Exploring research engagement among nurses in a Magnet®-recognized cancer center: An analysis of knowledge, attitudes, practices, and influencing factors

Objective Despite the significance of research in nursing practice and its role in enhancing the quality of life for cancer patients, nurses report limited opportunities to engage with research. Known barriers include limited organizational support, a lack of time, resources, and knowledgeable colleagues/mentors. The study aims to determine research knowledge, attitudes, and practices among cancer nurses and understand factors influencing nurses’ involvement in research. Methods Registered nurses responded to a cross-sectional questionnaire. Data were collected using a modified version of the Nursing Research Knowledge, Attitudes, and Practices survey and the Barriers to Nurses’ Participation in Research Questionnaire. Results Three hundred and sixty-six nurses responded, of whom 15% had previously been involved in research. Nurses reported moderate to high research knowledge (μ= 1.72), attitudes (μ= 1.92), and practice (μ= 1.79) scores. The most common barriers to engagement with research included a lack of time (78.0%), lack of incentive or reward (61.4%), lack of knowledge or skills (54.2%), lack of training opportunities (51.4%), and lack of experienced nursing research mentors (44.8%). Holding a specialist, advanced practice, or administrative role, and a postgraduate qualification were associated with higher scores on the knowledge, attitudes and practice subscales. Previous experience of conducting research was associated with higher knowledge and attitudes scores. Previous experience of authoring a paper and submitting a grant were associated with higher knowledge scores. Conclusions The study reveals a moderate–to-high level of knowledge, attitudes, and practice regarding research among nurses, but low engagement. Barriers include lack of time, incentive, knowledge, training, and mentorship. Nevertheless, attitude scores, reflecting nurses’ willingness to engage in research were high on average. The findings highlight the potentially modifiable nature of barriers to research engagement. Increasing capacity for nursing research may be achieved through investment in research support and training to overcome barriers to research, which may discourage nurses engagement.


Introduction
2][3][4][5][6][7][8] The Magnet® Recognition Program, for example, requires institutions seeking designation to base practice on evidence, ensure nurses apply research findings to practice, and support nursing research endeavors. 7,9Despite this, nurses report limited opportunities to engage with research, either

Design
A cross-sectional survey study was undertaken with registered nurses with a current nursing license working at Memorial Sloan Kettering Cancer Center.

Data collection
A modified version of the Nursing Research Knowledge, Attitudes, and Practices survey 29 was used to collect data on three subscales related to (1) research knowledge, (2) willingness to engage in or perform research (attitudes), and (3) perceived ability to perform research (practice) related to 23 research activities.The scale was modified with the permission of the instrument designer due to concerns from institutional leadership regarding the survey burden on potential participants.To minimize the burden on participants, the instrument was revised to condense instrument length, focusing on items related to the types of nursing inquiry that are conducted in the institution and those which aligned with strategic research development within the organization.The Nursing Research Knowledge, Attitudes, and Practices items are rated on a three-point ranking scale, with higher scores reflecting more positive knowledge, attitudes and practice.The Nursing Research Knowledge, Attitudes, and Practices Questionnaire was developed based on the Iowa Model for Evidence-Based Practice, [30][31][32] and has demonstrated acceptable test-retest reliability (knowledge r ¼ 0.83; attitude r ¼ 0.81; practice r ¼ 0.77) and internal consistency (knowledge α ¼ 0.94; attitude α ¼ 0.97; practice α ¼ 0.93). 29e Barriers to Nurses' Participation in Research Questionnaire 23 was used to assess barriers to nursing research via two subscales: research resources and personal relevance of research, and a standalone question relating to time.The Barriers to Nurses' Participation in Research Questionnaire items are rated on a five-point ranking scale, with higher scores reflecting higher levels of perceived barriers to participation in research.The Barriers to Nurses' Participation in Research Questionnaire has been psychometrically tested and demonstrated acceptable internal consistency (resources α ¼ 0.79; relevance α ¼ 0.74). 23e questionnaire was administered anonymously via Research Electronic Data Capture (REDcap). 33An email introducing the study was distributed to potential participants via the organization's all-nursing email distribution list.An eligibility screening question was used to ensure only nurses employed by the organization complete the survey.

Data analysis
Variables assessing nurses' knowledge, attitudes, practice and perceived barriers to research engagement were descriptively analyzed using frequencies.Instrument subscales were scored according to author guidelines, and measures of central tendency were generated for each of the Nursing Research Knowledge, Attitudes, and Practices and Barriers to Nurses' Participation in Research Questionnaire subscales.Demographic factors influencing knowledge, attitudes, practice and barriers to research were assessed using inferential statistical tests, including chi-square and independent sample t-tests.Relationships between the subscales of the Nursing Research Knowledge, Attitudes, and Practices and Barriers to Nurses' Participation in Research were tested via Spearman correlations.

Ethical considerations
Potential respondents were assured that participation in the study was voluntary and anonymous, and that return of a completed questionnaire implied consent.The study received approval from the Institutional Review Board (IRB No. X18-003).

Demographic characteristics
A total of 366 nurses took part in this study.Participants had an average of 15.1 years of experience (SD ¼ 11.3, range ¼ 0-46) and worked in in-patient (23.0%), out-patient (53.3%), perioperative (16.9%), pediatric (1.9%), and other (4.9%) settings.Participants were primarily clinical nurses (71.0%), with the majority working at levels I or II on the institution's clinical ladder, indicating less than 18 months or up to 3 years of nursing experience, respectively (42.5%).The remaining participants were Nurse Practitioners (11.5%),Clinical Research Nurses (6.0%), Clinical Nurse Specialists/Nursing Professional Development Specialist (3.8%), administrative (3.6%), or other (2.7%) nursing staff.At the time of the study, 19.6% of the participants were enrolled in further education.The majority of participants had completed a bachelor's degree at the highest level of education (64.7%), and more than one-quarter had completed a master's degree (27.4%).Over two-thirds (68.8%) of the sample expressed a desire to achieve higher levels of education, of whom the majority reported desiring master's-level education (55.4%), with 29.9% and 12.4% of participants desired DNP or EdD/PhD-level education, respectively.About one-third (29.9%) of respondents had achieved their desired level of education (Table 1), with the majority of these holding a bachelor's degree (50.5%) or master's degree (36.7%).

Previous involvement in research
There was limited reported involvement in research (14.8% of the sample): of these, 55.6% engaged as a principal investigator or co-principal investigator, and 68.5% as an investigator (Table 2).Those who had been involved in research previously reported having been involved in retrospective (40.7%), prospective (20.4%), quality improvement (37.0%), non-therapeutic (25.9%), or therapeutic studies (44.4%) (response options were not mutually exclusive).
Six percent of participants (n ¼ 22) had been involved in the submission of a grant.Eighty-two participants had previously submitted a research abstract (22.4%), of whom 84.1% reported the abstract had been accepted for poster presentation and 47.6% accepted as a podium presentation.A similar proportion of participants had been involved in the authorship of peer-reviewed publications (19.4%, n ¼ 71).Of those who had reported involvement in the authorship of peer-reviewed publications, 40.8% reported authorship of manuscripts focused on primary research, and 52.1% reported authorship of manuscripts with a clinical focus.

Nursing research, knowledge, attitudes and practice
Participants were invited to rate their knowledge, attitudes and practice of 23 research activities.The mean knowledge score for this sample was 1.72 (SD ¼ 0.49, range ¼ 0.09-3.00).The most common items that nurses expressed high knowledge of included the identification of clinical problems (44.4%, n ¼ 131), identifying new information in the literature (32.6%, n ¼ 95), gathering relevant literature (29.1%, n ¼ 85), getting support from your nurse leader (23.2%,n ¼ 66), and preparing a poster presentation (21.8%, n ¼ 62).The items for which participants were most likely to report low levels of knowledge were submitting a proposal for grant funding (71.3%, n ¼ 204), submitting a proposal for IRB review (63.4%, n ¼ 184), setting up procedures for the study (55.8%, n ¼ 159), finding the right data collection instrument (51.4%, n ¼ 148), and collaborating with the Office of Nursing Research (50.7%, n ¼ 145) (Table 3).

Barriers to nurses' participation in research
90.9% of participants (n ¼ 333) identified one or more barriers to research in their practice, with a mean of 4.8 barriers reported by the sample (SD ¼ 3.3, range ¼ 0-14).The mean score for the research    4).

Factors influencing nurses' knowledge, attitudes, practice and barriers to research
The results of t-tests to identify factors associated with Nursing Research Knowledge, Attitudes, and Practices Questionnaire subscales and Barriers to Nurses' Participation in Research Questionnaire subscales are presented in Tables 5 and 6, respectively.The results of Spearman correlations to establish relationships between the subscales of the Nursing Research Knowledge, Attitudes, and Practices and Barriers to Nurses' Participation in Research are presented in Table 7.
Higher research knowledge scores were associated with holding a specialist, advanced practice, or administrative role (P ¼ 0.006), a postgraduate qualification (P < 0.001), previous experience of conducting research (P ¼ 0.003), authoring a paper (P ¼ 0.007), and submitting a grant (P ¼ 0.001).Higher scores on the attitudes and practice subscales were associated with holding a specialist, advanced practice or administrative role, and a postgraduate qualification only (P < 0.05).Previous experience with research, authorship, or grantsmanship were not associated with differences in scores for research attitudes and practice (P > 0.05) (Table 5).
Those who had higher scores on the research barriers resource subscale were more likely to have postgraduate education (P ¼ 0.007), and have conducted research previously (P ¼ 0.009), been involved in the authorship of a manuscript (P ¼ 0.032), and have submitted a grant (P ¼ 0.042).Those with postgraduate education, working in specialist, leadership, and administrative roles, and who had been involved in the conduct of research, authorship of a paper, or submission of a grant were more likely to indicate research was relevant to them and more likely to report having less time available to conduct research (P < 0.05) (Table 6).
Years practicing as a registered nurse was positively correlated with participants' perceptions of time available to conduct research (P ¼ 0.044), such that those with greater experience were more likely to report having time available to conduct research.Years practicing as a registered nurse were negatively correlated with knowledge (P ¼ 0.031), attitudes (P ¼ 0.006) and practice (P ¼ 0.003) subscales, such that nurses with greater experience were less likely to report higher levels of knowledge, attitudes and practice toward research on these subscales; however, the correlation for each subscale was weak (range: À0.124-0.173)(Table 7).
Research resource subscale scores were weakly correlated with research practice (r ¼ À0.115, P ¼ 0.048), such that those who reported greater barriers to research as a result of resources were less likely to express a willingness to perform research activities.Participants who reported that research was less relevant to them on the personal relevance subscale of the questionnaire were more likely to express lower knowledge (P < 0.001), attitudes (P < 0.001), and willingness to perform research (P < 0.001).Time was not correlated with research knowledge, attitudes, or practice scores (P > 0.05).However, having less time to conduct research was correlated with a greater perception of resource-related barriers to research (P < 0.001) (Table 7).
Nurses knowledge, attitudes and practice were all correlated (P < 0.005), demonstrating that those with greater self-perceived knowledge were more likely to have more positive attitudes toward research and a greater willingness to perform research activities.Likewise, those with more positive attitudes reported a greater willingness to perform research activities (Table 7).

Discussion
While this study has highlighted moderate to high levels of knowledge, attitudes, and practice regarding research among nurses; yet, within this sample, there were relatively low levels of engagement, with less than 15% reporting involvement in research.Lack of time, incentive, knowledge, training and mentorship were identified as the most significant barriers to engagement in research.Nevertheless, a large proportion of participants expressed a desire to engage in further education involving research, at both the master's and doctoral levels.Furthermore, attitude scores, reflecting nurses' willingness to engage in research, were higher on average compared to knowledge and practice scores.Collectively, when considered alongside the potentially modifiable nature of barriers to research engagement, the findings suggest that there is an appetite among nurses to engage with research, where appropriate resourcing and training are provided.However, to overcome these barriers, investment is needed to address education, research culture, and resourcing to support nursing research.
The results of this study align with previous research regarding factors influencing knowledge, attitudes and practice related to research. 34,35Specifically, having higher levels of education and holding a specialist, advanced practice or administrative role were associated with higher levels of research knowledge and greater willingness and perceived ability to perform research.The majority of participants in this study reported that bachelor's-level was their highest educational achievement at the time of the study, reflecting that two-fifths of the sample had between 18 months and three years of clinical experience.Previous research suggests that the completion of master's-level education has a positive impact on graduate nurses'; including greater utilization of research to inform clinical practice, and an increased likelihood of engaging in research-related tasks. 36While the majority of participants reported lower levels of academic education in nursing, an almost equivalent proportion expressed a desire to progress to masters-and doctoral-level education.This positive trend presents an opportunity to build capacity for nursing research, particularly when considered alongside findings that participants express a desire and positive attitude towards conducting research.However, the means by which further education is supported and by which research is integrated into the nursing curriculum within the taught programs is critical.
Despite positive findings regarding perceived knowledge, attitudes and practice regarding research, the proportion of participants who had experience of research leadership or involvement in supporting research leadership activities was relatively low within this study.Just over one-

Table 7
Spearman's correlations between knowledge, attitudes, practice and barriers to research for nurses.tenth of participants had experience as a principal investigator or coinvestigator.Less than one-fifth of participants reported prior involvement in the preparation and submission of a research grant (6.0%), or the preparation and submission of a manuscript for peer-review (19.4%).These findings are reflected in participants' responses to the knowledge, attitudes and practice questionnaire, with a large proportion of participants reporting low or moderate willingness to engage with the preparation of a research grant and the preparation of a manuscript for publication.Predominantly, those who had experience of research dissemination reported that this was limited to poster presentation.These results lend significance to the assertion that nurses' roles in clinical research may more often be perceived as supporting research. 3,18,19Leveraging interest and willingness among nurses to engage in research will be crucial for capacity-building in the future.Role modeling and peer mentorship, as well as expert mentorship, may support the scaling of capacity for nursing research, particularly among early-career nurses, and nurses educated to bachelor-level.However, in order to foster positive research cultures in clinical practice, organizations must provide clear pathways to securing research mentorship within the clinical environment and through academic partnerships.
While this study presents tentatively positive results regarding nurses' willingness to engage in research, and knowledge and perceived ability to engage in research, there remain consistent barriers to engagement in research, including resourcing, incentivization, and supports to foster a more positive research culture.Subgroups who were less likely to engage in research, including those with lower levels of education and working within clinical roles, were more likely to report lower levels of knowledge, attitudes and practice regarding research, but less likely to report barriers to conducting research.Furthermore, nurses working in specialist, advanced practice, or administrative roles were more likely to report more positive knowledge, attitudes and practice toward research, nurses with more years of experience reported less positive knowledge, attitudes and practice toward research.These findings may be reflective of the distribution of the sample; more than 70% of participants worked in clinical nurse roles.Working as a clinical nurse was associated with a lower likelihood of recognizing research as part of one's role.

Implications for nursing practice and research
Without strategies to ameliorate barriers to research practice, there is little that can be achieved through education and mentorship to support enhanced capacity for clinical nursing research.Investment in Nursing Research Fellowships offer significant opportunities to build capacity, targeting aspects of research practice which nurses in this study reported lower levels of knowledge and confidence with, including preparation of the research protocol, submission for IRB review, and analysis and dissemination of results via peer-reviewed manuscripts. 37While the formal outcomes of the Mazzella Ebstein, Barton-Burke 37 Nursing Research Fellowship focused on program completion and internal dissemination, the results of this study demonstrate significant impact, extending beyond the vision for the program, with 21 manuscripts prepared from 15 IRB studies conducted within the Nursing Research Fellowship cohort to date.]26 Limitations While this study provides evidence to underpin the development of interventions to support capacity-building, resourcing, and enhance knowledge, attitudes and practice related to research in cancer nursing, the study is not without limitations.The generalizability of the results may be limited by the study setting and characteristics of the study sample.As a Magnet®-recognized cancer center, accreditation is in part dependent on ongoing scholarly work in the form of evidence-based practice implementation projects and new research. 38Our institution has invested in full-and part-time nurse scientist roles to support EBP and research efforts within the direct patient care setting, possibly influencing interest in and awareness of research practices.Furthermore, the majority of participants of this study were clinical nurses with 3 years or less of nursing experience, where interest in research may not yet be a priority.

Conclusions
Within this study, nurses employed in a Magnet®-recognized cancer center report moderately positive research knowledge, willingness to engage in research and self-perceived ability to conduct research.However, the study has highlighted several factors that challenge the potential to build nursing research capacity, with barriers including time, incentivization, knowledge, and access to training and mentorship to support nursing research.Further education has the potential to improve knowledge and attitudes towards research; however, at an organizational level, investment will be required to ensure nurses have access to adequate infrastructure and resources and have scope and capacity within their roles to engage with and eventually lead clinical research programs.Initiatives that have the potential to ameliorate resource-based barriers are the formation of clinical research fellowships for nurses, buyout of clinical time, seed funding to develop research projects, and investment in human resources, which can support nurses' development with regard to technical aspects of research processes, including protocol development, IRB approval processes, and data analysis skills.
Journal of Oncology Nursing.The article underwent standard review procedures of the journal, with peer review conducted independently of MBB and their research groups.

Table 1
Sample characteristics.
CNS, Clinical Nurse Specialist; NPDS, Nursing Professional Development Specialists; CRNA, Certified Registered Nurse Anesthetist; DNP, Doctor of Nursing Practice; MSc, Master of Science; EdD, Doctor of Education; SD, standard deviation.

Table 2
Previous involvement in research.

Table 4
Barriers to nurses' participation in research.

Table 3
Participants' self-rated knowledge, attitudes and practice related to research.

Table 5
Factors associated with participants' self-rated knowledge, attitudes and practice related to research.

Table 6
Factors associated with barriers to research for nurses.
CRN, Certification and Recertification for Nurse; CNS, Clinical Nurse Specialist; CRNA, Certified Registered Nurse Anesthetist; NP, Nurse Practitioner; DNP, Doctor of Nursing Practice; PI, principal investigator; SD, standard deviation.