Supporting rural and remote area nurses to utilise and conduct research: An intervention study

Collegian (2012) 19, 97 105 Available online at www.sciencedirect.com jo ur nal homep age: www.elsevier.com/locate/coll Supporting rural and remote area nurses to utilise and conduct research: An intervention study Anne Gardner, RN Crit Care Cert BA MPH PhD a,b,c,, Wendy Smyth, RN BA MAppSc GradDipQuality MBus PhD b,c,1, Bronia Renison, BA AssocDipLib d,2, Tina Cann, RN BNSc (Hons) b,3, Mary Vicary, RN RM BAdmin Nursing e,4 a School of Nursing (NSW&ACT), Australian Catholic University, Australia b Tropical Health Research Unit for Nursing and Midwifery Practice, Townsville Health Service District, Australia c James Cook University, Australia d Townsville Health Library, Townsville Health Service District, Australia e Ayr Hospital, Ayr Health Service, Australia Received 16 December 2010; received in revised form 1 September 2011; accepted 2 September 2011 KEYWORDS Research utilisation; Nursing practice; Evidence-based practice; Edmonton Research Orientation Scale; Rural nursing Summary Background: Nurses are expected to embrace research and evidence-based practice but in rural/remote facilities it is particularly difficult to develop and utilise research skills. Objectives: This collaborative study aimed to explore nurses orientation to research and address known inhibitors to engagement with research in rural/remote north Queensland locations. Participants: The sample comprised nurses from two rural/remote areas within a regional health service. Methods A pre-test post-test intervention study with two levels of data collection: responses to Edmonton Research Orientation Scale administered 3 times to all nurses, and number of research proposals developed. This intervention comprised provision of face-toface workshops, paper-based resources, and informal videoconference, email and telephone contact. Results: Survey response rates varied from 56% to 34%. Two-thirds of respondents were over 40 years old; 75% were Registered Nurses. One quarter rated understanding of journal articles as poor or very poor and 50% rated their knowledge of research similarly. However, 50% said Corresponding author at: School of Nursing (NSW&ACT), Australian Catholic University, Canberra Campus (Signadou), 223 Antill Street Watson, Canberra, ACT 2602, Australia. Tel.: +61 02 6209 1330. E-mail addresses: Anne.Gardner@acu.edu.au (A. Gardner), Wendy Smyth@health.qld.gov.au (W. Smyth), Bronia Renison@health.qld.gov.au (B. Renison), Tina Cann@health.qld.gov.au (T. Cann), Mary Vicary@health.qld.gov.au (M. Vicary). 1 Tel.: +61 07 4796 2666. 2 Tel.: +61 07 4796 1760. 3 Tel.: +61 07 4796 2666. 4 Tel.: +61 07 4783 0811. 1322-7696/$ see front matter 2011 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. doi:10.1016/j.colegn.2011.09.005

98 A. Gardner et al. research had changed the way they practiced. Older nurses, nurses with tertiary qualifications and those with senior appointments had more positive orientation to research scores. Several locally relevant research proposals were developed from one site; two received internal funding for further development and implementation. The intervention also led to increased utilisation of library resources which has continued past this study s end. Conclusions: The variation in uptake between sites reinforces the need for locally targeted support. This study has gone beyond measuring research utilisation by including evaluation of support mechanisms to engage nurses in developing research proposals. 2011 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. Background A culture that embraces research and evidence-based practice is a hallmark of professional nursing and is imperative when providing quality health care (ICN, 2006). Nurse clinicians are increasingly expected to incorporate the best available evidence into their practice, to participate in research teams and to plan and conduct their own research projects. However, nurses across all practice areas have identified difficulties with being actively involved in research (Milner, Estabrooks, & Humphrey, 2005). Many researchers have endeavoured to identify factors that facilitate and inhibit the utilisation of research in practice (Estabrooks, Floyd, Scott-Findlay, O Leary, & Gushta, 2003; Hutchinson & Johnston, 2004; Kajermo et al., 2008), with minimal research focused on the direct involvement of nurse clinicians in the conduct of research (Smyth, 2008). The Australian National Competencies for Nurses (Australian Nursing & Midwifery Council, 2005) include mention of research for all nurses. However, explicit employer expectations for clinically based nurses to participate in research are rarely documented, despite being recommended in the literature (Milner et al., 2005). Nurses of all levels working throughout a large regional health service in North Queensland (hereafter referred to as the district) are expected to embrace research and evidence-based practice. Unlike many other health services, the position descriptions of those designated as Clinical Nurses (a senior clinical nursing classification, also known as Clinical Nurse Specialists, in Australia) include overt reference to the need to undertake an action-based research project annually. The theoretical basis for this iniative includes the premise that local champions will lead others to implement research utilisation and more specifically evidence-based practice (Milner et al., 2005; Rogers, 2003). The district covers 169,400 sq km and includes 10 smaller rural and remote facilities in addition to the main tertiary referral hospital for North Queensland. A modest clinical nursing research unit has, as part of its mandate, a responsibility to support these Clinical Nurses. We have been successful in supporting nurses based at the large district hospital to undertake research and publish their findings (Hartig & Smyth, 2009; McArdle & Gardner, 2009) but nurses working within the smaller, rural and remote facilities find it difficult to fulfil this expectation. Many organisational factors, including distance from the regional hospital, local staffing levels and workload needs, have limited nurses face-to-face support and educational opportunities. These factors have compounded other so-called barriers in the literature, which relate to aspects associated with the organisation, the individual and the nature of research itself (Funk, Champagne, Wiese, & Tornquist, 1991). The Barriers Scale, originally developed by Funk et al. (1991) has been used in many countries with nurses at different levels working in diverse settings (Glacken & Chaney, 2004; Kajermo, Nordstrom, Krusebrant, & Bjorvell, 2000; Oranta, Routasalo, & Hupli, 2002). Whilst many studies about barriers to research utilisation emphasise factors associated with the individual nurse, the organisation s role in the provision of a climate conducive to research is increasingly being acknowledged (Adamsen, Larsen, Bjerregaard, & Madsen, 2003; Bonner & Sando, 2008) as is the complexity of implementing evidence-based practice, with no single method being adequate to effect change (Guldbrandsson, 2008). Other studies have used the Edmonton Research Orientation Survey (EROS) (Bonner & Sando, 2008; Carlson & Plonczynski, 2008; Henderson, Winch, Holzhauser, & De Vries, 2006) to focus on the positive attitude that clinicians have towards research as well as the relationship between education about research and its use (Bonner & Sando, 2008, p. 385). Furthermore, the mere identification of perceived barriers to research utilisation or intentions to increase involvement in research, does not necessarily translate into changed behaviours (Carlson & Plonczynski, 2008). Even involvement in an intervention to demonstrate the usefulness of research findings in resolving practice problems (Henderson et al., 2006, p. 1564) did not result in nurses reporting a greater intention to implement research findings. But research findings are conflicting; for example, Danish nurses who participated in a specifically designed 12-month research course reported greater commitment to using and conducting research, compared to the control group who did not receive the education (Adamsen et al., 2003). Very little research explores research orientation or involvement of nurses in rural and remote settings (O Lynn et al., 2009). Not all nurses need to conduct research but all need to be involved in utilising research and there are several models of research utilisation. The Ottawa Model, proposed by Logan and Graham (1998) has particular strengths because of its inclusion of patient and service outcomes in the evaluation process. Logan and Graham examine inputs, such as the working environment and do not stop at the practice of research utilisation but include its effects. Utilisation of research is just a stepping stone and is finally being

Supporting nurses to utilise and conduct research 99 clearly seen as an intermediate outcome (Estabrooks, 2007). Accordingly, there is a need to quantify the attitudes and orientation to research of rural and remote nurses in a region where the level of engagement is improving, and to test interventions with the potential for broader application across regional and rural Australia and overseas. We wanted to explore the particular issues for rural and remote facilities and evaluate the use of a tailored program building upon factors known to be supportive of developing a nursing research culture. This paper reports quantitative findings from a study undertaken in North Queensland, Australia. Research aims and questions This project aimed to explore associations between delivery of a multifaceted education program for senior clinical staff, development of locally relevant clinical research projects and nurses attitudes to and orientation towards research in two rural and remote Australian sites. There were two questions: Question 1: Is the implementation of a structured, multifaceted education and support program for senior clinical staff associated with improvement in all rural and remote nurses attitudes and orientation towards research? Question 2: Is the implementation of a structured, multifaceted education and support program associated with development of clinical research proposals related to the local context by rural and remote Clinical Nurses? Methods Study design This was an intervention study, with a pre-test post-test design. Data were collected at three time points in relation to Question 1 and a post-test only design with outcome data collected at one time point was included for Question 2. Setting Two healthcare sites were utilised. At the time of the study, Site X, was a 55-bed facility with 56 full-time equivalent nurses (FTE) and consistently had a nursing staff turnover of approximately 10% per annum. Site Y comprised a number of small facilities where the total nursing complement varied during the study period, ranging from 92 to 94 (including both full and part-time staff), with an unknown turnover, although suspected to be higher than at Site X. Population, sampling, recruitment strategies For Question 1 the sampling frame comprised all consenting nurses at the two study sites. For Question 2, purposive, non-probability sampling of the population of nurses from both sites was used and once the program was in place, some nurses decided to form teams in order to develop the clinical research proposals. The education intervention comprised initial face-toface workshops, conducted 1 week after the closing date for return of the first questionnaires, followed by further face-to-face visits and videoconferences over a 6-month period. Informal phone and email support was also provided. Ongoing contact was primarily aimed at the nurses developing research proposals. A multidisciplinary team comprising both nurses and librarians provided the workshops and ongoing support. The content of this multi-faceted intervention was adapted from face-to-face educational support already provided at the regional hospital but was responsive to the needs of the nurses at the rural and remote sites. To ensure all participants had access to necessary resources, textbooks and resource packages were provided as well as access to computers during the workshops. The intervention was primarily based on the recognition of nurses continuing need for education about research (McCleary & Brown, 2003b) and the importance of mentorship and collaboration between academic and clinical nursing (Downie et al., 2001; Happell, 2005). Data collection tools For Question 1 of the study, the EROS was used to collect data pertaining to nurses attitudes and perceived ability to use research (Pain, Hagler, & Warren, 1996). This is a validated and reliable self-report tool comprising three sections. This tool had already been adapted and used with permission in Far North Queensland (Bonner & Sando, 2008); the tool s original author granted similar permission for use in this study. Section A of the tool has 13 items and, as well as exploring demographics, includes a five item set measuring respondents understanding of research. Section B, the longest component, comprises 38 items and measures orientation to research and research related activities. Section C has five items and measures supports and barriers. All research related items are scored using five-point Likert scales. For Question 2 of the study, participating nurses were asked to prepare and submit, within 6 months, a research proposal that met the criteria for a local internal funding source. All completed proposals were reviewed by a nurse academic not involved with the study and feedback was provided to participants. Human research ethics approval was obtained from the health service district and university ethics committees. A participant information sheet accompanied the postal surveys and completion of the survey indicated consent. Questionnaire respondents created a code unique to them, to be used when completing the EROS at each of the three time points. This enabled linkage of responses over time but maintained anonymity. Initial mail outs were followed by one postal reminder and two email reminders to all nurses. Nurses recruited for the educational intervention component signed a consent form. Data management and analysis Data were entered into an electronic database and analysed using PASW Statistics 18 (PASW statistics 18, release 18.0, Polar Engineering and Consulting 2009). Results were

100 A. Gardner et al. Table 1 Response rate for both sites at Time 1, Time 2 and Time 3. Site X Site Y Totals at each time period Time 1 Number of surveys distributed 70 94 164 Total number of surveys returned 41 (59%) 38 (40%) 79 (48%) Time 2 Number of surveys distributed 77 92 169 Total number of surveys returned 33 (43%) 35 (38%) 68 (40%) Time 3 Number of surveys distributed 78 94 172 Total number of surveys returned 27 (35%) 20 (21%) 47 (27%) Totals at each site Number of surveys distributed 225 280 505 Total number of surveys returned 101 (49%) 93 (33%) 194 (38%) explored for erroneous coding and missing data. More than 10 respondents did not complete two items in Part B of the EROS; these items were removed from further analysis. Missing values for all other items were imputed using the mean replacement method (Munro, 2005). This conservative procedure reduces variance but provides a more complete dataset for analysis. Descriptive comparisons were made for all items in the survey, both within groups over time and between groups (Site X and Site Y). Consistent with previous reporting of research using EROS as a survey instrument (Henderson et al., 2006; McCleary & Brown, 2003a; Pain et al., 1996), Likert scales were reported using means and standard deviations as measures of central tendency and dispersion on the assumption that the Likert scale values were equidistant. Pain et al. (1996) identified four subscales possible within EROS, utilising 31 of the 38 items in Part 2 of the instrument and values were calculated for these subscales: being at the leading edge (6 items), valuing research (8 items), evidence based practice (10 items) and research involvement (7 items). Due to the nature of the response rate, with some respondents completing two or three surveys and others completing only one survey, it was not valid to make statistical comparisons either within or between groups. Results The first part of this study explored the attitudes and orientation to research of nurses working in two different rural and remote areas prior to, during and following an educational intervention. Overall response rate was 38%. Response rate reduced over time with a 48% response rate at Time 1 reducing to 27% at Time 3 (see Table 1). The reduction in response rate over time was seen at both sites; only 18 nurses responded to all three surveys. The characteristics of respondents at Time 1 are displayed in Table 2. Totals only are reported for sex ratio and clinical area to preserve the anonymity of each site. There were few males and the majority of nurses were aged over 40 years old. The nurses worked in a diverse range of clinical settings and many nurses stated that they worked in more than one area. A quarter of the workforce was Enrolled Nurses (Enrolled Nurses generally have a diplomalevel of education and work under the delegated authority of Registered Nurses). One third were Registered Nurses who held senior clinical, managerial or educational roles. Demographic, professional and clinical practice characteristics of survey respondents were similar over the period of the study at both sites with two exceptions. At Time 3 a higher percentage of respondents were senior nurses and fewer respondents reported previously studying research subjects at a tertiary level. Approximately 56% of nurses held tertiary qualifications with 13% currently undertaking further studies. Two thirds of respondents undertaking further studies were enrolled in post graduate courses. Turning now to the main results of the survey, the first section included five items about nurses knowledge and orientation, asking respondents to rate their understanding of research design and statistics. The five-point Likert scale was recoded into poor, average and good. The percentage of nurses who rated their understanding of research as good diminished over time, reducing from 11% at Time 1 to 5% at Time 3. The second section of the survey comprised 38 items about orientation to research, again using five-point Likert scales. As previously described, responses to two items were removed due to poor response levels. The possible mean score ranged from 36 to 180 with higher values being more positive. Table 3 presents mean scores at each site and across time. Whilst total means scores did not appear to change over time, the mean scores at each site were different. Thus orientation to research, as measured using EROS, appeared to improve over time at Site Y but decreased at Site X resulting in no total mean difference over time. The 38 items can be also grouped into 4 subscales. Table 4 provides the means for these subscales over time by respondents demographic and educational characteristics. Older nurses (aged 40 years and over), nurses with tertiary qualifications and those who were employed at more senior levels scored consistently higher mean scores across all subscales and all measurement times with the exception of nurses with tertiary qualifications at Time 1. Although the mean differences varied between groups and were generally not large, the order of subscales overall was consistent with leading edge being the highest scoring and involvement the lowest

Supporting nurses to utilise and conduct research 101 Table 2 Demographic, professional and clinical practice characteristics of respondents at each site at time 1. Site X (n = 41), n Site Y (n = 37), n Total (N = 78) a, n Gender Male Intentionally blank Intentionally blank 4 Female 74 Total 78 Age group 40 years old or less 12 13 25 Greater than 40 years old 29 23 52 Total 41 36 77 Clinical area Acute & OPD Intentionally blank Intentionally blank 42 Community 10 Mental health 13 Aged care 7 Management/admin/education 5 Total 77 Hours worked Full time only 14 24 38 Part time only 3 1 4 Combination 22 12 34 Total 39 37 76 Nursing classification Enrolled nurse 10 8 18 Registered nurse 22 11 33 Clinical nurse or higher 9 18 27 Total 41 37 78 Highest level education Hospital certificate/tafe 21 13 34 Bachelor degree 11 13 24 Post graduate degree 9 10 19 Total 41 36 77 Participants currently pursuing qualifications Yes 3 6 9 No 38 31 69 Total 41 37 78 Type of qualification currently being studied (n = 9) Bachelor of nursing 2 1 3 Post graduate degree 1 5 6 a Where total is less than 78, respondents did not complete this question. Table 3 Comparison of total orientation to research across time. Time period and location Mean (SD) at each site Total mean (SD) Time 1 Site X 120.1 (22.8) 121.5 (21.4) Site Y 123.1 (20.0) Time 2 Site X 121.0 (24.3) 124.9 (20.4) Site Y 128.5 (15.4) Time 3 Site X 117.3 (25.4) 123.2 (23.0) Site Y 131.2 (16.8) scoring. The order of evidence based practice and valuing were transposed for the subgroup Clinical Nurse or above at Time 2, and for nurses with tertiary qualifications at Time 3. The final section of the survey measured perceived supports and barriers to research participation. Response scores to two items were reversed for consistency of analysis and the total possible score ranged from 5 to 25 with higher scores indicating more negative response. There was no apparent difference in mean scores either across time or between sites with the total mean varying from 16.0 (SD 3.4) to 16.4 (SD 3.3) over time. For Question 2, 18 nurses consented to participate in the education component of the project, but three withdrew early in the intervention. These nurses either worked alone or in small groups to develop proposals for projects appropriate for their local context. Six teams at Site X (12 nurses)

102 A. Gardner et al. Table 4 EROS subscale means over 3 time periods. Characteristic EROS sub-scales Time 1 Time 2 Time 3 Age group 40 years or less Leading edge 3.75 3.59 3.76 Valuing 3.41 3.50 3.70 EBP 3.37 3.50 3.55 Involvement 2.09 2.45 2.50 Greater than 40 years Leading edge 3.85 3.94 3.81 Valuing 3.73 3.69 3.60 EBP 3.70 3.64 3.81 Involvement 2.58 2.66 2.51 Highest qualifications Hospital cert/tafe Leading edge 3.83 3.79 3.56 Valuing 3.67 3.59 3.21 EBP 3.59 3.49 3.22 Involvement 2.44 2.51 2.9 Tertiary qualifications Leading edge 3.79 3.99 3.98 Valuing 3.58 3.77 3.93 EBP 3.57 3.77 3.89 Involvement 2.37 2.70 2.75 Current position EN or RN Leading edge 3.73 3.79 3.59 Valuing 3.50 3.63 3.35 EBP 3.47 3.49 3.27 Involvement 2.29 2.59 2.39 Clinical nurse or above Leading edge 3.94 4.01 3.91 Valuing 3.84 3.75 3.88 EBP 3.78 3.81 3.85 Involvement 2.63 2.76 2.64 EN, enrolled nurse; RN, registered nurse. and three teams at Site Y (3 nurses) were established. Within this group of 15, there was one Enrolled Nurse, two Registered Nurses and 12 other nurses who were working at least at a Clinical Nurse level. Six proposals were produced from Site X and none were received from Site Y. The topics and clinical focus were diverse and addressed both practical and management issues. Each proposal was independently assessed and feedback provided. A summary of the main assessment findings are provided in Table 5. In summary, the survey results do not demonstrate any major changes over time in perceived knowledge of research, research orientation or perceptions of barriers and supports to research. Despite the same structured educational intervention being delivered at two rural sites, clinical nurses at only one site completed research proposals within the study timeframe. Discussion This study explored the attitudes and orientation to research of nurses in two rural and remote areas. The study had two outcomes of interest: first, to explore changes in levels of research orientation for all nurses at the study sites (not just Table 5 Specific strengths and weaknesses identified from proposals. Summary of proposal feedback Strengths Clearly stated aim and objectives The context behind the project identified Key ethical issues identified Budget implications identified Weaknesses Literature review, especially: - Sourcing and critiquing literature - The use of recent literature - Correct referencing style/technique Methodology - Design - Recruitment process - Instrumentation those nurses receiving the intervention); and second, to test the potential of the intervention to provide selected nurses with the skills and resources to enable them to develop highquality research proposals relevant to their local context.

Supporting nurses to utilise and conduct research 103 This study has gone beyond measuring research utilisation and has evaluated support mechanisms to directly engage nurses in developing research proposals and to influence the research orientation of their colleagues. The findings from this study were mixed. Whilst survey results from both sites suggest a multifaceted education intervention was not associated with changes in research orientation as originally hypothesised, several research proposals were developed, although only from one of the two sites. Models of research orientation and knowledge translation There are many models of research utilisation and knowledge translation. Our study was informed in part by the work of Rogers, now in its 5th Edition (2003), about the diffusion of innovations and especially his ideas about early adopters of innovation. Rogers earlier work informed Logan and Graham s work on the Ottawa Model of Research Use (OMRU) (Logan & Graham, 1998). The conceptualisation of OMRU attempted to identify elements that affect the transfer of research-based evidence into practice and relationships between these elements. The OMRU has six elements that represent inputs, processes, and outputs of the transfer of research into practice. The inputs are the practice environment, the potential adopters, and the evidence-based recommendations. The process elements are the strategies by which research is transferred and the adoption of that research. The outputs are the outcomes of the transfer processes. Although presented in a linear format, the relationships between the elements are not unidirectional. In practice, all elements of the model influence each other. Our intervention addressed several aspects of the OMRU. The lack of support for rural and remote nurses had been identified (practice environment) and our intervention targeted key nursing personnel (potential adopters). The study mainly explored the processes of knowledge translation with clinically relevant research proposals as a specific output to be measured. Understanding the conceptual framework that informs survey instruments is also important. The positive focus of EROS was an important factor in selecting this instrument for our study and the four subscales identified by Pain et al. (1996) potentially provide clarity in teasing out exactly what research orientation comprises: Being at the leading edge a value for innovation and change. Valuing research a positive attitude towards research. Evidence based practice this is a similar to instrumental utilisation, a construct forming part of research utilisation as discussed by Estabrooks (1999). Research involvement a measure of direct research participation by nurses. McCleary and Brown (2002) explored the ranking of these subscales and found a well reproduced ranking amongst health professionals. From highest to lowest the rankings in their study were as listed above. This ranking was largely reproduced in our study and has been previously identified in another Australian study (Henderson et al., 2006) suggesting strong content validity for the instrument internationally. In our study the mean score for research involvement was considerably lower than for the other three. One item in that subscale was consistently omitted by our respondents leading to removal of this item from our data analysis. In previous studies omission of several items relating to direct experience of research has been viewed as probably indicating no involvement and ascribed a low score (Pain, K., personal communication, July 21, 2010). Had we ascribed missing values for this item and included it in the subscale the mean value would have been even lower. Older nurses, those with tertiary qualification and those working in higher ranked positions had consistently higher mean subscores and total EROS (with the one exception as previously described) although these differences were not large. McCleary and Brown (2002, 2003a) identified an association between positive attitudes to research and generally higher educational levels using EROS as did Pain et al. (1996) in early work on the instrument. Not surprisingly, this association is also replicated when some other instruments measuring attitudes to research are used (Brown, 1997). However, in a systematic review of individual determinants of research utilisation, Estabrooks and team found that, although education was the most commonly studied presumed determinant of research utilisation, findings in individual studies were evenly divided (Estabrooks et al., 2003). Recommendations from the systematic review include a need for common approaches to measuring relevant factors. We need to know whether it is the general intellectual development and critical analysis hopefully gained from tertiary level study that improves research utilisation or whether specific research training modules are sufficient, for example to facilitate understanding of sample size calculations or statistical analysis. The contribution of respondent age to research utilisation is even more unclear. In our study older nurses had somewhat higher scores. In regression modelling for determinants of overall research utilisation amongst nurses in Canada, Milner et al. (2005) found that greater age had a significant negative effect on research utilisation scores. For age, Estabrooks et al. s (2003) systematic review found no studies that reported significant relationships between age and research utilisation. Others have reported that younger nurses have more negative attitudes to research utilisation that their older colleagues (Forman, Creswell, Damschroder, Kowalski, & Krein, 2008) a finding that would be especially disheartening to advocates of research utilisation given the increasingly degree-educated nursing workforce. Development of research proposals We are unsure why staff at one site managed to complete proposals and staff at the other site did not. This finding was all the more interesting given that mean EROS scores were slightly higher at the site where no proposals were developed. The recruited nurses from Site Y, where no complete proposals were developed, elected to work independently rather than in teams, which may have increased the workload considerably. The clinical facilities at Site Y were much more dispersed and there were significant unplanned changes in staffing at both senior and junior levels

104 A. Gardner et al. during the study. Whilst there is evidence that dispersed sites mitigate against collaborative research integration (Moffitt et al., 2009), we could find no specific identification in the published literature of staff changeover being a factor. All submitted proposals related to specific clinical problems encountered within the rural facilities and had been identified as needing to be solved at the local level. The independent reviewer indicated that the nurses were able to clearly state the context behind their project. This strength may be linked with the high ranking of being at the leading edge with nurses being excited at potentially solving their clinical problems. The reviewer s results are also consistent with the survey finding about perceived research skills. The nurses realisation about their knowledge of research skills may have become more acute as they developed the proposals, resulting in lower reported scores over the course of the study. In addition, their lack of previous research involvement may have contributed to their relative inability to describe research methods within the proposals. We were somewhat surprised about the lack of literature search and critique skills evidenced in the participants proposals given that a large component of the educational intervention focussed on electronic search techniques. The findings reinforce just how much education and ongoing support is needed. Limitations It was disappointing that we were unable to obtain a greater number of linked survey responses over time, although the overall response rate of 38% compares favourably with other similar surveys (Henderson et al., 2006; McCleary & Brown, 2003a). Bowling (2002) reports that sending out several reminders after the initial mailing is effective in increasing overall postal survey response rates, and estimates that each reminder should produce a return of approximately a quarter to a third of responses. The reminders did result in increased response rate in our study and we would certainly use the same process again. The small sample size must also be acknowledged as a limitation. However, given the small staffing numbers at rural and remote locations, sample size will always be a challenge when looking for quantifiable change over time. Adequately powered studies using cluster randomised trial design are needed but may mean that interventions cannot be tailored to local needs. The lack of strong site specific differentiation in mean scores is puzzling, given the marked difference in success at developing research proposals. The simplest explanation is that the sample size was not sufficiently great. It is also reasonable to postulate that there were unknown site specific factors that were difficult to identify in this comparison of just two sites. Implications for practice, education and research As a consequence of the mixed but interesting findings and generally very positive responses to the face-to-face site visits and follow-up support, a recommendation was made for the conduct of a district-wide survey to better understand the potential variation in research orientation across the district. This much larger sample size will enable adequately powered statistical comparisons to be made and will provide a more comprehensive perspective regarding research orientation across a district with diverse health facilities. From these findings there are implications for practice, education and research. There is great potential to support clinically based nurses in rural and remote areas to identify problems that can be successfully investigated but the nature of the support needed is complex. Specifically, from an educational perspective, support mechanisms that are successful in one area may not work in another and so educators and mentors need to be flexible in their interventions. These interventions require thorough exploratory work so that underlying systems are understood and this will necessitate use of both quantitative and qualitative methods (Milner et al., 2005; Rogers, 2003). From a research perspective, this study has reinforced the construct validity of EROS in an Australian nursing sample given that the ranking of the subscales is similar to that of Canadian and American nurses and other health professionals. Conclusions Nurses research orientation and utilisation are complex phenomena but there are discernable patterns internationally. As measured using the EROS, Australian nurses report valuing innovation and change most highly when compared with evidence-based practice and research utilisation. Like their international counterparts, few clinically based Australian nurses are directly involved in the conduct of research. Estabrooks called for multidisciplinary studies and explicit articulation of the theoretical framework in future published studies and this paper has addressed these demands (Estabrooks et al., 2003). More research is needed to identify clearly the nuances of nurses perceptions about research, research utilisation and innovation. Only when this is better understood will we be able to adequately support nurses to be clinical researchers. As a beginning the education and support model described in this study has been partially successful and will be extended to other rural and remote areas within the district to be tested more broadly. Conflict of interest statement The authors declare that there are no conflicts of interest. Acknowledgements This project was funded through a Queensland Health Nursing and Midwifery Grant Experienced Researcher Category, awarded in 2008. A paper, presenting preliminary findings, received the Director General of Health s Encouragement award at the Office of the Chief Nursing Officer s Passionate about Practice Conference, Brisbane, Australia in September 2010. Special acknowledgement goes to: Dr. Kerrie Pain and her team for permission to use the Edmonton Research Orientation Survey.

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