute of Medicine (2001) found that there is a widening
gap between research findings and their adoption into practice regardless of intensive efforts to
improve the translation of findings into evidence-based practice. According to Billings &
Kowalski (2006), the research-practice gap is not only real, but it results in diminished quality of
patient care and inefficient nursing practice. It also results in failure or excessive lag time in
incorporating current evidence into clinical practice and discontinuing ineffective practices.
Although a distinct body of knowledge is an attribute of any profession, nursing research is used
to legitimize nursing as a profession, form a foundation for nursing education, and must be used
as a basis for practice. However, only a modest number of practicing nurses use research
evidence as a basis for their practice (Mulhall, 1998). As a professional body, translation of
nursing research evidence must be a major goal to improve quality of patient care outcomes and
to demonstrate the effectiveness of nursing practice and our professional standing.
Background
In a presentation at the American Nursing Association’s 41st convention, Merton (1958)
maintained that a profession not rooted in systematic knowledge is a self-contradiction. More
than a decade later Abdellah (1970) found that a major gap in nursing was translating significant
5
research findings into practice and education. To demonstrate this point, Ketefian (1975) found
that out of 87 participants in a study, only one participant knew the correct placement time of an
oral thermometer, despite the fact this research finding had been widely disseminated in the
literature.
Because of the lack of adoption of research findings into clinical practice, efforts to
improve dissemination and adoption resulted in early projects aimed at improving research
utilization. According to Polit & Beck (2006), the Western Interstate Commission for Higher
Education (WICHE) Regional Program for Nursing Research Development and the Nursing
Child Assessment Satellite Training (NCAST) Project were among the earliest of the efforts to
increase nursing research and dissemination activities. Conduct and Utilization of Research in
Nursing (CURN) is one of the most well known early efforts to promote the use of evidence in
clinical practice (Horsley, Crane, Crabtree, & Wood, 1983). This project developed clinical
nursing protocols based on clinical research evidence and disseminated them to the hospitals that
participated as experimental sites. In the years since the development of these research
dissemination efforts, other researchers have also developed models designed to improve the
dissemination and adoption of research evidence into clinical practice (Watson, Bulechek, &
McCloskey, 1987; Stetler, 1994; Titler, et al, 1994; Goode & Piedalue, 1999; Rosswurm &
Larrabee, 1999; Watson & Foster, 2003).
In spite of these extensive efforts to improve research dissemination, the literature
continues to provide evidence that dissemination efforts have not achieved their goal. In an
evaluation of pain management interventions, Dufault & Willey-Lessne (1999) found that studies
continue to show that pain occurs in 60% to 90% of patients who seek health care, and most are
not receiving adequate pain relief despite our knowledge that well-managed pain results in better
6
recovery trajectories and fewer complications. Critically ill patients who require close
monitoring continue to have temperatures measured via tympanic, rectal, or axillary
measurements despite evidence that oral temperature measurements are more highly correlated
to core temperatures (Giuliano, 2003). In another example of the lack of diffusion, Billings &
Kowalski (2006) described four areas where there has been widespread dissemination in the
literature of nursing interventions designed to improve patient care and outcomes, but nurses
have yet to be persuaded to accept changes in practice supported by these research findings.
These interventions included: the use of chlorhexidine versus betadine for central line dressing
changes, utilizing pH testing to verify nasogastric tube placement, use of normal saline to flush
peripheral and central venous catheters as opposed to heparinization, and use of saline when
suctioning patients with artificial airways. In a final example, a large body of knowledge is
available on effective diabetes self-management interventions. Approximately 54% of people in
the US with type 2 diabetes have glycemic levels greater than current target levels, yet many
patients are not being taught research-supported self-management techniques (Clark, Fradkin,
Hiss, Lorenz, Vinicor, & Warren-Boulton, 2000).
There are now those who acknowledge that the body of research-based knowledge
generated by the profession is adequate. In order to effectively translate knowledge into practice,
our challenge is to identify what evidence practicing nurses know and use in practice. Then we
must determine factors and interventions that promote innovation diffusion and overcome the
barriers that have been identified in previous research studies.
Purpose of the Paper
This paper will review the progress made over the last few decades in the translation of
research into practice in the context of Roger’s Theory of Innovation Diffusion.

7
Systematic Review
Several bibliographical databases were selected for a systematic search. These databases
included CINHAL, MEDLINE, and Dissertation Abstracts. Then selected articles were hand
searched to determine whether other relevant studies could be identified. The search strategy
utilized subject headings, keywords and textwords including: research utilization, barriers,
barriers to research utilization, diffusion of innovations, innovation diffusion, knowledge
translation, research translation, nursing research, evidenced-based nursing. Only studies
published in English were selected. From the search, 43 studies that utilized the Barriers Scale or
other methods to describe barriers to research and the diffusion or translation of research findings
into clinical practice were identified. Each study was reviewed to ensure that the aim of the
study was to describe barriers to research utilization and/or the diffusion or translation of
research findings into practice. Studies that were selected for inclusion in the paper were then
evaluated based on Roger’s Theory of Innovation Diffusion to determine the stage in the
diffusion process for each selected study. Studies that were excluded included subpopulations
from a main study, those with student nurses, advance practice nurses or doctorally prepared
nurses as the primary participants in the study.
Theoretical Framework
Roger’s Theory of Innovation Diffusion (Rogers, 1995) proposes that adopters of an
innovation must traverse several stages before a new innovation is accepted and adopted.
Roger’s Theory of Innovation Diffusion (Figure 1) was developed in the context of an
agricultural setting. Rogers developed the theory to determine how new innovations are acquired
and utilized by their adopters so that he could bring innovations in agriculture practices to the
agricultural community. His study described the stages in the diffusion process demonstrating
8
how knowledge of a new agricultural practice is effectively diffused into and accepted by
agriculturally based cultures. His investigation found a significant gap between knowledge of an
important agricultural technology and its widespread adoption into practice. As an example, the
development of hybrid corn technology in 1928 allowed farmers to increase their yields by
approximately 20%; however, the innovation was shown to not be fully diffused and adopted
until the 1950’s (Rogers, 1995). Roger’s work led to the development of county-based
cooperative extension programs in the United States that disseminated agricultural innovations.
Figure 1. Roger’s Model of Innovation Diffusion.
Communication Channels
Knowledge-----Persuasion-----Decision------Implementation-----Confirmation
Characteristics Perceived Adoption Continued Adoption
of the Decision Characteristic of Discontinuance
Making Unit the Innovation Rejection Later Adoption
Continued Rejection
Source: Diffusion of Innovations 4th Edition

By Everett M. Rogers (F. 5-1, p 163). Copyright ©
1995 by Everett M. Rogers Copyright © 1962, 1971, 1983
by The Free Press, a Division of Simon & Schuster, Inc. Reprinted
with Permission of the publisher. All Rights reserved.
While nurse researchers have utilized Roger’s framework for their studies, few of them
have elucidated the stage of diffusion in their study aims or findings. Rather the emphasis has
been on barriers to research utilization probably because of a well developed measure of barriers.
Funk, Champagne, Weise, & Tornquist (1991) developed the BARRIERS Scale to evaluate
9
nurse’s perceptions to barriers that they encountered to research utilization. Subscales focused
on characteristics of the adopter, communication, research, and organization. These
characteristics are consistent with certain elements of Roger’s Theory of Innovation Diffusion,
and Roger’s framework served as the underpinning theoretical framework for the development of
the BARRIERS Scale. Since then many researchers have used this instrument in their
investigations of barriers to research utilization.
While other reviews of the research to practice gap have looked at the barriers to the use
of research findings in clinical practice, this review describes the progress, or lack thereof, of the
diffusion of nursing research evidence into practice based on studies focused on the research to
practice gap. Thus for each study in this review, the fit of Roger’s theoretical framework to the
study aims and findings was examined. Recognition of where nurses are in the diffusion process
based on Roger’s theory provides evidence of the progression of research utilization over time
and whether strategies employed to reduce the research to practice gap have been successful.
Analysis of Literature
The analysis that follows examines the aims and findings of the studies reviewed in the
context of the five stages of innovation diffusion according to Roger’s theory. Utilizing Roger’s
theory, studies that were identified through the literature search were reviewed to determine what
significant barriers had been discovered. Rank scores of Barriers instrument items or a
description of the barriers that were encountered were reviewed. A subjective determination by
the first author was made about whether the barriers that were identified were consistent with a
particular stage in Roger’s innovation diffusion process. The rubric in Table 1 demonstrates
examples of items used in this analysis process.
Stage 1: Acquisition of Knowledge. According to Roger’s (1995) the first stage

10
in the innovation-decision process begins with first knowledge of an innovation. He felt that
knowledge occurs when an individual is exposed to an innovation’s existence and gains some
understanding of how it functions and the potential benefits that may arise as a result of its
incorporation into individual schema. This means that an innovation applicable to the telemetry
unit may be useful to nurses practicing in this setting, but not to other nurses. Acquisition of
knowledge, it was argued, could be accomplished through several means including accidentally,
through communication channels, or from an active information seeker. It has been suggested
that knowledge acquisition could be a passive activity, or based on a perceived need by the
individual or organization.
Although Smolowitz and Murray (1997) found that adequate research applicable to
nursing practice was available, up to 75% of practicing nurses were not aware of its existence
(Carroll, Greenwoood, Lynch, Sullivan, Ready, & Fitzmaurice, 1997; Moch, Robie, Bauer,
Pederson, Bowe, & Shadick, 1997). LeMay, Mulhall, & Alexander, (1998) reported that their
nurse participants believed that research reports were not being disseminated appropriately with
Retsas & Nolan (1999) reporting that nurses did not know whether they could believe the results.
Many nurses reported that the research literature was unreadable or incomprehensible (Camiah,
1997; Lynn & Moore, 1997) and most nurses had difficulty understanding research jargon
(Dyson, 1997; Rutledge, Ropka, Greene, Nail, & Mooney, 1998). Moreover, Dunn, Crichton,
Roe, Seers, & Williams (1997) and McSherry (1997) found that nurses lacked the skills to
critically appraise research studies. Parahoo (2000) examined multiple issues related to
knowledge acquisition in a large study of 1368 nurses. Barriers reported supported previous
findings and expanded understanding. Barriers included incomprehensible results related to
statistical analysis, lack of confidence in translating or critically appraising research findings, and
11
organizational issues. More recent studies continue to demonstrate that research presentation and
comprehension are significant barriers to knowledge acquisition (Clifford & Murray, 2001;
Oranta, Routasalo, & Hupli, 2002; McCaughan, Thompson, Cullum, Sheldon, & Thompson,
2002; Briggs, Paley, Cash, & Closs, 2004; Brenner, 2005).
The lack of time to read research is another potential barrier to knowledge acquisition.
Multiple studies have shown that this barrier can be a significant factor (Lewis, Prowant,
Cooper, & Bonner, 1998; McCleary & Brown, 2003; Hutchinson & Johnston, 2004; Thompson,
McCaughan, Cullum, Sheldton, & Raynor, 2005). Several researchers reported that research
reports were not readily available or that nurses were not aware of the research (Champion &
Leach, 1989; Kajermo, Nordstrom, Krusebrant, & Bjorvell, 1998; Kajermo, Nordstrom,
Krusebrant, & Bjorvell, 2000; Patiraki, et al, 2004; Baernholdt, 2005; Fink, et al, 2005).
Of reviewed studies 26 of 43 selected studies focused on the knowledge stage of Roger’s
theory (Table 2) and found that nurses generally were entering the first stage of Roger’s model,
knowledge acquisition. In general the studies reviewed demonstrated considerable agreement
regarding the barriers to and facilitators of nursing knowledge acquisition. However, the order
of importance of various barriers and facilitators varied across studies.
Stage 2: Persuasion. Based on the knowledge obtained initially, Rogers hypothesized
that the individual would form a favorable or unfavorable attitude toward the innovation. This
process of persuasion could be affected by perception of certain characteristics of the innovation
such as (a) relative advantages; (b) compatibility with existing knowledge; (c) complexity, or
how difficult it is to assimilate or understand the innovation; (d) trialability, the ability of the
individual to utilize the innovation; and (e) observability of the innovation to the potential
12
adopter. Barriers to the acceptance of a new innovation could range from the characteristics of
the individual nurse to the characteristics of the organization or institutional administration and
the effect those characteristics have on the various issues of persuasion. For example, individual
nurses may feel secure in their practice and not be easily persuaded to change their nursing
practice based on new research findings.
Pettengill, Gillies, & Clark, (1994) found in their study that nurse participants were
reading and sharing information from research studies, while Hundley et al, (2000) attempted to
increase research awareness through an intervention. While nurses in these groups may have
obtained knowledge of new innovations, awareness did not necessarily translate into using
research findings in clinical practice, suggesting that these nurses may have obtained research
knowledge but not be persuaded to utilize the research findings. Barta (1995) found that changes
in clinical practice were being incorporated into an educational program. Gerrish (2005) more
recently found that nurses were well versed at accessing and reviewing research evidence, but
most nurses relied heavily on interactions with colleagues and medical staff to change their
clinical practice. Thus 4 of the 43 studies that were reviewed found that nurses had obtained
knowledge of new innovations but results did not demonstrate a decision to incorporate them
into clinical practice suggesting that these nurses were in the persuasion stage of Roger’s theory.
Stage 3: Decision. In Roger’s decision stage, the individual would engage in various
activities that would lead to a choice to either accept the innovation or reject it. Rogers felt that
the adopter might make an initial acceptance or rejection of the innovation that could be reversed
at some point in the future because of changes in how the innovation is perceived.
Discontinuance may result because of replacement by a better innovation or disenchantment with
the original innovation. Each of the elements of the innovation-decision process can bring about
13
a subsequent acceptance or rejection of the new innovation. Through this process, individual
nurses may utilize a new concept in practice and because of this process decide that there are
benefits to be achieved through the use of the new innovation. These benefits may be in the
form of improved patient outcomes such as decreased pain levels, shorter hospital stays, or
improved self-perception. Additional benefits may accrue to the nurse such as efficiencies in
workflow and improved professional identity. The organizational benefit may be to conserve or
better utilize nursing staff and other nursing resources or in improvements in a provider’s
healthcare reputation.
When organizational issues are identified as significant barriers, it suggests that nurses
may have obtained knowledge of new innovations but are prevented from using them in clinical
practice. Four studies (Greene, 1997; Retsas, 2000; Hommelstad & Ruland, 2004; Karkos &
Peters, 2006) indicated that organizational factors were the top three barriers to innovation
diffusion, this suggests that nurses had knowledge but organizational barriers prohibited them
from using research innovations in practice. In the seminal study by Funk, Champagne, Wiese, &
Tornquist (1991) eight of the top ten barriers identified were related to the setting or organization
including not enough authority to change practice followed by lack of support from
administration/physicians to change practice. These barriers seem to indicate that even if nurses
had acquired the knowledge to change their clinical practices they would be unable to do so.
Several studies demonstrated that the organizational barriers of lack of authority and time on the
job to implement new ideas were important impediments of knowledge translation to clinical
practice (Nolan, Morgan, Curran, Clayton, Gerrish, & Parker, 1997; Walsh, 1997; Closs &
Bryar, 2001; Sommer, 2003; Glacken & Chaney, 2004; Ashley, 2005). In addition to a lack of
time to implement new ideas Marsh, Nolan, & Hopkins (2001) found that inadequate facilities
14
were a major barrier. In these studies nurses may have acquired knowledge of new innovations
and made a decision to adopt those innovations but setting or other organizational barriers
prevent their adoption. 13 of the 43 reviewed studies appeared to focus on the decision stage of
Roger’s theory (Table 3) and found that nurses in those studies may have progressed through the
knowledge acquisition and persuasion stages but still had significant barriers to using an
innovation.
Stage 4: Implementation. According to Rogers, this stage of the innovation decision
process begins with the initial use of an innovation by the adopter. Rogers felt that this was an
important step because earlier processes were all mental. In implementation the adopter actually
uses the innovation rather than thinks about its use. Thus, the adopter is able to effectively begin
an analysis of how the innovation actually works for them. Uncertainty remains even though a
decision has been made to implement the innovation. In this stage, the adopter may recognize
benefits or problems with the innovation and may re-invent the innovation to better
accommodate the working environment and facilitate confirmation of the innovation. Nurses
may actually change their clinical practices but need to modify the innovation based on actual
clinical responses to the change in practice.
Of the studies that were reviewed, only one study by Adamsen, Larsen, Bjerregaard, &
Madsen (2003), a Danish study, found that nurses involved in the conduct of research had higher
levels of implementation of research supported evidence in clinical practice (Table 5).
Stage 5: Confirmation. Roger’s predicted that the adopter will seek confirmation and
reinforcement of their decision to adopt the innovation. At this stage there is continual
information seeking by which individuals attempt to reinforce their decision regarding adoption
15
of the innovation. This occurs as an ongoing process with conflicting messages from the social
system either supporting or rejecting the innovation adoption. Confirmation can be supported if
those within the social structure begin to accept the new innovation. Rejection by members of
the social system can bring about a subsequent rethinking of the innovation by the individual that
results in a new decision to reject the innovation as described in the decision process. Through
this process, individual nurses may share their experiences of the new innovation with other
members of the social system who in turn share their experiences with the innovation to help
confirm or reject acceptance of the innovation. None of the studies that were reviewed addressed
the confirmation stage of Roger’s theory.
Discussion
This review demonstrates that many of the nurses in these studies appeared to be at the
knowledge stage of the innovation decision process with many nurses appearing to not have
obtained knowledge of innovations at all. In fact only one study (Adamsen, et al, 2003)
described nurses as at the implementation stage who were actively working to utilize research
findings in practice. The review also demonstrated that the research to practice gap appears to
have changed little over two decades. Ketefian (1975) demonstrated low rates of innovation
adoption, similarly, Green (1997) demonstrated a 9% diffusion rate of pain management
guidelines. Thus it may be argued that there has been little progress in overcoming perceived
barriers that have been identified in the literature.
A major limitation of earlier studies has been their failure to describe the stage in the
innovation diffusion process of their participants. For decades, nursing science has focused on
the barriers to translating research supported nursing interventions into clinical practice using the
Barriers scale. These studies have provided us with information on what barriers nurses perceive
16
as significant with multiple studies indicating remarkable consistency on the perceived barriers.
However, the Barriers scale, as an outcome measure, is limited because it measures self-reported
barriers at the exclusion of examining where nurses are in the innovation diffusion process.
Also, the Barriers scale only measures perceived barriers not actual barriers that prevent
innovations from being diffused into practice. Thus although we have consistent agreement on
perceived barriers, our knowledge of progress of innovation diffusion, an essential aspect of
translating evidence into practice, is limited. The focus on perceived barriers has been at the
exclusion of examining where nurses are in the diffusion process and what they actually know as
well as determining what interventions are successful in translating research findings into clinical
practice. We must determine whether the perceived barriers that have been identified are related
to stages of innovation diffusion. Moreover, we need to determine whether nurses have actually
obtained knowledge of new innovations and use it in their nursing practice. So future studies
should examine these issues.
By applying Roger’s theory to studies that have or may be conducted, the nursing
profession becomes better positioned to develop interventions associated with research
dissemination. We must direct our attention beyond barriers if we are to move nurses further
along in the innovation diffusion process and move evidence into practice. Specifically we need
to determine nurse’s knowledge and utilization of selected evidence-based interventions and
examine how knowledge and its utilization are correlated with perceived barriers to the
translation of research into practice. Future research should also describe the innovation
diffusion process, facilitators of diffusion, and where nurses are in the diffusion process.
Interventions need to be developed and tested that facilitate each stage of the diffusion process.
Interventions should also aim to educate nurses to be research consumers and to foster
17
innovation diffusion. Ultimately improved translation of research innovations will improve
patient outcomes and foster professional development and professional identity.
This review has several limitations. It is a subjective analysis of the application of
Roger’s Theory of Innovation Diffusion. Moreover, the studies reviewed were conducted over
nearly 20 years in a variety of settings and countries. Thus, the educational preparation, role,
practice, and culture of nurse participants are diverse.
Conclusions
Studies reviewed demonstrated that many of the major barriers to translating research
evidence into practice appear to exist at the knowledge acquisition level and therefore
significantly affect the research to practice gap. Perceived barriers to research use have been
reported for many years, and there is consistent agreement concerning what are the most
significant barriers. Future studies should focus on describing the innovation diffusion process
and what interventions facilitate translation of research into practice. This review provides
another point of view of the utilization of research and hopefully will encourage researchers to
move forward in addressing issues related to the research to practice gap. Barriers to translation
of research findings into evidence-based nursing practice have been studied extensively. We
must now move forward and determine how to minimize the research to practice gap.
18
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26
Table 1 Barrier Studies Analysis Rubric.
Stage of Roger’s Theory Sample Research Findings
Knowledge • Lack of time to read research
• Research not available
• Analyses not understandable
• Unawareness of research findings
Persuasion • Collaboration or sharing of information
• Benefits of changing practice are minimal
• Does not see the value of research for practice
Decision • Lack of time to implement innovations
• Lack of authority to change procedures
• Staff not supportive of implementation
Implementation • Descriptions indicating innovation use in practice
Confirmation • Descriptions indicating active application of innovations
27
Table 2. Studies identified at Stage 1 – Knowledge Roger’s Innovation Diffusion Theory.
Citation Findings
Champion, & Leach, Mean score of research availability was the lowest of the barriers
(1989). examined. This finding suggests that the study subjects found the
most significant barrier was having the knowledge available for
their use.
Camiah, (1997). Found that nurses viewed research reports as incomprehensible and
unreadable. Because of this nurses were not acquiring knowledge
of research evidence and therefore could not move to next stage of
innovation-decision process.
Carroll, Greenwood, Found that 75% of the sample was not aware of the existence of
Lynch, Sullivan, research findings. According to the innovation-diffusion process,
Ready, & Fitzmaurice, these nurses would be viewed at the level of knowledge acquisition.
(1997).
Dunn, Crichton, Roe, Found that many participating nurses felt they did not have the skills
Seers, & Williams, or confidence to find and critically evaluate research evidence. This
(1997). suggested that these nurses lacked knowledge of research finding to
incorporate into their practices. Thus they were at the initial phase
of Roger’s theoretical model.
Dyson, (1997). Determined that most nurses do not understand the “jargon” of
nursing research, so were unable to acquire knowledge.
Lynn, & Moore, Very small study of nurse managers that found comprehension and
(1997). accessibility were major barriers indicating that these managers had
difficulty acquiring knowledge to change clinical practice.
McSherry, (1997). Found that nurses were receptive to research use because of an
emphasis on research use. However, most nurses reported a lack of
skill to critically evaluate research, which limited their knowledge
acquisition.
Moch, Robie, Bauer, Case studies where investigators found remarks such as
Pederson, Bowe, & “practitioners are not reading what researchers have out there” or
Shadick, (1997). “manuscripts are too abstract and not understandable for practicing
nurses”. Findings were consistent with the initial knowledge stage
related to obtaining the necessary knowledge.
Kajermo, Nordstrom, Top ranked perceived barriers was that research reports were not
Krusebrant, & Bjorvell, readily available. This finding suggests that there was a lack of
(1998). knowledge among these nurses.
LeMay, Mulhall, & Participants felt that research results were not being disseminated
Alexander, (1998). and many nurses were unclear of research findings. This suggests a
low level of knowledge by these participants.
Lewis, Prowant, Major barriers that were identified included a lack of time to read
Cooper, Bonner, research and not being aware of research findings. This suggests
28
(1998). nurses had not acquired the knowledge to change clinical practice.
Rutledge, Ropka,
Greene, Nail, & Ranked among the top barriers responses were a lack of
Mooney, (1998). understanding of statistical analysis of research reports, awareness
of the research itself, and confidence in evaluating the quality of the
research. While there were other highly ranked barriers these
findings lend support that this group of nurses lacked the knowledge
of research innovations.
Retsas, & Nolan, Found that nurses had difficulty with accessing the research
(1999). literature and did not believe results were justified. This seems to
indicate nurses did not have knowledge but believability issue may
suggest persuasion stage.
Kajermo, Nordstrom, Greatest barriers were that research reports/articles were not readily
Krusebrant, & Bjorvell, available. Finding suggests a lack of knowledge acquisition by
(2000). these nurses.
Parahoo, (2000). Evidence indicated that statistical analyses were not understandable
and a lack of confidence in interpretation indicating progression to
the knowledge stage of Roger’s theory.
Clifford, Murray, The authors found a lack of knowledge of research findings and an
(2001). inability to comprehend the literature were the barriers of
importance. Findings suggest nurses were not acquiring knowledge
to change clinical practice.
McCaughan, Study established four barriers to research information use. Barrier
Thompson, Cullum, accounting for most of the variance was related to confidence and
Sheldon, & Thompson, products of research, e.g. the products of research were overly
(2002). complex; confidence was lacking in understanding. These
descriptions seems to indicate that this sample of nurses was at the
knowledge stage of the innovation diffusion process, knowing
information was available but they were not able to adequately
access the research findings to promote the use of this knowledge in
practice.
McCleary, & Brown, Highly ranked barriers identified included not enough time to read
(2003). research, research not complied in one place and statistical analysis
is not understandable. These perceived barriers suggest nurses were
not acquiring the knowledge to change their clinical practice.
Briggs, Paley, Cash, & Lack of comprehension and awareness of available research were
Closs, (2004). identified as the most significant barriers. Nurses in this study
appear to lack knowledge of research supported innovations.
Hutchinson, & Among the top barriers were not enough time to read research and
Johnston, (2004). that the nurse is not aware of the research. These findings suggested
nurses lack the knowledge necessary to change nursing practice.
Patiraki,Karlou, Top barriers included research reports not readily available or not
Papandopoulou, complied in one place. Perceived barriers demonstrate Greek nurses
Spyridou, did not have the knowledge of research supported innovations.
29
Kouloukoura, Bare, &
Merkouris, (2004).
Baernholdt,(2005). Study of chief nursing officers in 100 countries demonstrated that
Doctoral Dissertation. accessibility and awareness of research were major barriers
University of indicating that nurses worldwide may not have the knowledge
Pennsylvania. required to change clinical practice.
Brenner, (2005). Found that nurses have difficulty with how research findings were
presented. This lack of research skills prevents the translation of
knowledge.
Fink, Thompson, & Highest ranked barriers included being unaware of the research, lack
Bonnes, (2005). of time to read research and a lack of authority. These barriers
suggest that nurses had not acquired knowledge of new
interventions.
Thompson, Three site case study design involving Q methodology designed to
McCaughan, Cullum, collect reported and observed behaviors. Perceived lack of time for
Sheldon, & information-seeking and use was a contextual backdrop for major
Raynor, (2005). themes. Found nurses lacked information handling skills and that
summaries may help with dissemination. Appears this group had not
attained the knowledge level based on the description of the major
barriers for this group.
Oranta, Routasalo, & Found that one of the most significant barriers was the difficulty of
Hupli, (2002). understanding statistical analyses and that the reporting itself is
unclear and difficult to read. Since many of the published reports
were in a language foreign to these nurses acquiring the knowledge
was a major challenge for this group of nurses.
30
Table 3. Studies identified at Stage 2 - Persuasion Roger’s Innovation Diffusion Theory.
Citation Findings
Barta, (1995). Found that pediatric nurse educators were at the level of persuasion
and implementation when researchers looked at research findings that
they were incorporating into their BSN programs.
Hundley, Milne, Found that the level of research awareness at a mean level of 42/65.
Leighton-Beck, Graham, This finding suggested that nurses were aware of some of the
& Fitzmaurice, (2000). research that was available. With the knowledge of available
research these nurses could be at the persuasion stage of the
innovation-decision process.
Gerrish, & Clayton, Found that nurses tended to draw upon experiential knowledge
(2004). acquired through patients and colleagues. Thus these nurses appear
to be in a persuasion stage, discussing certain innovations and
whether they should be implemented.
31
Table 4. Studies identified at Stage 3 – Decision Roger’s Innovation Diffusion Theory.
Citation Findings
Pettengill, Investigators found that in this sample most nurses were reading and
Gillies, & Clark, sharing information about research findings. They felt that this was
(1994). consistent with Roger’s decision process.
Retsas, (2000). This study ranked the top three barriers as related to the organization or
setting. While a top barrier was related to statistical analysis that are
not understandable, the findings in general suggest that nurses have the
knowledge of research findings since they are identifying other barrier
issues to using these research findings in practice.
Funk, Champagne, This major study identified the characteristics of the setting as the most
Weise, & Tornquist, significant barrier to the use of research findings in practice. Eight of
(1991). the top ten barriers identified were related to the setting including, not
enough authority to change practice followed by lack of support from
administration/physicians to change practice. Identifying these barriers
lends support to the conclusion that this group of nurses may have
acquired the knowledge and perhaps the desire to implement new
innovations to practice. Because of this it appears that this group of
nurses was at Roger's Decision stage in the innovation diffusion
process.
Walsh, (1997). Study found that lack of cooperation; authority and time on the job to
implement new ideas were the significant barriers. Findings suggest
these nurses may have knowledge to apply in clinical practice.
Closs, & Bryar, Found that lack of time to implement, lack of cooperation and authority
(2001). as highest barriers suggesting knowledge acquisition had occurred but
nurses were experiencing other barriers to research utilization.
Marsh, Nolan, & Appears organization barriers, including lack of time on the job to
Hopkins, (2001). implement new ideas and inadequate facilities to implement findings.
These findings suggest knowledge acquisition had been achieved.
Glacken, & Major barriers that were found include lack of authority and time to
Chaney, (2004). implement new ideas. From this information it appears that nurses may
have had knowledge but lack authority and time to implement them and
were the issues preventing utilization.
Sommer, (2003). Significant barriers included lack of time to implement new ideas, lack
of authority to bring about change, time to read research. These
findings suggest nurses may have had new knowledge to apply but
organizational barriers prevent their incorporation into practice.
Hommelstad, & Two of top three barriers were organizationally based. These included
Ruland, (2004). lack of time to implement new ideas and lack of cooperation from
physicians demonstrating nurses may have had knowledge to apply but
these perceived barriers prevent their use.
32
Ashley, (2005). Critical care nurses barriers demonstrate they may have had knowledge
but perceive they lack the authority, time on the job to implement new
ideas and a lack of support from staff to implement them.
Karkos, & Peters, The setting domain was found to be the greatest barrier for nurses. Four
(2006). of the top 5 barriers related to the setting, suggesting that nurses may
have obtained knowledge to apply in clinical practice.
Nolan, Morgan, Findings suggest nurses may have obtained knowledge to apply in
Curran, Clayton, practice but lack time, resources and authority to implement new
Gerrish, & Parker, innovations.
(1997).
Greene, (1997). Barriers measured in this study were viewed by the nurses as having
little or no effect on their adoption of innovations. Lack of time and
cooperation of physicians and administrators constrained their authority
and effectiveness in changing pain management practice.
33
Table 5. Studies identified at Stage 4 – Implementation Roger’s Innovation Diffusion Theory.
Citation Findings
Adamsen, Larsen, Found that nurses in clinical practice having developed a research
Bjerregaard, & proposal had higher levels of research use as compared to nurses not
Madsen (2003). having developed a research project. The research active nurses
demonstrated a higher level of research use and were implementing
more research supported evidence.
34
Introduction to Manuscript II
The purpose of Manuscript II, was to develop and test an instrument to measure the
extent to which evidence-based innovations related to managing cancer-related fatigue symptoms
were known by Oncology Nursing Society (ONS) RN’s and adopted in their clinical practice.
Knowledge diffusion or translation is an important issue for the nursing profession that has had
multiple barriers examined in the literature. The Barriers Scale, an instrument designed by Funk,
Champagne, Weise and Tornquist (1991) has been used extensively since it development to
examine barriers to research utilization. However, few studies have examined whether nurses
have the knowledge of research evidence and whether that evidence is used in clinical practice.
Studies such as those by Beitz, Fey, & O’Brien (1999), Greene, (1997), Dufault & Willey-
Lessne (1999), Ketefian (1975) show the there is a significant research to practice gap. Nurses in
those studies demonstrated low rates of knowledge and use of research evidence. Only the
Green (1997) evaluated the impact of the perceived barriers on knowledge and use of research
evidence, finding no relationship existed. The development of the CRF Knowledge and Use
Instrument which, was shown through psychometric analysis to be both content valid and a
reliable instrument, allowed a larger investigation diffusion of innovation, perceived barriers and
the relationship among several variables.
35
Running head: CANCER-RELATED FATIGUE INTERVENTIONS: KNOWLEDGE AND
USE
Development of an Instrument to measure RN’s Knowledge and Use of Research Evidence:

The Cancer-Related Fatigue Knowledge & Use Instrument
Lawrence J. Wilcox
Jean K. Brown
Yow-Wu Wu
Kay Sackett
Grant funding: ONS Foundation, through an unrestricted grant from Genentech
BioOncology.
Mark Diamond Research Fund, University at Buffalo.
Gamma Kappa Chapter, Sigma Theta Tau International.
36
Abstract
Introduction
There are few studies in the literature that quantify nurses’ knowledge level of research
findings that have been disseminated in the literature. Studies that have been conducted
primarily have focused on barriers to research use at the exclusion of determining what research
innovations are known and used by nurses in their clinical practice.
Purpose of this study
The purpose of this study was to develop and test an instrument to measure the extent to
which evidence-based innovations related to managing cancer-related fatigue symptoms were
known by Oncology Nursing Society (ONS) RN’s and adopted in their clinical practice.
Methods
Design and setting. The study evaluated the psychometric properties of the Cancer-
Related Fatigue (CRF) Knowledge and Use instrument among oncology nurses working in an
oncology setting.
Samples. Three unique samples were utilized to determine clarity of the instrument,
content validity and test-retest reliability. A group of five graduate students reviewed the
instrument for clarity; a panel of five experts in cancer-related fatigue evaluated the instrument
for content validity. A nationwide random sample of 400 ONS RN’s were mailed study
documents and resulted in a 23% response rate.
Instrument development and testing procedures. The instrument was developed to
measure whether oncology nurses have obtained knowledge of CRF symptom management
innovations that have been widely disseminated in the literature. The instrument was reviewed
for clarity by a group of 5 graduate students. Content validity was determined by majority
37
agreement among a group of five experts, and test-retest reliability was done over a two week
period among a group of 400 registered nurses who are members of the ONS. Scantron scoring
forms were used to create an electronic data file to increase accuracy of data entry with a 10%
random check of the file to original documents.
Analysis. Clarity was determined by a review of the instrument instructions and items.
Content validity was determined by the content validity index. Test-retest reliability was
analyzed by Pearson’s correlation.
Results. The clarity review found no revision necessary to the instrument. The content
validity index was 0.91, and test-retest reliability was r = 0.83.
Conclusions
The results of this study demonstrated adequate clarity, content validity, and test-retest
reliability for the CRF instrument, which supports its use in this population. Determining what
research innovations nurses know and use in their clinical practice is an important step toward
improving the translation of research into clinical nursing practice.
38
Development of an Instrument to measure RN’s Knowledge and Use of Research Evidence:
The Cancer-Related Fatigue Knowledge & Use Instrument
Few studies have examined evidenced-based knowledge and use of interventions in
clinical practice in part because of a lack of valid measurement tools. Ketefian (1975) found that
1 in 86 knew the correct placement time for an oral thermometer despite widespread
dissemination of that information in the nursing literature using an innovation specific measure
developed specifically for the study. While the author took steps to assure instrument clarity
with a small group of nurses, there was no evidence of psychometric evaluation of the
instrument. Greene (1997) examined perceived barriers and their relationship with oncology
office nurses knowledge of pain management guidelines and whether these nurses used the
guidelines in their clinical practice setting. This author provided appropriate evidence that the
instrument used to measure knowledge of pain management guidelines was content valid but did
not evaluate the instrument for reliability. In Greene’s study, perceived barriers scores had no
relationship with either the knowledge of the pain management guidelines or of their use in
clinical practice. Consistent with other studies, she found that knowledge of the practice
guidelines was very low, with 9% of nurses having knowledge of these evidence-based
innovations to manage pain in cancer patients. Likewise, Dufault & Willey-Lessne (1999)
evaluated a collaborative research utilization model testing the effects of clinical pathways for
pain management. They reported that 60% to 90% of patients who seek health care are in pain,
and most are not receiving adequate pain relief despite widespread dissemination of knowledge
that well-managed pain results in better patient outcomes. In a small study (n=86), Beitz, Fey, &
O’Brien (1999) evaluated nursing staff’s knowledge about pressure ulcer risk factors and wound
39
care. Their instrument demonstrated content validity and clarity based on literature review and an
expert panel review. Internal consistency reliability of the original instrument was demonstrated
with a score of 0.66. Their analysis of the data demonstrated poor knowledge about pressure
ulcer care including pressure ulcer treatment modalities.
Studies such as those discussed provide empirical data that translation of evidence-based
findings to clinical practice needs improvement. Nursing science for decades has focused on the
perceived barriers to research innovation use. Few researchers have sought to determine what
evidence nurses know and what they use in clinical practice. Early studies that have been
conducted to determine what nurses know and use in their clinical practices lacked appropriate
content validity and psychometric analysis of instruments demonstrating a need to improve the
quality of this type of measurement. To move the translation of evidence into clinical practice
forward and reduce the research to practice gap, we must address measurement of knowledge
and use of research evidence. Thus, the development of instruments to measure knowledge and
use of research-supported innovations is required.
Purpose of this study
The purpose of this study was to develop and test an instrument to measure the extent to which
evidence-based innovations related to managing cancer-related fatigue symptoms were known by
Oncology Nursing Society (ONS) RN’s and adopted in their clinical practice. Specifically
clarity, content validity and test-retest reliability were examined.
Methods
Design and setting. This study evaluated the psychometric properties of the CRF
Knowledge and Use instrument to determine its reliability and validity. The study was
conducted by interview, email, and mailed survey.

40
Samples. A group of three unique samples were utilized for this study. First a group of 5
graduate nursing students were asked to determine instrument clarity. Second, five oncology
nurses with recognized research or clinical expertise in the area of cancer-related fatigue
symptom management participated in content validity testing. Third, a random sample of 400
registered nurses who were ONS members was mailed instruments for test-retest reliability
testing. The sample was proportionally stratified by highest level of educational preparation
based on ONS membership statistics. They were selected from a roster of over 31,000 ONS
members. The inclusion criteria include: (1) RN, (2) educational preparation through the
Masters level, (3) living and practicing in the United States, (4) currently practicing at least ½
time and (5) full member of the ONS. Those not meeting the inclusion criteria were excluded
from the sample. From the sample 93 (23%) responded to the first test of the questionnaire, of
these responses 13 were excluded from the analysis due to incomplete data responses providing
80 complete responses for the first test. Retest responses to the questionnaire from the group
completing the first test was 67 (84%). From the retest group a total of 5 responses were
incomplete and dropped from the analysis resulting in an N = 62 for the study.
Instrument development and testing procedures. This instrument measures whether
nurses have obtained knowledge regarding cancer-related-fatigue (CRF) symptom management
innovations that has been widely disseminated and whether they use those innovations in their
practice. The CRF Knowledge and Use instrument was constructed by the first author utilizing
the ONS’s “Putting Evidence into Practice” guidelines (Mitchell, Beck, Hood, Moore, & Tanner,
2007) and the National Comprehensive Cancer Network’s (NCCN) “Cancer-Related Fatigue and
Anemia: Treatment Guidelines for Patients Version III” (2005) as guides for item construction.
The initial instrument included 28 items. Sample items are shown in Table 1. The instrument
41
was reviewed by a group of graduate nursing students for clarity. After this review the
instrument was submitted to a group of five oncology nurses who have research and clinical
expertise in the area of CRF symptom management for content validity review. For an
innovation to be included on the instrument, a majority of the experts had to agree that the
nursing intervention was a valid empirically-based innovation for CRF symptom management.
Additional changes in item construction would also be made based upon a review of comments
made by the group of experts. Once content validity was established, test-retest reliability of the
instrument was determined over a two week period by mailed questionnaire with a reminder
postcard sent two weeks later to those who had not responded to the initial mailing of study and
Scantron scoring documents. As study materials were returned, scoring forms were reviewed for
completeness, and Scantron answer forms were computer scored, generating an electronic data
file. Participants responding to the test phase of the study had retest documents sent to them two
weeks from their response date. A 10% random sample of the test and retest data files was
checked against original Scantron scoring documents to ensure accuracy.
Analysis. A content validity index score of the 28-item instrument was determined based
on the review of the group of oncology experts. Each of the participant surveys were evaluated
for completeness, and surveys that were not 100% complete due to missing data were removed
from the data file and analysis. Data were analyzed utilizing SPSS 16.0. Test 1 responses were
correlated with test 2 to determine test-retest reliability. If test-retest correlations were found to
be less than r = 0.70, further revision of the instrument would be necessary.
Results. The review for instrument clarity determined that no revisions were necessary to
the instrument. The original 28-item instrument was determined to have a content validity index
(CVI) score of 0.83 with a range of 0.60 to 1.0 for each of the items. The deletion of 8 items
42
where there was no majority agreement by the experts resulted in a refined instrument containing
20 items with a refined CVI score of 0.91, with item CVI scores ranging from 0.80 to 1.0. After
deleting 8 items the review for content validity resulted in revision of one instrument item. Test-
retest reliability testing resulted in an overall correlation of r = 0.83. Item and overall test-retest
correlations are shown in Table 2.
Discussion
Through this psychometric evaluation, the CRF Knowledtge and Use instrument has been
shown to be an instrument that is easily comprehended by those who utilize it. This was
evidenced by the group who evaluated it for clarity and recommended no revisions. The results
of the panel of five experts in managing CRF symptoms further determined that the instrument
was content valid and was a valid instrument to measure knowledge and use of CRF symptom
management innovations in a larger study. Test-retest correlations demonstrated that the
instrument was stable over a 2-week period. Thus the psychometric analysis of this instrument
with a CVI score of 0.91 and a test-retest correlation score of 0.83 provided evidence that the
instrument is both content valid and reliable for future studies of this population.
The study does have limitations in the response rate. Only 16% chose to participate in
the study at time one and two, and only responses with 100% completion were included in the
analysis. The random selection process for mailing provided a sample representative of
registered nurses who belong to the ONS and met the inclusion criteria, but sampling bias could
occur among those nurses who chose to participate in the study. Findings from this study are
limited to oncology nurses who are members of the ONS and would not be generalizable to
nurses in other practice settings.
Conclusions
43
The research to practice gap can be a significant impediment to improving the delivery of
evidence-based nursing care. In order to determine whether current efforts at research translation
are effective, investigators must determine whether research results are reaching the respective
target populations. The CRF Knowledge and Use instrument was developed for this purpose.
This instrument provides a valid and reliable way to measure oncology nurses’ knowledge of
specific empirically-based innovations for cancer-related fatigue and whether they use them in
their oncology nursing practice. This instrument was developed specifically to quantify the
efficacy of cancer-related fatigue innovation diffusion efforts, and is a model that can be adopted
to measure other specific areas of nursing science and practice. Measures such as this can
provide the profession with important information that will ultimately improve research
translation efforts. The CRF Knowledge and Use instrument will be utilized to examine the
effectiveness of translation of CRF symptom management innovations among ONS members.
Because the instrument has been shown to be both content valid and reliable, its use should yield
important information about the innovation diffusion of cancer-related fatigue evidence. While
research evidence may show that specific interventions can improve patient outcomes, the
challenge is to translate those findings into everyday nursing practice in a timely manner. For
two decades, research efforts have focused on perceived barriers to research utilization in nursing
practice. Shifting the focus to translation of research findings into clinical nursing practice
should provide important improvements in patient outcomes.
44
References
Beitz, J.M., Fey, J., & O’Brien, D. (1999). Perceived need for education vs. actual
knowledge of pressure ulcer care in a hospital nursing staff. Dermatology Nursing.
11(2), 125-126, 131-136.
Dufault, M.A., & Willey-Lessne, C. (1999). Using a collaborative research utilization
model to develop and test the effects of clinical pathways for pain management. Journal
of Nursing Care Quality. 13(4), 1933.
Funk, S.G., Champagne, M.T., Wiese, R.A., & Tornquist, E.M. (1991). Barriers to using
research findings in practice: the clinician’s perspective. Applied Nursing Research. 4(2),
90-95.
changing practice: A study of office practice oncology nurses. Ph.D. dissertation, Georgia
State University, United States -- Georgia. Retrieved September 25, 2008, from
Ketefian, S. (1975). Application of selected nursing research findings into nursing
practice: a pilot study. Nursing Research, 24(2), 89-92.
Mitchell, S.A., Beck, S.L., Hood, L. E., Moore, K., & Tanner, E.R. (2007). Putting
evidence into practice: Evidence-based interventions for fatigue during and following
cancer and its treatment. Clinical Journal of Oncology Nursing, 11(1), 99-113.
National Comprehensive Cancer Network, (2005).Cancer-related fatigue and anemia:
Treatment guidelines for patients, Version III.
45
Table 1. Selected CRF knowledge and use instrument items.
1. Cancer patients who experience fatigue may need iron supplementation which is a good
way to correct anemia experienced from bleeding. (F)
2. Cancer patients who experience fatigue may need folic acid supplementation which is a
good way to correct anemia experienced from bleeding. (F)
3. Activities such as gardening, meditation, volunteer activities not related to illness, or
just walking or sitting in a natural environment can help to reduce cancer-related fatigue.
(T)
4. Very few effective pharmacological agents for treatment of cancer-related fatigue are
available. (T)
5. Generally, eating a balanced diet including proteins and 8 to 10 glasses of fluids a day is
a method to reduce cancer-related fatigue. (T)
6. Planned, long rest periods during the day have been shown to be an effective
intervention to reduce cancer-related fatigue. (F)
7. Distractions can help to reduce cancer-related fatigue such as playing games, listening to
music, reading, or visiting with friends. (T)
8. Pain, emotional disturbance, sleep disturbance, anemia and hypothyroidism can all be
causes of cancer-related fatigue. (T)
9. Gradual increases in aerobic exercise has been shown to be one of the most effective
interventions for cancer-related fatigue symptom management. (T)
10. Exercise has been shown to be an effective intervention for chronic fatiguing illness. (T)
46
Table 2. Item and overall test-retest correlations for the refined CRF knowledge and use
instrument (N=62).
Item r=
Number Value
1 .77
2 .77
3 .89
4 .71
5 .79
6 .82
7 .74
8 .94
9 .76
10 .79
11 .95
12 .71
131 .87
14 .86
15 .93
16 .89
17 .95
18 .97
19 .91
47
20 .65
Overall .83
48
Introduction to Manuscript III.
The purpose of this large study was multifaceted using Roger’s theory of innovation
diffusion (Rogers, 1995) as a conceptual framework to examine perceived barriers to the use of
research innovations among ONS nurses and their relationship to knowledge and use of
innovations to manage cancer-related fatigue, which were supported by research evidence and
have been well disseminated in the literature. The study also described the relationship of
knowledge and use of those innovations with professional and demographic characteristics. The
study had eight research questions:
1. What are oncology nurses perceptions of barriers to and facilitators of the use of research
findings in their practices?
2. What are the information sources that oncology nurses use to update their clinical
practices?
3. Is having a mentor or facilitator to research findings related to research utilization among
oncology nurses?
4. To what extent are demographic or professional characteristics related to oncology nurses
perceptions of barriers to research use?
5. What are oncology nurses’ perceptions of the effect of regulatory bodies on the use of
current research findings in practice?
6. To what extent are CRF symptom management innovations that have been disseminated
in the literature known by oncology nurses and used in their practice?
7. Is utilization of information sources predictive of utilization of CRF symptom
management in oncology nursing practice?
49
8. To what extent are the four constructs of Rogers’ theory of diffusion of innovations (the
characteristics of the adopter, organization, communication and the research itself) predictive of
diffusion of CRF symptom management innovations knowledge and use in practice by oncology
nurses?
Through these research questions several gaps in the research literature were addressed
providing nursing science with valuable information. Recognizing the importance of the barriers
that have been reported, their relationship to the knowledge and use of research evidence allows
investigators to focus their research efforts. The knowledge of whether other variables affect the
knowledge or use of research evidence further empowers the profession to adopt interventions
and strategies to enhance the translation of research evidence, ultimately to not only improve
patient outcomes, lower healthcare costs but to strengthen the foundation of the profession.
50
Running head: CANCER-RELATED FATIGUE RESEARCH EVIDENCE
Knowledge and Use of Cancer-related fatigue research evidence by ONS RN’s
Lawrence J. Wilcox
Jean K. Brown
Yow-Wu Wu
Kay S. Sackett
Acknowledgements: ONS Foundation, through an unrestricted grant from
Genentech BioOncology.
Mark Diamond Research Fund, University at Buffalo.
Gamma Kappa Chapter, Sigma Theta Tau International.
51
Abstract
Purpose/Objectives
The study examined perceived barriers to the use of cancer-related fatigue (CRF)
research innovations among Oncology Nursing Society (ONS) nurses and the effect on
knowledge and use of these evidence based CRF innovations. Specific aims included describing
the barriers and facilitators of research utilization and a description of the diffusion of evidence-
based innovations for CRF symptom management.
Methods
Setting and Design. This was a nationwide, non-experimental descriptive correlational
study.
Sample. A random sample of 4500 ONS RNs was stratified by educational level. The
final sample of survey respondents included 608 (13.5%) ONS RNs.
Measures. Barriers Scale, CRF Knowledge and Use instrument, and questions on
selected demographic and professional characteristics.
Procedures. A nationwide mailing included the Barriers Scale, CRF Knowledge and Use
Instrument, and a questionnaire on demographic and professional characteristics and innovation
diffusion issues. Reminder postcards were sent 2 weeks after the initial mailing.
Analysis. Descriptive statistics, correlations, ANOVA, and multiple regression were used
in the data analysis.
Results
Reported barriers to research use were consistent with previous studies. Average
knowledge scores were 59% (sd=.12) correct, and on average 45% (sd=.18) of participants had
accurate knowledge and used it in their clinical practice. Using Roger’s theory of innovation
52
diffusion CRF research knowledge and use scores were not related to characteristics of the
adopter, organization research or communication. Two information sources, National
Comprehensive Cancer Network (NCCN) guidelines and the Oncology Nursing Forum, were
significantly related to higher CRF symptom management knowledge or use scores. The
National Cancer Institute (NCI) Website and the American Cancer Society (ACS) Website were
significantly related to use of CRF innovations.
Conclusions
This large national study examined several unique features that extend knowledge and
translate research into nursing practice. This study demonstrated that barriers previously
reported across many studies have little or no relationship with knowledge and use of CRF
evidence among this group of oncology nurses. Professional and demographic characteristics
showed some significant relationships. The study findings suggest that use of practice guidelines
and specialty research journals are related to higher knowledge and use of research evidence.
53
Knowledge and Use of Cancer-related fatigue research evidence by ONS RN's
Research-based clinical practice has long been a goal of the nursing profession, but it
remains elusive. The research to practice gap, or the time it takes to have a research-supported
innovation accepted into clinical practice, appears to be related to multiple barriers that have
been identified in the literature. Various sources suggest that the practice gap may be anywhere
from 8-30 years (Bostrum & Wise, 1994; Landrum, 1998). More recently there is evidence
(Committee on Quality of Health Care in America, 2001) that the research to practice gap is
becoming larger, despite efforts to improve knowledge translation. Multiple barriers appear to
extend the time period for innovation adoption with some innovations never adopted. This time
lag from dissemination to adoption in practice can result in less than optimal patient care and
inefficient practice (Billings & Kowalski, 2006).
Background
A basic premise of evidence-based practice and translational research is that significant
improvement in the delivery of nursing care can be realized through the adoption of research-
supported innovations in clinical practice. As the body of nursing research grew over three
decades, investigators and educators envisioned a profession that was grounded by research
evidence, but they came to realize that nursing practice was slow to adopt research. Instead
nursing practice continued to be based on past practice, custom or what seemed to be good
practice. Recognition of the problems associated with this research to practice gap led to
several early project. The CURN project, the NCAST project and the WICHE Regional Program
for Nursing Research Development were some of the early projects evaluating research use and
implementation (Dunn, Crichton, Roe, Seers, & Williams, 1998; Kraus, 2000; Pettengill, Gillies,
54
& Clark 1994; Polit & Beck, 2006). This early work helped to identify some of the variables
affecting the use of research in nursing practice and help to establish the utility of mid-range
theory such as the Roger's theory of the diffusion of innovations (Barta, 1995; Carroll, et al.,
1997). Another example of efforts to move toward nursing practice grounded by evidence was
the Oncology Nursing Society's (ONS) implementation of the Fatigue Initiative through Research
and Education (FIRE) project to further advance the knowledge and use of important clinical
research findings in oncology nursing practice.
Barriers to research utilization. Characteristics of the adopter (nurse), organization
(setting), innovation (research) and communication have been consistently found to be barriers to
research use (Ashley, 2005; Baernholdt, 2005; Carroll et al., Dunn, et al., 1997; Funk et al., 1991;
Hutchinson & Johnston, 2004; Kajermo, Nordstrom, Krusebrant, & Bjorvell, 1998; Kajermo,
Nordstrom, Krusebrant, & Bjorvell, 2000; Kenny, 2005; Lemay, Mulhall, & Alexander, 1998;
McSherry, 1997; Parahoo, 2000; Pettengill, Gillies, & Clark, 1994; Rutledge, Ropka, Greene,
Nail, & Mooney, 1998). Nurse characteristics included lower level of education, resistance to
change, or negative attitudes toward research as impediments to research use. Organizational
barriers included lack of authority to bring about change, lack of resources, or a culture resistant
to change. Moreover, characteristics of the research such as the structure, nomenclature, and
limitations of the research itself were identified as important barriers. Lack of communication,
accessibility of research reports, awareness of research findings, collaboration and few role
models were also significant barriers to the use of research findings in practice. Study findings
are not in agreement on which specific issues ranked highest as barriers to the utilization of
nursing research. Carroll, et al. (1997) respectively ranked "nurses unaware of research",
55
"insufficient work time to implement new ideas", and "unavailability of research reports" as the
top three barriers to research utilization. Kajermo, et al. (2000) found nurse clinicians ranked the
top three barriers as "insufficient work time to implement new ideas", "unavailability of research
reports", and "facilities inadequate for implementation of research". Retsas (2000) found the top
three barriers to be "insufficient time on the job to implement new ideas", "lack of authority"
and "inadequate facilities for implementation of research" as the most important barriers.
Examples such as these demonstrate the lack of consistency that exists in the science today.
Although rankings are inconsistent there are several barriers that receive consistently high
rankings as barriers. These barriers include the lack of time to read or implement research
findings, nurses' lack of confidence in a critical appraisal and statistical analysis skills, and a
perception that they lack authority to implement research findings. All of the cited studies have
used the Barriers Scale developed by Funk, Champagne, Tornquist, & Weise (1991) to
investigate barriers to the use of research evidence. While many studies concentrated on barriers
to the exclusion of facilitators, there are several studies that examined facilitators of the
translation of research into practice. Specific factors identified as facilitators included: role
modeling, availability of research reports, research awareness groups and proactive research
committees (Camiah, 1997; Dyson, 1997; Carroll, et al., 1997; Hundley, Milne, Leighton-Beck,
Graham, & Fitzmaurice, 2000; Kajermo, et al., 1998; Kajermo, et al., 2000; Lemay, Mulhall, &
Alexander, 1998; Parahoo, 2000; Pettengill, Gilles, & Clark, 1994).
It has been posited that educational preparation is an important characteristic of the nurse
in research translation. Dillon (1997) noted that most nurses in the United States receive their
education at the Associate Degree level where there is little emphasis on nursing research and its
56
utilization. Parahoo's (2000) study included an evaluation of the effectiveness of an increased
emphasis on research as part of a government mandated nursing program change in the United
Kingdom. This author found no difference between before and after evaluations of the change in
didactic emphasis. A Swedish study by Kajermo (2000) found significant differences in research
findings use between 2-year and 4-year programs of study.
Knowledge and use of research innovations. A gap in the literature has been an
examination of whether nurses demonstrate knowledge and use of research innovations that have
been disseminated in the literature. This may be because of a lack of instruments to measure
knowledge and use. Ketefian (1975) developed an instrument to measure a specific innovation
and found that only 1 in 86 participants knew the correct placement time for oral thermometer
use. Another study evaluating knowledge and use of pain management guidelines by Green
(1997) found no relationship with barriers that have been reported. The study also reported that
52% of the nurse’s had knowledge of the pain management guidelines and that 10% routinely
utilized them in their practice. Patient outcomes can be improved with well-managed pain yet,
Dufault & Willey-Lessne (1999) reported that 60% to 90% of patients who seek health care in
pain despite widespread dissemination of knowledge related to pain management. A study by
Beitz, Fey, & O’Brien (1999) reported poor knowledge and use of research related to pressure
ulcer care and appropriate treatment interventions.
The empirical data from these studies provided evidence that translation of evidence-based
innovations to nursing practice remains a critical issue. For decades the barriers to research
innovation use have been studied extensively. This has been to the exclusion of determining what
57
research evidence nurses know and use in practice. Studies are needed to improve translation of
evidence and thereby shorten the research to practice gap.
Research utilization gaps. A review of current research literature demonstrated that there
are several gaps in the research utilization literature. We need to determine where nurses obtain
information to change clinical practice, whether nurses believe a research mentor or facilitator
would improve research use, the effect of regulatory agencies, whether nurses have knowledge of
specific interventions supported by research and whether they use these interventions in practice,
and what characteristics are related to improving the use of research findings.
Strategies for reducing the research gap. There are few studies that tested effective
strategies for reducing the research to practice gap. A study by Hundley, Milne, Leighton-Beck,
Graham, & Fitzmaurice (2000) evaluated an educational and training intervention using an
intervention and control group. While they found statistical significant improvement with
training the study was limited by a Hawthorne effect and a short intervention timeframe. In
contrast, Clifford & Murray (2001) found no statistical difference between a pre- and post-test
for an educational intervention. An intervention study by Fink & Bonnes (2005) was conducted
over a one year period provided practicing RN's with a user friendly manual to enhance the use
of the research process and research supported interventions. After implementation of
organizational strategies to improve the use of research findings, significant improvements were
noted in barriers related to characteristics of the setting and nurse. The authors' reported that
participation in a journal club was a key factor. However, a major study limitation was a
Hawthorne effect and the hiring of a nurse executive with international recognition for her work
in research utilization during the study. This organizational change toward improved support for
58
research utilization confounded the results but offered insights for future investigations. The
ONS FIRE project, which sought to disseminate research evidence to ONS members, may have
improved evidence use, but there has been scant evaluation of the project's impact on knowledge
or use of research evidence. So evidence supporting intervention strategies to decrease the
research to practice gap is weak.
Summary. A strength of the current literature has been the widespread use of Roger’s
model of the theory of diffusion of innovations (Barta, 1995; Carroll, et al., 1997; Dooks, 2001;
Fink & Bonnes, 2005; Olade, 2004; Pettengill, Gillies, & Clark, 1994; Rutledge, Ropka, Greene,
Nail, & Mooney, 1998) and the use of the Barriers Scale developed by Funk, Champagne,
Tornquist, & Weise (1991). Major weaknesses associated with many of the studies reviewed
were the use of convenience samples, limited geographical areas, low response rates, and the
inadequate sample sizes. Many of the recent studies were international studies that have limited
application within the United States. And there has been very little research on nurse's actual
knowledge and use of research evidence in nursing practice. Thus, intervention research aimed
at determining effective knowledge translation strategies and research on the translation of
research into practice are needed.
Conceptual Framework
Roger's Theory of the Diffusion of Innovations (Rogers, 1995) described the diffusion
process of an innovation that is communicated through channels over time among members of a
social system. Rogers identified five stages through which potential adopters would progress
before an innovation is fully adopted. Those stages are: 1) knowledge, 2) persuasion, 3)
59
decision, 4) implementation and 5) confirmation. The diffusion process could be affected by
characteristics of the adopter, setting, innovation and communication.
Purpose/Objectives
Based on Roger’s theory of innovation diffusion (Rogers, 1995) , the purpose of this
study was to examine ONS RNs’ perceived barriers to the use of research innovations and the
relationship of these barriers to knowledge and use of innovations to manage cancer-related
fatigue (CRF) that were evidence-based and well disseminated in the literature. The study also
described the relationships of knowledge and use of CRF innovations with professional and
demographic characteristics as well as issues related to research translation. The study had
specific aims, research questions, and hypotheses were as follows.
Aim 1. Describe barriers and facilitators of research utilization among nurses
specializing in oncology.
1a. What are oncology nurses perceptions of barriers to and facilitators of the
use of research findings in their practices?
2a. What are the information sources that oncology nurses use to update their
clinical practices?
3a. Is having a mentor or facilitator to research findings related to research
utilization among oncology nurses?
Hypothesis. The incorporation of a nurse mentor or facilitator to improve
the use of research findings is positively related to CRF symptom
management knowledge and use by oncology nurses.
60
4a. To what extent are demographic or professional characteristics related to
oncology nurses perceptions of barriers to research use?
Hypothesis. Demographic or professional characteristics are not
significant predictors of barriers to the use of research in clinical practice.
5a. What are oncology nurses’ perceptions of the effect of regulatory bodies
on the use of current research findings in practice?
Hypothesis. Oncology nurses will report that regulatory bodies have a
positive impact on improving research use in practice.
Aim 2. Describe the diffusion of evidence-based innovations for CRF symptom
management.
1a. To what extent are CRF symptom management innovations that have been
disseminated in the literature known by oncology nurses and used in their
practice?
Hypothesis. A majority of oncology nurses will lack the knowledge of
well-disseminated specific CRF symptom management innovations that
are necessary to change clinical practice.
2a. Is utilization of information sources predictive of utilization of CRF
symptom management in oncology nursing practice?
Hypothesis. Use of oncology nursing specific information sources is
predictive of higher scores on CRF symptom management knowledge and
use in practice.
3a. To what extent are the four constructs of Rogers’ theory of diffusion of
61
innovations (the characteristics of the adopter, organization, research and
communication) predictive of diffusion of CRF symptom management
innovations knowledge and use in practice by oncology nurses?
Hypothesis. Oncology nurses reporting fewer adopter, organizational,
communication and research barriers are related to higher scores of CRF
symptom management knowledge and use.
Methods
Design and Setting. The study employed a cross sectional correlational design. A
mailed survey was distributed to national ONS members. A reminder was mailed two weeks
after the initial mailing.
Sample. 4500 randomly selected RNs who were members of the ONS were
proportionally stratified by the highest level of educational preparation based on ONS
membership statistics. They were randomly selected from a roster of over 31,000 ONS
members. Inclusion criteria were: (1) RN, (2) educational preparation through the Masters level,
(3) living and practicing in the United States, (4) currently practicing at least ½ time, and (5) full
member of the ONS. Those not meeting the inclusion criteria were excluded. A total of 634
(14%) responses were returned. Of these 26 responses were incomplete and were excluded from
the analysis. Thus the study sample included 608 ONS RN’s, which was 13.5% of those to
whom questionnaires were mailed.
Measures. CRF innovation knowledge and use information was measured by the CRF
Knowledge and Use Instrument. Developed by the principal investigator, this 20-item
instrument measures whether nurses have obtained knowledge regarding CRF symptom
management innovations that have been published in the literature. The instrument also
62
measures whether these nurses utilize those innovations in their clinical practice. The ONS and
the National Comprehensive Cancer Network’s (NCCN) guidelines for managing CRF
symptoms were used as the foundation for the development of the CRF Knowledge and Use
Instrument. Participants scored their answers by indicating that an answer was “true and they
used the innovation in their clinical practice”, “true and they did not use it”, “false”, or “they did
not know the correct answer.” Total knowledge scores of participants were calculated as the
total percentage correct for the 20 items on the instrument. Use scores of participants were the
total percentage correct with an indication that the participant used the innovation in their clinical
practice. The instrument has previously demonstrated a content validity index score of 0.91 and
a test-retest reliability correlation of 0.83 (Wilcox, Brown, Wu, & Sackett, 2009).
The Barriers Scale, an instrument developed by Funk, Champagne, Weise, & Tornquist
(1991), to identify characteristics that could affect the diffusion process was used to measure
barriers and identify facilitators to research use in oncology nurse’s clinical practice.
Participants rated barriers on a Likert Scale where one equaled “a barrier to no extent” to four
equaled “a barrier to a great extent”; a no opinion option was also available. This instrument has
previously been shown to have both construct validity and reliability. Cronbach alphas reported
by Funk on the barrier subscales were nurse .80, setting .80, research .72 and communication .65.
Barriers Scale Cronbach alpha scores obtained for this study were; nurse .84, setting .84,
research, .79 and communication .74. This measure has been utilized extensively by
investigators nationally and internationally since its development. Permission was obtained from
Dr. Funk prior to study implementation to use this instrument.
Demographic and professional characteristics such as age, gender, sex, marital status,
number of children, as well as first degree held, highest degree earned, years practiced as an RN,
63
oncology nursing certification (OCN, CPON, or AOCN), employment status, employment
setting, information sources, and magnet hospital status were obtained by survey questionnaire.
Additional questions concerning the use of a mentor and perceived effect of regulatory bodies
were also included on the questionnaire.
Procedures. Study documents were prepared in October of 2007 and mailed by first
class through the United States Postal Service. The mailing included a cover letter outlining the
study and implied consent, the CRF Knowledge and Use Instrument, the Barriers Scale and the
demographic and professional characteristics questionnaire. The mailing also included a
Scantron scoring sheet, #2 pencils and a prepaid-postage business reply envelope to return all
study materials. Two weeks after the initial mailing reminder postcards were mailed to potential
study participants. The principal investigator accepted returns until the end of 2007. At that time
Scantron scoring sheets were copied and the originals sent for computer scoring. Once a
database of scores was returned from computer scoring, a random sample representing 10% of
the original documents were hand checked against the database to insure accuracy of scoring.
This review found no errors. Data from the Barriers Scale that required hand entry into the
database were double checked to insure accuracy of entry.
Analysis. Data were analyzed utilizing SPSS version 16.0, and descriptive statistics were
employed to summarize the data. Statistical significance was set at the 0.05 level. Missing data
were likely to be an issue from participants in the study, so a decision was made a priori to
exclude participant responses with more than 10% missing data. This resulted in excluding 26
responses. Missing data constituting less than 10% were imputed using a predicted score based
on a regression analysis for each individual question with missing data. Item scores were
imputed for 75 questions in the data file. For categorical data that were missing, no information
64
was substituted. This study demonstrated that barriers previously reported across many studies
have little or no relationship with knowledge and use of CRF evidence among this group of
oncology nurses. Professional and demographic characteristics showed some significant
relationships. The study findings suggest that use of practice guidelines and specialty research
journals are related to higher knowledge and use of research evidence.
Results
Study participants had a mean age of 47 years (SD = 10.42) and ranged from 21 to 76
years old. Women represented 96% of the sample. The highest educational degree obtained by
study participants (compared with ONS membership statistics) was Associates Degree- 20%,
(29%); Diploma – 8%, (11%); Bachelor’s – 44%, (41%); and Master’s – 28%, (17%)
respectively. Table 1 further describes the demographic and professional characteristics of the
sample.
Barriers and facilitators of research utilization among nurses specializing in oncology.
The top four barriers based on ranking of mean scores were: 1) there is insufficient time on the
job to implement new ideas (M=3.10, SD=1.00), 2) the research has not been replicated
(M=3.08, SD=1.46), and 3rd tied), the nurse does not have time to read research (M=3.05,
SD=0.96) and the research has methodological inadequacies (M= 3.05, SD=1.56). When
participants were asked to rank the top three barriers, the number one barrier was insufficient
time on the job to implement new ideas, followed by the nurse did not have enough time to read
research, and the nurse did not feel they had enough authority to change patient care procedures.
On this section of the instrument nearly one third of the participants chose not to rank barriers.
Table 2 provides the means scores and standard deviations for each of the barriers scale items.
Barriers Scale subscale mean scores were, characteristics of the organization (M = 2.69, SD =
65
.66), communication (M = 2.36, SD = .63), nurse (M = 2.23, SD = .67), and research (M = 2.00,
SD = .62). Categories of facilitators of research utilization were developed from qualitative
descriptions by study participants and includes the following categories and number of individual
responses for that category: 1) presence of a research mentor (n = 42); 2) presentation of
research in meetings, conferences or seminars (n = 12); 3) journal club (n = 10); 4) research
review committee (n = 10); 5) regulatory mandate (n = 6); 6) conducting research (n = 2); and 7)
grand rounds (n = 2).
Information sources used to update clinical practice. Top ranked sources used to update
participants’ clinical practices included other information sources (66%), Clinical Journal of
Oncology Nursing (65%), and the ONS website (63%). The least utilized information source
was the Cochrane Database (9%). Table 3 provides a complete description of sources used by
study participants.
Facilitating research translation with a mentor or facilitator. The correlation of CRF
innovation knowledge with the availability of a mentor was r = -.03. p >.05 and with use of a
mentor was r = .00, p >.05. The correlation of CRF innovation use with the availability of a
mentor was r = -.01, p >.05 and with use of a mentor an r = .05, p >.05.
Relationship of demographic and professional characteristics with barriers to research
use. CRF knowledge and use scores were regressed on the demographic characteristics
including age, marital status (dummy coded 0 = single, 1=married) and children at home
(dummy coded 0 = no children, 1 = has children). This relationship of the variables with CRF
knowledge was not significant (R2 = .01, df = 562,3, F = 1.65, p >.05) with the exception of
children at home (beta = -.094, p <.05) nor was the relationship of use significant on these
variables (R2 = .01, df = 562,3, F = 1.75, p > .05).

66
CRF knowledge and use scores were regressed on professional characteristics including
highest degree obtained (0 = Associates , 1 = Bachelor’s or higher), full or part-time status (0 =
part-time, 1 = full-time), practice setting (0 = hospital/community, 1= cancer teaching center),
professional role (0 = staff nurse, 1 = nurse leader ), magnet hospital status (0 = no, 1 = yes), and
whether they had specialty certification (0 = no, 1 = yes). Significant regression coefficients for
CRF knowledge scores were on highest degree earned (beta = .115, p <.05), on specialty
certification (beta = .097. p <.05) and full-time work status (beta = .100, p <.05). No significant
regression coefficients were found for practice setting either cancer teaching center / hospital or
community setting, practice role either staff nurse or nurse leader, or magnet hospital status.
Significant regression characteristics for CRF use scores were on specialty certification (beta =
.100, p <.05), practice role (beta = .128, p <.05) and on practice setting (beta = -.111, p <.05).
Regression coefficients for highest degree, full-time work status and magnet hospital status were
not significant.
Perceptions of the effect of regulatory bodies on research translation. 13% of
participants viewed the impact of regulatory bodies on the use of current research findings
positively, 46% viewed the effect as negative, and 40% perceived no effect. Using independent
t-tests, a comparison of mean CRF knowledge and use scores by perceptions (negative = 0,
positive = 1) of the role of regulatory bodies found no significant difference either on knowledge
(F = 2.00, df =2, 355, p > .05) or use of innovations (F=.50, df =2, 355, p >.05).1
Knowledge and Use of CRF symptom management innovations. The average participant
knowledge score on the 20-item CRF knowledge and use instrument was 59% correct. Among
1
Degrees of freedom are reduced due to participants choosing a response of “no effect”.
67
participants who correctly identified a research supported intervention 76% reported using those
innovations in their clinical practice. Means and standard deviations for CRF knowledge and use
scores are shown in Table 4.
Information sources predictive of utilization of CRF symptom management innovations.
Pearson correlations of information sources with knowledge and use scores were calculated. The
analyses demonstrated a significant relationship between CRF knowledge and two information
sources, the NCCN Guidelines (r = .14, p <.05) and the Oncology Nursing Forum (r = .10, p
<.05). On use of CRF innovations, the analysis showed significant relationships between NCCN
guidelines (r =.19, p <.05), NCI Website (r =.10, p <.05), Oncology Nursing Forum (r =.09, p
<.05), and the ACS Website (r =.09, p <.05). All correlations are shown in Table 5.
Extent to which Roger’s theory predicted diffusion of CRF symptom management
evidence knowledge and use. The Barriers Scale subscales, measuring constructs of Roger’s
theory accounted for R2 = .019 or 1.9% (F = 2.563, df = 4, 522, p >.05) of the variance of CRF
knowledge and on CRF use R2 = .019 or 1.9% (F = 2.563, df = 4, 522, p >.05) of the variance2.
Discussion
This large national study examined several unique features that extend knowledge
regarding the translation of research into nursing practice. This study focused on CRF after
intensive research and educational efforts designed to create and disseminate knowledge. It
addressed several gaps in the literature including testing Roger’s theory of the diffusion of
innovations.
2
No opinion responses on the Barriers instrument reduce the degrees of freedom.
68
Results of this study indicated that the top barriers to research utilization for ONS RNs
were: insufficient time on the job to implement new ideas, lack of research replication,
insufficient time to read research, and methodological inadequacies of the research. The most oft
mention facilitator was that of the availability of a research mentor, but few respondents
answered questions about their perceptions of research facilitators. Barriers identified were
consistent with previous studies with the exception that lack of replication of research results was
a highly ranked barrier. Since the development of the Barriers Scale, nursing research has
focused on perceived barriers to knowledge translation, yet it appears there has been little change
in these perceptions over 18 years.
The top three information sources that ONS nurses reported using to update their clinical
knowledge were the Clinical Journal of Oncology Nursing, the ONS website and the NCCN
guidelines on CRF symptom management. Information sources that nurses used to update
clinical practice is a new finding with no other reports in the literature.
The availability or use of a research mentor was not related to higher knowledge or use of
CRF symptom management innovations in clinical practice. Based on Roger’s Theory, it was
hypothesized that the use of a research mentor would be associated with higher CRF innovation
knowledge and use scores. This hypothesis was not supported. Specifically participants were
asked 1) Does your organization provide a research mentor or facilitator to enhance research
utilization in your clinical practice setting? (yes = 49%, no = 50%) and, 2) In your clinical
practice setting, do you use a research mentor or facilitator or do you have a colleague you
consider as a research mentor or facilitator to help you to utilize research findings in your
practice (yes = 47%, no = 52%)? The superficial nature of the questions suggests that a more
definitive investigation would be warranted.

69
Demographic and professional characteristics such as age and marital status were not
associated with higher CRF innovation knowledge and use scores among this group of RN’s.
Although there was a weak negative relationship shown for children living at home. However,
significant positive relationships of CRF innovation knowledge with professional characteristics
of Bachelors degree level or higher, full-time work status, nurse leaders versus staff nurses, and
specialty certification in oncology. Significant relationships of CRF innovation use were
demonstrated with full-time work status, nurse leaders versus staff nurses, specialized cancer
setting versus community setting, and certification in oncology. It was hypothesized that
demographic and professional characteristics were not significant predictors of barriers to the use
of research in clinical practice. The results of this study did not support the hypothesis because
of the relationship demonstrated on certain professional characteristics. As demonstrated here
professional characteristics such as education, or specialty certification can play a role in
enhancing the use of research evidence in practice, but continued investigations are required to
further define the relationship.
Knowledge or use of CRF research evidence was not related to participant’s perception
of the impact of regulatory agencies. Most participants had a negative perception of the impact
of regulatory agencies on research use (negative 13%, positive 13%, no impact 40%). It was
hypothesized that oncology nurses would report that regulatory bodies have a positive impact on
improving use of research evidence in practice. This was not supported. It has been suggested
that one approach to achieve evidence-based nursing practice is through regulatory fiat. It
should be recognized that the impact of regulatory agencies was a subjective perception of the
participants and may reflect a negative bias toward regulatory agency intervention. It is possible
70
that regulatory intervention may improve the use of evidence in practice even though RNs appear
to be biased against regulation, so further investigation is warranted.
This study found that 45% of the of ONS RNs in this study had knowledge of and used
CRF symptom management innovations that have had widespread dissemination in their
oncology nursing practice. The knowledge score of the total sample was 59%, so the hypothesis
that a majority would lack the knowledge of well disseminated specific CRF symptom
management innovations that are necessary to change clinical practice was not supported. The
results reported here are in contrast to the few studies that demonstrated relatively low
knowledge and use of research evidence in clinical practice. Although the current study did not
directly test the effects of the ONS FIRE project, these findings lend support to the success of the
ONS FIRE project’s widespread dissemination of cancer-related fatigue research results.
Two of the information sources, the NCCN Guidelines on CRF symptom management
and the Oncology Nursing Forum, predicted higher CRF innovation knowledge scores. The use
of CRF innovations was predicted by use scores of participants who reported using the NCCN
guidelines on CRF symptom management, NCI Website, ACS Website and the Oncology
Nursing Forum that were used by study participants as sources to determine the best oncology
nursing practice intervention. This is new information that has not been reported previously. It
addresses a major gap in our knowledge of the translation of research evidence into practice and
suggests that practice guidelines and original research reports may be effective means to translate
research innovations into clinical practice. At the time this study was designed, the ONS Putting
Evidence into Practice (PEP) guidelines for CRF had just been released, so they were not
included as an information source on our questionnaire. One might extrapolate that these
71
practice guidelines may also be related to higher CRF innovation knowledge and use, but future
studies should be performed to confirm our findings and add the PEP guidelines.
The study also found no significant relationships between the constructs of Roger’s
theory (measured by Barriers subscale scores) and the knowledge and use of CRF symptom
management innovations. Based on Roger’s theory of diffusion of innovations, it was
hypothesized that the oncology nurses reporting fewer adopter, organizational, research and
communication barriers would have higher CRF symptom management knowledge and use
scores. This hypothesis was not supported. This is the first study to test the relationship of
Rogers theory with knowledge and use of research innovation so findings suggest that the
Barriers Scale may not be a valid instrument to measure constructs of Roger’s Theory of
Diffusion of Innovations or that the barriers measured are not related to CRF knowledge and use.
This critical finding suggested that researchers should move from studies about barriers to
research utilization to translational research studies focused on factors that improve innovation
diffusion. It might also be suggested that Roger’s theory is not relevant, but its tremendous
success in the diffusion of agricultural innovations through the cooperative extension system
make this less likely. This is vital new information that could help to close the research to
practice gap more quickly. Adapting and testing strategies utilized in the agricultural
cooperative extension model may be warranted.
While this study provided important new information concerning the translation of
research findings to clinical practice, there were some limitations. Participants of this study were
ONS members, so the results were not generalizable to other specialty areas or to nurses who do
not belong to a specialty organization. Although surveys were mailed to a randomly selected
sample, the study had a low response rate of 14%, which is lower than similar studies of this
72
population. However, the sample size of this study (n = 608) was substantially larger than
previous studies where average sample sizes were about 350 (Hutchinson & Johnston, 2006).
There could be differences in knowledge between those who responded and those who did not
participate. For example, those who felt comfortable with their knowledge levels may have
opted to participate and those with a low level of confidence in their knowledge level may have
chosen not to participate. Generalizability of the findings is also limited due to the non-random
participant responses and the characteristics of the sample, e.g. the under sampling of Associate
degree nurses and over sampling of Masters prepared nurses according to ONS membership
statistics, 72% of the sample specialty certified, 52% employed in a Cancer center or teaching
hospital. The data were self-reported based on RNs perceptions that could differ from objective
data due to personal factors inherent to each participant.
Implications
Research. Future studies are needed to confirm the results of this research, much of
which are new findings. Based on the lack of a relationship between Roger’s theory (as
measured by the Barriers subscale scores) and knowledge and use scores of CRF symptom
management innovations, future research should focus on how knowledge is diffused, evaluate
RN’s knowledge of specific innovations and determine what factors are associated with higher
knowledge and use scores of research evidence. Studies need to be designed to test specific
interventions using information sources such as practice guidelines, which predicted higher CRF
knowledge and use scores in this study. The use of research facilitators could be further
evaluated by an intervention study to test whether the RN perceptions reported in this study
affect research translation in practice settings. While their perceptions of regulatory agencies
were not positively associated with higher knowledge, further studies should address these
73
issues. The World Health Organization (2004) said that in the absence of research on effective
translation of scientific evidence, there can be no improvement in healthcare. The research to
practice gap in nursing has been resistant to improvement over several decades. Changing our
research emphasis may provide the impetus to move the translation of research evidence into
practice forward.
Clinical. Evidence-based nursing practice is a critically important goal for improving the
quality of nursing care. The findings of this study provide evidence for a shift in the focus of
research translation to the use of research-supported practice guidelines. Differences in
knowledge and use of research evidence from earlier studies compared to this study provide
evidence that the innovative ONS FIRE Project may be a productive strategy to improve
evidence based nursing care. Although this study did not test the effects of the FIRE project, it
has similarities with the successful Cooperative Extension model that is based on Roger’s theory
of innovation diffusion. By successfully implementing similar strategies, research evidence can
begin to bring about important evidence based advances in symptom, disease management and
structural delivery of healthcare into everyday nursing practice.
74
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Table 1. Demographic and Professional Characteristics of the sample (n=608).
Characteristic Mean S. D.
Age 47 (10.4)
Characteristic Percent
Marital status
Single 17
Married 70
Divorced/separated 11
Widowed 2
Number of children at home
None 56
One 23
Two 5
Three 15
Four or more 1
Nursing degree
First obtained
Associate 37
Diploma 16
Bachelor 46
Master 1
Highest attained
Associate 20
Diploma 8
Bachelor 44
Master 28
Conferences attended
ONS Congress 2.6
79
ONS Fall Institutes 1.7
ONS Research Conference 1.1
Other conferences 3.0
Information sources accessed monthly 3.9
Practice Setting
Cancer institute/center 29
Teaching hospital 23
Community hospital 22
Hospice 3
Home care 2
School of nursing 1
Ambulatory care 8
Physician office 19
Other practice setting 7
Practice role
Staff nurse 64
Clinical nurse leader 10
Advance practice nurse 17
Nurse manager 8
Nurse educator 1
Magnet hospital designation
Yes 25
No 44
Oncology specialty certification
No certification 29
OCN 61
AOCN 10
CPON <1
Geographic location
Northeast 27
Southeast 20
80
Midwest 29
Northwest 10
Southwest 13
81
Table 2. Barriers scale items means and standard deviations.
Mean Std. Dev.
There is insufficient time on the job to implement new ideas 3.10 .996
The research has not been replicated 3.08 1.464
The nurse does not have time to read research 3.05 .959
The research has methodological inadequacies 3.05 1.555
The nurse does not believe she/he has enough authority to change patient care procedures 3.00 1.044
The relevant literature is not complied in one place 2.91 1.178
The nurse is unaware of the research 2.83 1.074
Statistical analyses are not understandable 2.80 1.005
The nurse does not feel capable of evaluating the quality of the research 2.74 1.065
The facilities are inadequate for implementation 2.70 1.139
Physicians will not cooperate with implementation 2.66 1.117
The nurse feels the benefits of changing practice will be minimal 2.31 1.146
The nurse is uncertain whether to believe the results of the research 2.22 1.178
The nurse feels results are not generalizable to own setting 2.65 1.024
The literature reports conflicting results 2.65 1.280
Other staff are not supportive of implementation 2.64 1.108
Administration will not allow implementation 2.64 1.222
Research reports/articles are not published fast enough 2.58 1.528
The research is not reported clearly and readably 2.57 1.109
The nurse is isolated from knowledgeable colleagues with whom to discuss the research 2.48 1.117
The conclusions drawn from the research are not justified 2.33 1.464
Implications for practice are not made clear 2.32 1.027
There is not a documented need to change practice 2.20 1.188
The nurse is unwilling to change/try new ideas 2.19 1.087
The nurse sees little benefit for self 2.14 1.249
The research is not relevant to the nurse’s practice 2.13 1.020
Research reports/articles are not readily available 2.12 1.032
The nurse does not see the value of research for practice 1.91 1.138
82
Table 3. Frequencies of information sources utilized by study participants.
Information resource Percent
Other information source 66
Clinical Journal of Oncology Nursing 66
ONS Website 63
NCCN Guidelines 47
Oncology Nursing Forum Journal 46
EBN Journal 47
Cancer Journal 39
ACS Website 24
Cancer Nursing 17
NCI Website 17
Cochrane Collaboration Database 9
83
Table 4. Mean % correct (SD) CRF Knowledge and Use scores.
CRF Mean % (SD)
Knowledge .59 (.115)
Use .76 (.178)
84
Table 5. Pearson correlations of information sources with CRF knowledge and use scores.
Information source CRF CRF
Knowledge Correlation Use Correlation
NCCN guidelines .142* .190*
Oncology Nursing Forum .104* .087*
Cancer Nursing .065 .068
Cochrane Collaboration Database .056 .075
NCI Website .036 .099*
ONS Website .031 .050
EBN Journal .036 .053
Cancer Journal .015 -.005
ACS Website .014 .088*
Clinical Journal of Oncology Nursing .005 .015
Other information source .000 .030
*p < .05.
85
Dissertation Synthesis and Discussion
86
Dissertation Synthesis and Discussion
The manuscript type of dissertation presented here included a collection of three distinct
manuscripts which reported and summarized a doctoral program of research the focused on
barriers to the use of research evidence in clinical nursing practice. The program also evaluated
the knowledge and use of research supported innovations to manage cancer-related fatigue. The
Social and Behavioral Sciences Institutional Review Board review the research proposal and
granted approval. The systematic literature reviews development of the CRF Knowledge and
Use Instrument, the conduct of the study and the analysis of data and reporting of findings were
the sole responsibility of the principal investigator. Co-authors to the manuscripts served as
expert reviewers relative to the focus of each of the manuscripts. The provided guidance
throughout the entire process, reviewing written material and data analyses for each of the
manuscripts.
Manuscript I, Innovation Diffusion and Barriers to the Translation of Research findings
into Nursing Practice: A systematic review presented a review of the literature concerning
barriers to the utilization of research evidence in clinical nursing practice. This review updates
the state of the science through a review of studies from the point of view of how these studies
related to Roger’s Theory of the Diffusion of Innovations. While studies have examined barriers
to research utilization in the past this review linked the findings of each study to constructs of
Roger’s theory to demonstrate where nurses are in the diffusion process. The review indicates
that most nurses are at the initial or knowledge stage of the diffusion process.
Manuscript II, Development of an Instrument to measure RN’s Knowledge and Use of
Research Evidence: The Cancer-Related Fatigue Knowledge & Use Instrument presented the
findings from a psychometric analysis of the CRF Knowledge and Us instrument. This
87
instrument was specifically developed by the PI to test the knowledge and use of research
evidence that has been show through research investigations to improve cancer-related fatigue in
cancer patients. The instrument was based on the ONS “Putting Evidence into Practice”
guidelines for managing cancer-related fatigue. The NCCN’s guidelines for managing cancer-
related fatigue also provided the theoretical foundation for the instrument. The manuscript
describes the process of instrument clarity, content validity and test-retest reliability testing and
analysis that was conducted. The instrument was determined to be suitable for testing in a larger
sample of ONS members.
Manuscript III, Knowledge and Use of Cancer-related fatigue research evidence by ONS
RN’s was a large study among N = 608 ONS members. Eight research questions were
developed for this study that addressed two specific aims of the research. Results demonstrated
critical new information for nursing science. The study demonstrated that a measurement
instrument that has been used extensively in the literature for over 17 years may not have
construct validity to measure the constructs of Roger’s theory of the diffusion of innovations. It
also demonstrated that certain information sources are predictive of high knowledge or use
scores of research evidence in clinical practice. This information has the potential to move the
focus of investigations to other areas that may have to enhance efforts to reduce the research to
practice gap. It also allows interventional research aimed at increasing the use of research
evidence in clinical nursing practice. Together these insights may help to improve patient
outcomes, enhance professional autonomity and strengthen the foundation of nursing science.
88
Appendix A
Institutional Review Board Approval
89
University at Buffalo | State University of New York
Social and Behavioral Sciences Institutional Review Board
Federal Wide Assurance ID Number: FWA00008824
515 Capen Hall Buffalo, NY 14260
Telephone: (716) 645-3321
DATE: 12/28/2005
TO: Dr. Lawrence Wilcox
NUR
FROM: Joel O. Raynor, Chair

Christian Marks, Administrator
RE: Study # 2 1 28: Use of Cancer-related fatigue research evidence by OSN RN's
Approval of Proposal
The above referenced protocol was reviewed and approved by the Social and Behavioral Sciences
Institutional Review Board (SBSIRB) at the University at Buffalo. We are pleased to inform you that
your project is now approved by the Board. The project was approved via a review of the full board. The
expiration date of this approval is . The SBSIRB has also determined that this study presents no greater
than minimal risks to participants and therefore renewal/continuing review may be performed using
expedited procedures.
Research investigators are responsible for obtaining informed consent and for insuring that no human
subject will be involved in the research prior to the obtaining of the consent. The use of a signed consent
document has been waived for all participants in this study by the SBSIRB and therefore stamped consent
forms are not provided with your approval.
As principal investigator for a study involving human participants, you assume certain responsibilities to the
Social and Behavioral Sciences Institutional Review Board. Specifically:
1. No subjects may be enrolled prior to the 1RB approval date or continued on the study after the expiration date.
2. For all projects that have not been granted an exemption, the SBSIRB must be notified that the project is closed. When
your
research is completed, fill out a continuation/renewal form and submit it to the Administrator.
3. Report to the 1RB within 5 working days all unanticipated and all serious adverse events.
4. Conduct the protocol exactly as approved unless a protocol amendment is prospectively approved by the 1RB- Changes in
research
during the period for which !RB approval has already been given shall not be initiated by research investigators without IRB
review
and approval, except where necessary to eliminate apparent immediate hazards to the subject.
5. Submit any changes in participant recruitment methods or advertisements to the IRB for review and approval.
6. Comply with all IRB decisions, conditions, and requirements. Principal Investigators are responsible for making sure that
studies
are conducted according to the protocol and for all actions of the staff and sub-investigators with regard to the protocol.
A copy of your protocol will go on file under your name and the study number title above. Please refer to this
number/title in all future correspondence about the project.
Thank you for this submission to the IRB and we wish the best for you and your participants. Should
you have any questions regarding human participants, please contact the Chair of the IRB. Dr. Raynor
at 645-3650 ext. 322. or the Administrator Dr. Marks at 515 Capen Hall, 645-3321.
90
Appendix B
Cover letters – Implied Consent
91
April 2007 Phase 1 – Cover Letter
To: Members of Oncology Nursing Society
From: Lawrence J. Wilcox MS, RN, FNP-BC
Re: Cancer-related Fatigue Symptom Management Innovation Knowledge and Use
As a member of the Oncology Nursing Society (ONS) you have been randomly selected for
participation in a psychometric study that will evaluate a method for determining whether ONS
nurses have acquired knowledge about new clinical innovations related to Cancer-related Fatigue
Symptom Management innovations that have been described in the research literature. I also
hope to determine the extent of clinical use, if any, of these new clinical innovations. This study
will lay the foundation for a larger study that will examine knowledge and use of these
innovations, as well as issues related to barriers and facilitators to the use of research innovations
in cancer nursing.
If you are an associate degree, diploma, baccalaureate, or master’s prepared nurse who works
full time in oncology, you are invited to participate in this study. If you do not meet these
criteria, please stop here and do not complete the survey enclosed. Participation in this study is
voluntary and there is no compensation for your involvement. Study documents are enclosed for
your review and completion should you desire to participate in the study. Completion and return
of the documents will be accepted as consent to participate in the study. As part of the process
involved with this study you will receive a second mailing several weeks after you return the
original documents. You will need to complete and return those documents as well. This
method will help me to determine whether the measure is a reliable indicator of the knowledge
and use of cancer-related fatigue clinical innovations.
A requirement of the study is that the names associated with the study remain confidential.
Names of RN’s who agree to participate in this study will not be released to anyone other than
those working on this research effort. At the conclusion of the study, documents that identify
participants will be destroyed.
Your involvement in this research endeavor is important to ONS members and the nursing
profession. I hope that you will take the time to complete the enclosed material. Should you
choose to participate the documents are enclosed for your use. Please use a # 2 pencil to mark
the enclosed scoring sheet. A prepaid response envelope is also enclosed for your use.
Completion of the material should take approximately 10-15 minutes of your time.
Thank you in advance for your assistance in this important study on evidence based nursing
practice.
Sincerely,
92
Lawrence J. Wilcox MS, RN, FNP-BC Jean K. Brown, PhD, FN, FAAN
Principal Investigator, Doctoral Candidate Dissertation Chair, Professor in Nursing,
Nutrition, and Rehabilitation Science
Cc: Enclosures
93
Phase 2 – Cover Letter
October 2007
To: Members of Oncology Nursing Society
From: Lawrence J. Wilcox MS, RN, FNP-BC
Re: Study to evaluate research use.
As a member of the Oncology Nursing Society (ONS) you have been randomly selected for
possible participation in a study that will evaluate potential barriers and facilitators to research
knowledge and use in your clinical practice. This study has important implications for ONS
members and the nursing profession.
Participation in this study is voluntary and there is no compensation for your involvement. Study
documents are enclosed for your review and completion should you desire to participate in the
study. Completion and return of the documents will be accepted as consent to participate in the
study. A requirement of the study is that the names associated with the study remain
anonymous. Because of this responses cannot be linked to anyone who chooses to participate in
the study.
The issue of barriers and facilitators to the use of research in practice is an important
consideration for the nursing profession in general. Timely completion of the study documents
will help nursing scientists to better understand the issues from the perspective of practicing
nurses. Through this understanding, improvements in how research is conducted, how it is
reported and disseminated to nurses may be accomplished. Recognizing what prevents you from
using up-to-date information in your clinical practice and some of the things that may overcome
this are an important goal of this research. Your involvement in this important endeavor is
important. I hope that you will take the time to complete the enclosed material. Should you
choose to participate the documents are enclosed for your use. Please use a # 2 pencil to mark
the enclosed scoring sheet. A prepaid response envelope is also enclosed for your use.
Completion of the material should take approximately 30-45 minutes of your time.
Sincerely,
Lawrence J. Wilcox MS, RN, FNP-BC

Principal Investigator and Doctoral Candidate
Jean K. Brown, Ph.D., RN, FAAN

Dissertation Chair
Professor in Nursing, Nutrition, and Rehabilitation Science
94
Cc: Enclosures
95
Appendix C
Reminder Postcard
96
To Whom It May Concern:
Recently you should have received a study questionnaire on evidence

based practice regarding cancer-related fatigue. If you have taken the time to
complete the study materials and returned them please disregard this request.
Your assistance is greatly appreciated.
If you have not completed the study material I hope that you will take
the time to review and complete the questionnaire. This study is important
research for oncology nursing evidence-based practice and your viewpoints are
important.
Sincerely,
Lawrence Wilcox MS, RN, FNP, BC Jean K. Brown Ph.D. RN, FAAN
Principal Investigator Co-Investigator
97
Appendix D
CRF Knowledge and Use Instrument
98
Cancer-Related Fatigue Symptom Management Knowledge and Use
Instructions: On your green scoring sheet select the answer that reflects your knowledge regarding the following statements about
research evidence for management of cancer-related fatigue. If you believe that a statement is true and you use the evidence in your clinical
practice please fill in the answer as “A”. If your answer is true and you do not use the evidence in clinical practice please fill in the answer
as “B”. If you believe the statement is not supported by research evidence please fill in the answer as “C”. Do not check what you think
might be right; only a true reflection of your knowledge. If you are unsure, fill in “D”, “don’t know” as the best answer.
True and I use in my clinical practice = intervention supported by research evidence.

True and I do not use in my clinical practice = intervention supported by research evidence
False = Research evidence lacking or inconclusive
Don’t know = unsure
True and I do not use

True and I use
Don’t know
False
1. Cancer patients who experience fatigue may need iron supplementation
which is a good way to correct anemia experienced from bleeding. A B C D
2. Cancer patients who experience fatigue may need folic acid supplementation
which is a good way to correct anemia experienced from bleeding. A B C D
3. Activities such as gardening, meditation, volunteer activities not related

to illness, or just walking or sitting in a natural environment can help to
reduce cancer-related fatigue. A B C D
4. Very few effective pharmacological agents for treatment of cancer-

related fatigue are available. A B C D
5. Generally, eating a balanced diet including proteins and 8 to 10 glasses of

fluids a day is a method to reduce cancer-related fatigue. A B C D
99
True and I use
Don’t know
False
Statement
6. Planned, long rest periods during the day have been shown to be an
effective intervention to reduce cancer-related fatigue. A B C D
7. Distractions can help to reduce cancer-related fatigue such as playing

games, listening to music, reading, or visiting with friends. A B C D
8. Pain, emotional disturbance, sleep disturbance, anemia and

hypothyroidism can all be causes of cancer-related fatigue. A B C D
9. Gradual increases in aerobic exercise has been shown to be one of the

most effective interventions for cancer-related fatigue symptom
management. A B C D
10. Exercise has been shown to be an effective intervention for chronic

fatiguing illness. A B C D
11. Energy management strategies to conserve energy can be beneficial in

the management of cancer-related fatigue symptoms. A B C D 100
12. Cognitive-Behavior therapy to address negative thinking can help to

prevent or relieve cancer-related fatigue. A B C D
True and I use
Don’t know
False
Statement
14. A cancer patient with a low hemoglobin level < 8.0 gm/dl gm may
experience fewer fatigue symptoms after a blood transfusion which
restores hemoglobin levels to 11-12 gm/dl. A B C D
15. Medications such as Paxil (paroxetine), or Wellbutrin (bupropion) have

been shown to reduce cancer-related fatigue symptoms. A B C D
16. Aricept (donepezil) may reduce cancer-related symptoms in some patients. A B C D
17. Assessment of patients with cancer-related fatigue should include

treatable etiological factors such as pain, nausea, depression, anemia,
sleep disturbance, fluid and electrolyte imbalances, and sedation
secondary to specific classes of medications. A B C D
18. Diet supplementation with Omega –3 fatty acids has been shown to
reduce cancer-related fatigue symptoms. A B C D
19. A specific combination intervention with aromatherapy, foot soak, and

reflexology has been shown to reduce cancer-related fatigue symptoms. A B C D
20. Studies have shown that joining a support group for cancer patients has
no effect on fatigue levels. A B C D
101
Appendix E
Demographic and Professional Characteristics items
102
Professional and Demographic Characteristics Questionnaire
From the following questions, please select your answer and fill in the corresponding letter on
your green scoring sheet.
21. What was the degree obtained when you first registered for RN licensure?
a. Associate degree
b. Diploma
c. Bachelor’s degree
d. Master’s degree
22. What is the highest degree you have obtained?
a. Associate degree
b. Diploma
c. Bachelor’s degree
d. Master’s degree
e. Doctoral degree
23. Do you practice oncology nursing:
a. Full time
b. Part time
c. Do not work in oncology nursing at this time
24. If you are working in oncology nursing, what is your practice setting?
a. Cancer institute/center
b. Teaching Hospital
c. Community Hospital
d. Hospice
e. None of the above
25. If you are working in oncology nursing and you selected None of the above in the
preceding question please select a practice setting from the following list.
103
a. Home care agency
b. School of Nursing
c. Ambulatory care
d. Physician’s office
e. Other not listed practice setting
26. If you are working in oncology nursing, what is your practice role?
a. Staff nurse
b. Clinical nurse leader
c. Advanced practice nurse
d. Nurse Manager
e. Nurse educator
27. If you work in a hospital setting, does your hospital have a Magnet Hospital designation?
a. Yes
b. No
d. Do not work in a hospital
28. Do you have oncology specialty certification?
a. No
b. OCN
c. AOCN
d. CPON
29. Where in the United States do you live?
a. Northeast
b. Southeast
c. Midwest
d. Northwest
e. Southwest
30. Does your organization provide a research mentor or facilitator to enhance research
utilization in your clinical practice setting?
a. Yes
b. No
104
31. In your clinical practice setting, do you use a research mentor or facilitator or do you
have a colleague you consider as a research mentor or facilitator to help you to utilize
research findings in your practice?
a. Yes
b. No
32. Do you believe that regulatory agencies such as JCHO or a Department of Health have a
positive or negative impact on research utilization in clinical oncology practice?
a. Positive
b. Negative
c. No Impact
33, How many ONS Congresses have you attended?
a. None
b. One
c. Two
d. Three
e. Four or more
34. How many ONS Fall Institutes have you attended?
a. None
b. One
c. Two
d. Three
e. Four or more
35. How many ONS Research Conferences have you attended?
a. None
b. One
c. Two
d. Three
e. Four or more
36. How many other oncology nursing conferences have you attended?
a. None
b. One
c. Two
d. Three
e. Four or more
105
37. On average how many information sources (publications, internet sources, seminars) do
you access in a month.
a. None
b. One
c. Two
d. Three
e. Four or more
38. Which information sources do you use when you want to determine the best oncology
nursing practice intervention? (You may make multiple selections in this and the next two
questions)
a. ONS Website
b. Oncology Nursing Forum journal
c. Clinical Journal of Oncology Nursing
d. Cancer Nursing
e. NCCN Guidelines
nursing practice intervention. (You may make multiple selections in this and the next question)
a. NCI Website
b. ACS Website
c. Cochrane Collaboration Database
d. Evidence Based Nursing journal
e. Cancer journal
nursing practice intervention. (You may make multiple selections)
a. Journal of Clinical Oncology

b. Other information source
41. Marital Status
a. Single
b. Married
c. Divorced/Separated
d. Widowed
42. Number of Children living at home?

a. None
b One
c. Two
106
d. Three
e. Four or more
Birthdate___________________ ( Enter on Side 2 of your green scoring sheet).
Sex (Enter on Side 2 of your green scoring sheet).
a. Female
b. Male
Enter no other identifying personal information on either Side 1 or Side 2 of your green
scoring sheet and continue with question 43 on the barriers and facilitators questionnaire
in the final section on the next page.
On the barriers and facilitators questionnaire the final six questions include subjective
information that cannot be entered on the green scoring sheet so be sure to mark the
questionnaire with your responses and return the green scoring sheet with all
questionnaires in the prepaid postage envelope.
107
Appendix F
Barriers Scale
108
Barriers and Facilitators to Using Research in Practice
THIS IS A BARRIER
Articles in nursing journals indicate that nurses in practice do not use the
results of research to help guide their practice. There are a number of
To a moderate extent
reasons why this might be. We would like to know the extent to which
To a great extent
you think each of the following situations is a barrier to nurses’ use of
To a little extent
research to alter/enhance their practice. For each item, fill in the letter
To no extent
No opinion
on your green scoring sheet of the response that best represents your view.
Thank you for sharing your views with us.
43. Research reports/articles are not readily available A B C D E

44. Implications for practice are not made clear A B C D E
45. Statistical analyses are not understandable A B C D E
46. The research is not relevant to the nurse’s practice A B C D E
47. The nurse is unaware of the research A B C D E
48. The facilities are inadequate for implementation A B C D E
49. The nurse does not have time to read research A B C D E
50. The research has not been replicated A B C D E
51. The nurse feels the benefits of changing practice will be A B C D E
minimal
52. The nurse is uncertain whether to believe the results of the A B C D E
research
53. The research has methodological inadequacies A B C D E
54. The relevant literature is not compiled in one place A B C D E
55. The nurse does not feel she/he has enough authority A B C D E
to change patient care procedures
56. The nurse feels results are not generalizable to own setting A B C D E
57. The nurse is isolated from knowledgeable colleagues with A B C D E
whom to discuss the research
58. The nurse sees little benefit for self A B C D E
59. Research reports/articles are not published fast enough A B C D E
109
THIS IS A BARRIER
To a moderate extent
To a great extent
To a little extent
To no extent
No opinion
60. Physicians will not cooperate with implementation A B C D E
61. Administration will not allow implementation A B C D E
62. The nurse does not see the value of research for practice A B C D E
63. There is not a documented need to change practice A B C D E
64. The conclusions drawn from the research are not justified A B C D E
65. The literature reports conflicting results A B C D E
66. The research is not reported clearly and readably A B C D E
67. Other staff are not supportive of implementation A B C D E
68. The nurse is unwilling to change/try new ideas A B C D E
69. The nurse does not feel capable of evaluating the quality of
the research A B C D E
70. There is insufficient time on the job to implement new ideas A B C D E
Are there other things you think are barriers to research
Utilization?
If so, please list and rate each on the scale:
71. --------------------------------------------------------- A B C D E
72. --------------------------------------------------------- A B C D E
73. --------------------------------------------------------- A B C D E
74. ---------------------------------------------------------- A B C D E
75. Which of the above items do you feel are the three greatest barriers
To nurse’s use of research?
Greatest Barriers…………………………Item#---------------
Second Greatest Barrier………………….Item#---------------
110
Third Greatest Barrier……………………Item#---------------
76. What are the things you think facilitate research utilization?
c.1987, Funk, Champagne, Tornquist & Wiese (Used with Permission).
Please return the green scoring sheet and the entire

questionnaire packet in the enclosed postage paid return
envelope.
Thank you for sharing your views!
111
Appendix F
Permission to use Copyrighted Material
112
S I M O N & S C H U S T E R
1230 Avenue of the Americas Agnes Fisher

10'h Floor Director
New York, NY 10020 Permissions Department
(212) 698-7260
(212) 698-7283 (fax)
agnes.fisher@simonandschuster.com
January 16, 2009
LawrenceWilcox3105
Cable Road Fredonia, NY
14063
Dear Lawrence Wilcox:
In reply to your fax dated January 11th, you have our permission to use Figure 5-11, A Model of Stages
in the Innovation-Decision Process, page 163 of Diffusion of Innovations, 4th Edition by Everett M.
Rogers, in your doctoral dissertation and in all copies to meet degree requirements at the University at
Buffalo, State University of New York. Reapply for permission for all subsequent uses.
The following attribution is to be reprinted in the caption for Figure 5-1:
Source: Diffusion of Innovations, 4'1' Edition by Everett M. Rogers (F. 5-1, p 163). Copyright © 1995 by
Everett M. Rogers. Copyright © 1962,1971,1983 by The Free Press, a Division of Simon & Schuster,
Inc. Reprnted with permission of the publisher. All rights reserved.
Sincerely,
113
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Major Professor: Dr. Jean K. Brown

Doctor of Nursing Science

All rights reserved

UMI Microform 3356130

professionally. Dr. Bill Wu is the consummate statistician, unparalleled in his statistical

thoughtful guidance demonstrate the important contributions he makes to further the

development of future scientists. Several times I would stop by unannounced, without an

Our frequent discussions allowed inevitability, calmness, as we progressed forward. Without

have been a good role model and father.

Diffusion of Innovations to test Research Utilization of Cancer-related Evidence by Oncology

nursing literature. Manuscript II presents the psychometric analysis of the Cancer-related

diffusion of evidence-based innovations related to cancer-related fatigue (CRF) symptom

diffusion of evidence-based innovations for CRF symptom management. Roger’s Theory of

were not significant relationship between demographic or professional characteristics on

1 Innovation Diffusion and Barriers to the Translation of Research findings

Introduction to Manuscript I………………………………...…….1

Purpose of the paper.……………………………….……………...7

Analysis of the Literature…...…………………………………….9

Stage 1. Knowledge Acquisition…………………………10

Stage 2. Persuasion ..…………………………………….12

Table 2. Studies identified at Stage 1 – Knowledge………….…28

Table 3. Studies identified at Stage 2 – Persuasion…………..…31

Table 4. Studies identified at Stage 3 – Decision……………….32

Table 5. Studies identified at Stage 4 – Implementation………..34

II. Development of an Instrument to measure RN’s Knowledge and Use of

Introduction to Manuscript II………………………………….…35

Purpose of the study……………………………………………...40

Design and setting………………………………………....40

Instrument development and testing procedures…………..41

Table 1. Selected CRF knowledge and use items for the

CRF knowledge and use instrument………………...…………...46

Introduction to Manuscript III……………………………..…..49

Barriers to research utilization….…...…….…………....55

Knowledge and use of research innovations……….......57

Strategies for reducing the research gap…………….…58

Aim 1: Describe barriers and facilitators of

research utilization among nurses specializing in

Aim 2. Describe the diffusion of evidence-based

innovations for CRF symptom management……….…61

Design and setting……………………………………..62

Barriers and facilitators of research utilization

among nurses specializing in oncology………………..65

Information sources that oncology nurses use to

update their clinical practices…………………………..66

Facilitating research translation with a mentor or

Demographic or professional characteristics

related to oncology nurses perceptions of barriers

Perceptions of the effect of regulatory bodies

Knowledge and Use of CRF symptom

Information sources predictive of utilization

of CRF symptom management innovations……………68

Extent to which Roger’s predicted diffusion

of CRF symptom management evidence knowledge

Table 1. Demographic and Professional Characteristics of

Table 2. Barriers scale items means and standard deviations…82

Table 3. Individual information sources as reported by

Table 4. CRF Knowledge and Use………………….…………84

Table 5. Pearson correlationis for all information sources….…85

IV. Dissertation Synthesis and Discussion…………………………86

A Institutional Review Board Approval………………………….89

B Cover letters – implied consent………………………………...94