Initially 53 registered nurses (RN) volunteered and signed a consent to participate, however not all responded to the contact emails to arrange a focus group time or were able to find a suitable time to participate, and so 40 registered nurses completed the study in 14 focus groups of 1–6 participants. All focus groups were planned to be at least three participants in addition to the investigator, however last-minute cancellations meant that was not always possible and three focus groups proceeded with only one participant and the researcher conversing.
All participants were registered nurses licensed to practice in Australia, located in every state and territory of Australia in a variety of urban (n = 23), rural and remote areas (n = 17). Most participants were female, and their ages ranged from 24 – 65 years. Participants were working in a wide range of clinical settings including emergency department (n = 7), medical-surgical (n = 7), intensive and critical care (n = 5), mental health (n = 5), perioperative services (n = 3), oncology (n = 3), remote area nursing (n = 3), family nursing (n = 2), pediatrics (n = 1), occupational health (n = 1), community nursing (n = 1), rehabilitation (n = 1), and Aboriginal health (n = 1). All spoke fluent English, as required for nursing registration in Australia , however several spoke English as an additional language. Most were very experienced in their nursing career, with an average length of nursing experience of over 20 years and the majority of participants had a postgraduate level of education (Table 1).
The 14 focus groups with 40 participants yielded three themes: ‘Coming into learning about research’, ‘Fitting research into the reality of nursing life’, and ‘Working towards using research’ and ten subthemes (Table 2). All participant names used here have been pseudonymized. Pseudonyms, ages and length of RN career are provided in parentheses with each participant quote to give further context to participants’ responses.
Theme 1: Coming into learning about research
Given our interest in nurses’ early learning experiences regarding research, a significant part of each group discussion focused on participants’ first encounters with research. Participants had come to nursing from a variety of paths; as school-leavers, mature-age students changing careers or entering the workforce at a later age, so they had a range of educational and life-skills preparation as they entered nursing. Some participants had begun nursing prior to tertiary nursing education implementation, having been trained in hospitals, and this also impacted on their experiences of learning about research even if they had completed tertiary studies at a later time.
Most of our participants had begun their careers when nurse education was very different from today, some in the early days of university education and some through the hospital training system. This time gap had an impact on the recall of these early events for some participants but for others the memories of their experiences were very clear. Participants described, some with laughter, their initial feelings when first faced with learning about research, either in their undergraduate nursing degree or subsequent graduate level studies, conveying a range of reactions:
When I was first exposed to research as an undergrad, I was horrified (Jack, 55, RN 26 years), I mean it was really good. I loved it, but it was a very steep learning curve (Anna, 59, RN 13 years), and, I didn’t really take any interest in articles until I started my first Masters (Joy, 52, RN 33 years).
Difficulty understanding the concepts and feeling lost were common experiences for these nurses as they began to learn about research. Using self-deprecating humor, participants spoke of trying to find simple articles they could understand:
What I would try to do is I would try to find this… Try, try to find the sort of research that spoke in the most simplest of terms.., once I got halfway through it and I recognized that it was well beyond, above me…(Walter, 49, RN 29 years)
The volume of research available was confusing to them as students and they found it hard to identify which was relevant:
It’s so broad trying to get so much, I think I actually did, you know, like I went to areas that wasn’t meant to be trying to gather information because of time limit I found it was overwhelming (Fatima, 47, RN 9 years) and evidence for practice was not necessarily connected to research being used for an assignment: I think as an undergraduate, you can’t… The research underpins your theory so that you have some kind of extended understandings to what you’re doing and why, but once you actually get into a prac experience and you’re actually on the floor with your mentors or etcetera, then you kind of don’t link the two together (Kathy, 46, RN 11 years).
Early learning also brought with it problems of how to interact with the research literature. How and if to critique the literature was recalled as a significant problem:
I vividly remember thinking, who am I to put up an argument against this? These people have published this, for goodness sake. You know who am I to say that they’re wrong? So that was my first thing was it was really difficult (Sophie, 51 RN 30 years)
Developing a critical mindset was not something they found easy to develop:
I just took them all as gospel. You know, what was in these articles was gospel, and I used what I could (Joy, 52, RN 33 years)
Others, however, felt they had personal characteristics that helped them in their early learning years:
I was always a bit of a bookworm, so yeah, I didn’t struggle too much with that (Jenny, 52, RN 27 years)
Help with learning
A great deal of the focus groups’ conversations about their formative years dealt with the help participants had received with their research learning, including help from mentors and role-models. One participant remembered:
When I was doing my nursing degree, one of the best and most memorable tutorials I ever had was in a research topic, which are traditionally the ones everyone hates, find really difficult to do. I had a very inspiring tutor in that topic, and the most memorable tutorial I think I ever had was when we discussed ethics in research (Tess, 42, RN 13 years)
Other participants recalled helpful programs such as peer mentoring, learning success programs, and academic writing courses, as well as library services and librarians that were another source of valuable help. Mentors, lecturers, educators and peers were described as helpful, inspirational, or supportive, and they were described as key to surviving these early learning experiences, according to participants’ recollections:
Having good role models, and as I said… Or as I said, mentors, but having mentors, good role models, good people around you that value it helps you to value research ’cause you see what they can make of it (Jack, 55, RN 26 years) and: Study-wise, like I said, I had a fantastic mentor that just encouraged me and pushed me and pushed me, and it was wonderful (Sarah, 59, RN 40 years)
Similarly, the absence of role models was felt to be an additional source of difficulty:
…they tell you to find a mentor or… There just wasn’t anyone. You know, it’s yeah, a small country town. You don’t find anyone, there’s, there’s nobody that understands it, there’s nobody that… that can do that interpretation for you…that…can help you with how to do that (Jenny, 52, RN 27 years)
Theme 2. Fitting research into the reality of nursing life
This theme and its three subthemes (organizational issues, interpersonal issues, and confidence) emerged from discussions of how reading and using research connected with the rest of their nursing lives. Participants were asked about how any difficulties they had with learning to understand research impacted on how they perceived their chances for success as a nurse, how pressures from their working life impacted on interacting with research literature, and how their degree of comfort with reading and using research influenced their involvement in work activities. The need or desire to read and use research sometimes did not fit well with a nursing career, especially in the early years when it was perceived that consolidating the tasks of nursing was paramount. Supportive structures, senior staff and peers were spoken of admiringly, with a sense that they were ‘lucky’ to be in a research-friendly environment. Achieving confidence with reading and using research was seen as a function of personal characteristics rather than the actions of educators and workplaces.
A prevalent view across multiple focus group discussions was that organizations were perceived to view nurses’ involvement in evidence-based practice (other than simply complying with policy) as an optional extra in the context of getting the job done:
There’s really no time for anything else, and from a higher level, research is considered something of a luxury. If there’s resource cuts, then education and research are always hit first (Samantha, 55, RN 22 years).
Some participants perceived that preserving the status quo was a higher priority than promoting practice change:
…if people understood how to use the databases, how to research evidence to back up practice or to, or even just to augment their practice great, but it’s so hierarchical in nursing and people guard their policies and procedures with their life. I don’t think they want change sometimes (Kerry, 53, RN 18 years)
The hierarchical nature of many nursing structures also worked against participants’ desires to become involved in EBP activities:
I have never been involved in projects, before because of the hierarchy, I’m at the bottom level (Fatima, 47 RN 9 years)
Many participants worked in organizations with expectations that staff participate in EBP activities, but that did not necessarily mean that resources or support was available to facilitate these activities:
The fact that I was in a, a large metropolitan health service still didn’t mean that I could reach out and grab somebody to help me, So but in more recent times, they’ve put some structures in place to improve that, and it has improved. However, would I call it supportive? I don’t know that I’d call it that (Walter, 49, RN 29 years)
There was a consciousness of different organizations being at different levels of engagement with EBP:
…other organizations I’ve worked for in the past, they’re at the forefront, they’re engaged with universities and tertiary providers which work alongside the clinical service, and I think that people have a greater understanding about the importance of research and generating research outputs and also using that to inform practice. Whereas, I think that not all organizations are at that stage, which is just how it is really (Ron, 40, RN 16 years)
Many participants recognized that EBP was not something they could really achieve alone, and that without the cooperation of their team it was unlikely they could influence practice change. There was also considerable discussion of the overt hostility some had faced when trying to change practice or undertake further studies. The nature of interpersonal interactions was of considerable importance to these nurses, reflecting the strong focus on teamwork in nursing. Being ‘different’ or acting outside the team’s norm put individuals at risk of feeling out of place in their workplace or in their job. Other participants related stories of assistance and support and spoke of their pride in their workplace and team for providing high quality care.
The perception that research and EBP are not really core to nursing was clear from several participants, as one said:
I don’t think I actually put the two together as either being the researcher or the clinician nurse, in that I often probably was looking for something because I couldn’t find the answer to it. So, I would… Nobody else was looking up anything and so I guess I felt odd, actually (Ella, 34, RN 14 years)
The demarcation between EBP and practice as it happens ‘in real life’ was made quite clear:
And when you have eight hours to finish everything that you have to get done, the urgent priorities take over the important or even, really don’t know if you call it important, I’d call it a side gig(Mei, 35, RN 14 years)
Caring was seen to be at odds with intellectual activity:
…whereas nurses, well, you’re supposed to care, like where’s where does research fit into that? (Jenny, 52, RN 27 years)
People inside and outside of nursing did not seem to perceive research as something that nurses should be concerned with:
a fairly new RN, who’s got a position as a researcher and yeah, she’s had a lot of flak from people, including in our family, about, “Why are you doing this? Is that what you did nursing for?” So yeah, it just speaks to the stereotypes about how research is not an essential part of our profession, which of course it is (Jack, 55, RN 26 years)
Supportive teams and colleagues were seen to enable practice improvement through research use:
I don’t have much experience outside emergency departments, but I do think emergency and critical care, there is generally a good culture around that sort of thing. When I was quite a junior nurse, for my graduate certificate, I had to do a literature review on pressure area injuries in emergency care. And through that I was able to alter our nursing assessment charts to include a Braden score because of the evidence that I showed the organization about the risks of pressure injuries and things like that. And they were very receptive to that I found (Tess, 42, RN 13 years)
Participants appreciated a supportive culture in the workplace:
So, I’ve just become interested in research recently, and just talking to people who are in that field in the hospital has been really easy and very helpful and supportive. And yeah, and helping me try to do that in helping you try to learn that as well. So, it’s yes. Really, really good. Really supportive (Maya, 30, RN 3 years).
Participants identified their own personal characteristics as being key to their confidence with research:
I was always very ambitious and thirsty for knowledge. So I read every you know, there are professional magazines that come out like my first place as a registered nurse was the operating theatre. So I read all the operating theatre magazines that came out (Mona, 52, RN 32 years)
Participants related early experiences with reading research that increased their confidence:
I went to search in the library at the [hospital] and got out some articles and read them, and then told my educator that this is what I’m gonna do, and she was of course very impressed. But that was sort of like an automatic. But not all students did that though. You know what I mean? It’s probably because I’m just a type A personality and it worked for me… (Diya, 48, RN 20 years)
Confidence with one aspect of using research was perceived as leading to other things:
Yes, I’ve been taking on, like, you know, the mentoring and the facilitation of the students. And I wasn’t really looking into that side of stuff until I started to get a little bit more into the research stuff (Eve, 30, RN 10 years)
Confidence with research literature was something they perceived in other nurses as well:
The nurses who do read articles do stand out, and they’re usually of that caliber, and so they’re usually in the middle of their Masters or in the middle of pursuing some form of formal education, and even if they weren’t, the thing is they’re few and far between, that’s what I mean by “they stand out,” as nurses, the team is receptive to their passion, but they wouldn’t be going looking for articles the way this person would (Mei, 35, RN 14 years)
Theme 3. Working towards using research
This final key theme emerged from the discussions about the participants’ experiences with research literature, the feelings they had about using it, and strategies they used for dealing with texts they might find difficult. Four subthemes were identified through repeated readings of the transcripts: approaches to reading and understanding research; using research; mathematics difficulties; and research language. In addition, as a final question to all the focus groups, participants were asked how they would feel if they were asked to read a research paper “right now” and their reactions to that prompt, including their non-verbal observed reactions are discussed.
Approaches to reading and understanding research
This was a somewhat unexpected subtheme developed over the course of the focus groups and so was discussed in more detail with the later groups. Participants spoke of how difficult and time-consuming reading research literature was and related their strategies for extracting the meaning, as they understood it, from the papers they read. Very few participants who spoke about their reading strategies stated that they always read the whole article, instead using a range of different approaches.
The methods section of a research paper was a particular source of discomfort, as this participant described in her approach prior to commencing her research degree:
I’d read the abstract and the introduction, skip through all the middle bits, and read the conclusion. None of the actual research methodologies or any of that made any sense whatsoever (Ella, 34, RN 14 years)
Participants developed strategies to allow them to extract some meaning from research articles, even if they had to take the paper’s reliability on trust:
…discussion sections were fine as a uni student but trying to interpret what they was talking about in their methods…. And like their results section I kind of skipped past that to the discussion because it was just easier. They even if they were doing something really simple the terminology they used made no sense (Lyn, 24, RN 3 years)
Details of the methods and results were not considered by some participants to be “relevant” to their needs:
I just want to go straight to the facts, I don’t care about all that stuff that’s probably relevant to a researcher but it’s not to me. I tend to go straight to the end to see what the outcomes were and skip everything in the middle, where it’s leading to because that stuff just isn’t relevant to me on a day to day basis, I just want the information that is relevant (Maryanne, 46, RN 10 years)
Participants also spoke of making pragmatic decisions about reading papers in the context of their limited time:
If I’ve got the time, I’ll read the whole thing. If not, I won’t. Definitely being wary of the methodology and the size of the study, and I guess the particular context and any notes on that (Andy, 25, RN 2 years)
They were aware their strategies were not always ‘correct’ but they were perceived as effective:
Read the abstract content and results. Read the conclusion. That was enough to get through my 3rd year evidence-based practice subject (Eve, 30, RN 10 years)
Many of the participants were undertaking or had completed postgraduate studies and spoke about using research in writing assignments, but they were also using research to underpin practice and to justify their practice choices. They seemed acutely aware of the expectations on them to use research in education and practice, and sometimes these expectations were felt to be burdensome. Despite the difficulties many experienced with understanding research literature, they were still generally willing to try to use it whenever it was needed.
Using evidence to drive practice change in the interests of patient safety was discussed by several participants:
I don’t do research. I use research. So, my emphasis is on finding solid stuff to back up things or, you know, what is evidence based on? That’s where I’m still quite active in this field of health and safety (Danni, 54, RN 36 years)
There was a sense that proposed change based on strong evidence was less likely to be argued with:
If I put in an improvement form, I’ll often staple a couple of research articles to back it up when I hand it in, and highlight what’s relevant, and they don’t argue anymore (Noni, 54, RN 38 years).
Participants’ own personal safety was also seen to be preserved by the use of the right evidence in practice: Like I work for agency as well. If I don’t believe it—if their practices are not based on evidence based practice—I just stick to those places that I know that are evidence based practice because I work in medical oncology/ hematology and I’m very cautious about the fact of how much it will affect me, because I’m still of child-bearing age. So… So, if I work in an area that is not using best practice, I’m not gonna go back there (Bella, 36, RN 14 years).
For some participants working in education, using and normalizing using research was challenging but necessary:
And so, my challenge has been to try and make it relevant to day to day practice. And it’s slow, but it’s achievable if you can find projects or links where you can sort of embed a little bit of research in there. And then they say that it’s not a mystical kind of weird thing that only a bunch of weirdos do somewhere else (Samantha, 55, RN 22 years)
Difficulties with understanding use of numbers, mathematics, and statistics emerged as a strong theme from these discussions. Participants expressed dismay at the problems they experienced in understanding quantitative results and statistical terminology. Qualitative research, on the other hand, was not considered to be difficult to understand, and the focus of participants’ discomfort was centered strongly on numbers and statistics.
Participants found the way that numerical results were written to be confusing:
For me it’s the way it’s written with all the 0.5 s and all that sort of thing, it doesn’t make sense. If it was simple percentages, then that makes sense (Joan, 60, RN 30 years)
There was a sense that statistical terms were a language they did not speak:
…just enough on stats. I think there’s something a bit harsher about them being a bit more numbers, but thing I hate about them is almost that foreign language involved, you know, squared chi Wilcoxon and whatever the hell of the names of the and so they frighten me a bit (Sally, 50, RN 8 years)
One participant queried whether discomfort with numbers was related to gender:
It’s feeling comfortable with using numbers and whether that’s a male or female thing, talk about it as gender, but just feeling really more comfortable, with say, phenomenological studies and things like that just seem to make more sense, and whether that’s why I’m a nurse or it’s..[trailed off] (Gen, 65, RN 48 years)
However, male participants expressed discomfort also:
The second I saw like, you know, the analysis and all that kind of stuff, I’m like I’m not gonna read over this, you know, You see that I’m not a very numbers person (Bob, 48, RN 1 year)
There was a sense that numbers and feelings were diametrically opposed:
I much prefer to read a qualitative paper… Yeah, rather than… I’d rather read about people’s feelings, than the numbers (Joan, 60, RN 30 years)
Numbers were seen as excluding the human element that nurses value:
I also think it’s about whether you like the human element and people mattered more to me than numbers. I think it’s maybe that and probably I think, you know, when I went to midwifery and child health, that’s all about more about humans (Lisa, 54, RN 33 years)
The specific language used in research was a problem for many participants. They seemed alienated by the language; despite the often-complex terms used by their various clinical specialties the terms used in research seemed untethered from logical meaning. That lack of connection to an action or object that could be clearly conceptualized meant that participants often felt that research was not written with them as readers in mind. When they could see a clear connection to their work or studies, research language became more relatable and easier to understand.
Research language was viewed as alien or foreign:
I think there’s an aspect of unfamiliarity with the language too, because it’s like reading anything in a foreign language, it’s really hard work. And to a lot of nurses, research is a foreign language. They’re not being exposed to it (Jack, 55, RN 26 years)
There was a strong sense that research was genuinely regarded as language not everyone could speak:
I haven’t done research, so I can talk about research I’ve read with people at work, but it’s like talking another language (Noni, 54, RN 38 years)
Trying to understand the language was full of pitfalls:
So, I started in that levels of hierarchy and evidence. I started then really starting to get picky about what I was really and looking at the language then got confused with intervals and confidence of a lot of talk about 0.95 (Eve, 30, RN 10 years)
Particularly in their early years, it was difficult to engage with research literature due to the language:
I lost interest straight away… I’m better now than I was then, obviously, but in those days, yeah, I was absolutely intimidated by the, the way it was written (Walter, 49, RN 29 years)
The language used in the paper was tied to how much effort participants would put into trying to understand it:
…it was so full of so much jargonized rubbish, that you almost needed to research that research paper, whereas then you find another person who’s writing it in a tone or a language that you can understand and you immediately resonate (Kathy, 46, RN 11 years)
Difficulties understanding the language also influenced their reading strategies:
It’s a discussion section that I go to. First, the abstract, but then after that the discussion, and only if it’s got anything useful, then I will go further if I have to, but that’s because the plain English is in the discussion section, that’s where they don’t dribble on about X equals Y, and we found that, blah, blah, and the average of this was that and… Yeah, ’cause I understand they have to spell out their tables and Excel tables and findings and everything. But the discussion is where the English is, that’s where normal human speak is (Mei, 35, RN 14 years)
Despite these issues, most participants, when asked how they would feel if asked to read a research article “right now”, responded at least somewhat positively. Some conveyed considerable wariness or concern in the tone of their responses:
I would want to know what the topic was and I would want to know. I would want to know why you wanted me to read it (Nina, 57, RN 9 years)
Some responded with defensiveness:
Again, why? I’ve got plenty to read. I don’t need what you want to give to me to read. Is there any benefits in this particular paper? What is it trying to achieve? So is it a valid study or is it just some ivory tower, need to know something for the sake of it? (Anna, 59, RN 19 years)
Even with a hypothetical request, participants were cautious about committing their time:
I’d be more likely to actually be able to get through it if it was a shorter one rather than a 20 page (Karen, 35, RN 13 years)
Most, however, responded with confidence they would give it a try:
I’m gonna say yes. Tell me what it’s about, and I’ll say yes, let’s read it and see what we can do (Diya, 48, RN 20 years)
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