Our findings raise several important issues for discussion. First, several dimensions of organizational context predict pediatric nurses’ use of research findings in clinical practice. Second, there are several differences with respect to which dimensions of context predict IRU compared to CRU. Third, select individual (nurse) characteristics remain significant predictors of nurses’ use of research after controlling for organizational context.
The importance of organizational context
Our findings show that certain dimensions of context predict research use by pediatric nurses. This builds on our previous work in which we reported that pediatric nursing units where nurses reported the highest mean overall research utilization scores (defined as any kind of research use) clustered together on the following contextual factors: unit culture (measured by work creativity, work efficiency, questioning behavior, co-worker support, and the importance nurses place on access to continuing education) and environmental complexity (measured by changing patient acuity and re-sequencing of work) . In a subsequent study, we explored the importance of three dimensions of context (culture, leadership, and evaluation using the measures used in the current study) in relation to instrumental and conceptual research use . In that study, we reported that pediatric nursing units with the highest IRU and CRU scores by nurses had a more positive context (i.e., nurses perceived the culture, leadership, and evaluation of the unit to be positive) compared to units where nurses reported lower research use scores . In our current study, we extended these findings by showing that not only do these dimensions cluster around research use but also that they and additional dimensions of context (i.e., formal interactions, informal interactions, and organizational slack) are important predictors of nurses’ instrumental and/or conceptual research use.
In recent years, we have seen a number of studies examining the organizational ‘social’ context in pediatric social services [4, 5, 13, 43, 44]. In this work, Glisson and colleagues reported statistically significant associations between organizational climate (defined as ‘the way people perceive their work environment’ ) and child health outcomes (e.g., child psychological functioning) . They also reported that child mental health and social service organizations have a variety of culture profiles and that those profiles are associated with criteria that are important to research implementation [5, 13, 44]. Most recently, Aarons and colleagues  conducted a national survey with 1,112 mental health service providers in 100 mental health service (including pediatric) institutions in 26 US states, and found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice generally. These findings, although conducted in pediatric social services and mental health, align with the findings we report in this paper. Further, our findings also offer the first empirical support of several additional dimensions of context relating to communication (i.e., formal interactions, informal interactions, and organizational slack-space) not previously reported that show promise as important to research use by pediatric healthcare professionals.
Context and CRU
The contextual dimensions that predicted IRU and CRU differed substantially with only one dimension (culture) displaying significance with both IRU and CRU. The remaining contextual dimensions predicted either IRU or CRU, and substantially more contextual dimensions predicted CRU than IRU. There are several plausible reasons for this finding. First, while not necessary for IRU, CRU may be a precursor to IRU in some instances. That is, using research to change one’s own thinking, while not necessary may in some cases, lead to using research to change one’s behavior. Second, changing the behavior of healthcare professionals (IRU) is both a difficult and multi-component process. It involves consideration of multiple contextual, personal, and behavioral factors. The Theoretical Domains Framework [46, 47], for instance identifies 128 constructs tapping different factors important to health professional behavior change. It is therefore plausible that more and different factors than those measured in our study contribute to IRU compared to CRU. Finally, our modeling approach only allowed us to identify which contextual dimensions predict research use and not to determine ‘how’ context influences research use. It may be that different interactions between contextual dimensions or between context and individual characteristics produce different effects on IRU and CRU or that context indirectly influences IRU through CRU. It is also possible that CRU influences the context variables, or other individual level predictor variables in our models. For example, a nurse who is high in CRU may become higher in ‘efficacy’, or view the ‘leadership’ as superior because they are high in CRU.
The majority of our findings revealed that a more positive context predicted higher conceptual research use as hypothesized; however, we did observe two unexpected findings in relation to CRU. Culture (defined as “the way that “we do things in our organizations and work units” with items generally reflecting a supportive work culture ) and formal interactions (defined as “formal exchanges that occur between individuals working within an organization (unit) through scheduled activities that can promote the transfer of knowledge” ) both displayed negative estimates with CRU indicating a more positive culture and participating in more formal interactions leads to less CRU by nurses. These findings are contrary to theories of context and research use (e.g., PARiHS [34, 35]); however, these theories focus on instrumental research use. There is currently no theory and/or empirical research examining contextual predictors of CRU. Therefore, these two findings, while unexpected require replication in future studies before drawing conclusions on these relationships. If the finding persists, it should be investigated qualitatively to better understand the mechanism by which this may occur.
The importance of individual characteristics
Consistent with a recent systematic review , our findings point to the continued importance of individual characteristics. Two individual characteristics in particular, belief suspension and use of research in the past, were significant predictors of both IRU and CRU in our models.
The Theory of Planned Behavior (TPB)  proposes that motivation determines behavior, and therefore the best predictors of behavior are factors that predict or determine motivation. The theory further asserts that motivation strength is determined by three variables: attitudes, subjective norms, and perceived behavioral control, which in turn are based upon salient beliefs about the behavior . Belief suspension in our study refers to this - an individual’s perception of the degree to which they are able to suspend such beliefs in order to use research. Godin and colleagues , in a recent systematic review, found healthcare professionals’ beliefs about their own capabilities and the consequences of their behavior to be consistently and positively associated, at statistically significant levels, with their motivation to change their behavior. This is in line with our findings that belief suspension is important to nurses’ IRU. Future research should focus on determining how belief suspension leads to research use, both instrumentally and conceptually.
Research use in the past
‘Research use in the past’ was operationalized as the use of research findings to change practice in the past (i.e. greater than six months ago). Action theories such as Operant Learning Theory (OLT), which are also frequently used to explain behavior, postulate that past behavior is one of the most predictive factors for future behavior. According to OLT, as rewarded behaviours are repeated, they can become ‘habitual’ in the context in which they are rewarded. As a result, the frequency of past behavior can be a powerful predictor of future behavior [51, 52]. Our findings support this with respect to both IRU and CRU. Future research that explores the relationship between past behavior and research use however is needed.
First, our sample is drawn from academically affiliated hospitals only and only includes nurses from pediatric medical, surgical, and intensive care units. Since we were able to contact (to invite to participate) 80% of all eligible participants, we believe our sample is representative of Canadian pediatric nurses in the medical, surgical, and intensive care units that we surveyed. However, our results should not be generalized beyond these settings or this particular group of nurses. For example, we do not know if the findings would be similar for nurses from community geriatric settings. Second, it is important to note that we did not collect data on several potentially important contextual factors such as overall hospital size, functional differentiation, decision-making structure, data infrastructure, and information systems [17, 18]; future research should incorporate these systems-level dimensions. Third, as with all modeling techniques, our approach is not without limitation. While the GEE model is an appropriate approach for our data, allowing us to reduce the potential for biased estimates by accounting for the naturally nested structure in our data, it is possible that the proportion of the intra-group variability may change with some explanatory variables, which our GEE models do not allow for. An alternate model such as a mixed effect model with heteroscedasticity would account for such changes in covariance and could be potentially done in the future with larger datasets and fewer explanatory variables (as theory on what dimensions of context predict research use advances, we will be able to narrow the number of explanatory variables to allow such testing).