INTRO: THANK YOU FOR THE OPPORTUNITY TO DISCUSS WITH YOU THE CHALLENGES OF CONDUCTING RESEARCH IN CLINICAL ENVIRONMENTS. IT IS A TOPIC THAT IS CLOSE TO MY HEART --- AND I BELIEVE INCLUDES BOTH USING RESEARCH FINDINGS AND DOING STUDIES THAT PRODUCE NEW RESEARCH FINDINGS.
AT THE IWK CHILDREN'S HOSPITAL -- ON THE OTHER SIDE OF THIS GREAT COUNTRY -- THE HOME OF THE BLUENOSE IN CANADA'S OCEAN PLAYGROUND -- WE ARE FINDING THAT BOTH USING AND DOING RESEARCH IN CLINICAL ENVIRONMENTS ARE INCREASINGLY POSSIBLE FOR NURSES. BUT IT IS NOT AN EASY ENDEAVOUR, IT REQUIRES RESOURCES AND COMMITMENT AND WE MIGHT SOMETIMES BE TEMPTED TO ASK WHY BOTHER?
NURSING CARE IS HIGHLY VALUED BY THE PEOPLE WE SERVE, AND, AS NURSES, WE ARE CONVINCED THAT WE MAKE AT LEAST SOME, PERHAPS EVEN "THE", DIFFERENCE IN PEOPLE'S ENCOUNTERS WITH ILLNESS AND HEALTH CARE. NEVERTHELESS, WE STRIVE CONTINUALLY TO FIND BETTER WAYS TO IMPROVE THE QUALITY OF THE CARE WE PROVIDE. BUT - WE ARE AN EXPENSIVE RESOURCE IN HEALTH CARE. AND, AS HEATHER CLARKE HAS SO ABLY DISCUSSED, IN THESE TIMES OF RAPID CHANGE, INCREASING COMPLEXITY, AND ECONOMIC CONSTRAINT IN HEALTH CARE AND SOCIETY, WE ARE CHALLENGED BY MANY TO DEMONSTRATE THE COST EFFECTIVENESS OF THE CARE WE PROVIDE. NURSING RESEARCH CAN HELP US TO MEET THOSE CHALLENGES.
NURSING RESEARCH HAS A LONG HISTORY, BUT WE CONTINUE TO SEE A "GAP" BETWEEN OUR RESEARCH KNOWLEDGE BASE AND THE EVIDENCE OF THAT BASE IN OUR PRACTICE. STUDIES HAVE REPEATEDLY SHOWN THAT MANY RESEARCH-BASED INNOVATIONS IN NURSING CARE ARE NOT COMMONLY PRA CTICED.
WE ARE NOT ALONE IN HAVING SUCH A KNOWLEDGE-PRACTICE GAP; INDEED, IT IS ESTIMATED THAT AS MUCH AS 80% OF PHYSICIAN PRACTICE LACKS AN EVIDENCE BASE. GETTING RESEARCH INTO PRACTICE IS A MAJOR ISSUE AND A TOPIC OF BOOKS AND ARTICLES IN MANY DISCIPLINES - ONE OF THE MOST RECENT IS BY DUNN ET AL. "DISSEMINATING RESEARCH/CHANGING PRACTICE".
IN NURSING, WE HAVE A VERY LIMITED KNOWLEDGE BASE ABOUT SOME OF OUR PRACTICES, BUT WE DO HAVE SOME EVIDENCE THAT WE TOO HAVE A PROBLEM IN ASSURING THAT THE MOST UP-TO-DATE RESEARCH BASED KNOWLEDGE IS USED BY THOSE PROVIDING THE CARE. INDEED, MANY NURSES QUESTION WHETHER NURSING RESEARCH HAS ANY RELEVANCE OR PRACTICAL BENEFIT AT ALL.
THERE ARE MANY REASONS THAT HAVE CONTRIBUTED TO SUCH A SITUATION IN NURSING. THEY INCLUDE, FOR EXAMPLE, THE FACTS THAT MOST NURSES HAVE NOT BEEN INVOLVED IN NURSING RESEARCH IN ANY WAY, AND DO NOT WORK IN AN ENVIRONMENT THAT FOSTERS A SPIRIT OF INQUIRY. A SPIRIT AND A CLIMATE OF INQUIRY ENABLE THE INVOLVEMENT OF NURSES IN USING AND DOING RESEARCH, AND ARE ESSENTIAL INGREDIENTS TO MAINTAINING AND ENHANCING THE QUALITY AND COST-EFFECTIVENESS OF OUR CARE. BUT OTHER REASONS INCLUDE OUR TRADITIONS - OUR SACRE D DINOSAURS; AND THE RELEVANCE OF EXISTING RESEARCH TO PRACTICE -- SUCH A PROBLEM THAT IT IS NOT UNUSUAL TO HEAR NURSES EXCLAIM "USE NURSING RESEARCH IN PRACTICE? YOU ARE KIDDING, RIGHT?!"
IF THOSE ARE THE PROBLEMS -- WHAT DOES CREATE A "RESEARCH FRIENDLY" ENVIRONMENT? WHAT DOES MAKE IT POSSIBLE TO CONDUCT RESEARCH IN CLINICAL ENVIRONMENTS?
THIS PRESENTATION WILL FOCUS ON TWO MAJOR ANSWERS TO THAT QUESTION: STRATEGIES TO FOSTER A CLIMATE OF INQUIRY AND THE INFRASTRUCTURE SUPPORT THAT ENABLES RESEARCH. I WILL RELY MAINLY ON OUR EXPERIENCE AT THE IWK CHILDREN'S HOSPITAL -- A TERTIARY LEVEL RE FERRAL CENTRE IN A VERY "HAVE-NOT" PROVINCE. WE HAVE A NURSING STAFF UNDER 300 FTE'S, HAVE A HUGE AND GROWING AMBULATORY CARE PROGRAMME, AND FEEL STRETCHED WHEN WE HAVE MORE THAN 130 CHILDREN AS IN-PATIENTS!
I WILL ARGUE THAT, IN ORDER TO CONDUCT RESEARCH IN CLINICAL SETTINGS, EVERY NURSE MUST TAKE RESPONSIBILITY TO ENACT SOME ROLE IN RESEARCH, AND THAT SUCH INVOLVEMENT CAN RESULT IN MORE COST-EFFECTIVE NURSING CARE.
EVERY NURSE HAS ONE OR MORE ROLES TO PLAY IN NURSING RESEARCH - AND HAS THE CAPACITY TO BE INVOLVED IN THOSE ROLES - BUT THEY MUST HAVE A SENSE OF CURIOSITY AND A DESIRE TO SATISFY THAT CURIOSITY. THINK ABOUT THE CURIOSITY OF CHILDREN...WHAT FOSTERS THE CONSTANT WHYS? THE DELIGHT IN NEW EXPERIENCES? IN PART IT IS DELIGHT AND ENCOURAGEMENT FROM PARENTS; MODELING BY PARENTS - -QUESTIONS; AND "ANSWERS" LIKE "GO AND LOOK IT UP". WHAT DESTROYS IT? ANSWERS LIKE "JUST BECAUSE" OR BORED RESIGNATION AND OTHER "DON'T BOTHER TO ASK" MESSAGES; REGIMENTATION; RIDICULE FOR QUESTIONS OR "MISTAKES". WHAT HAPPENED TO OUR CURIOSITY WHEN WE "GREW UP"? HOW ACCEPTING ARE WE OF INQUIRY IN NURSING?
THIS SLIDE SHOWS JUST HOW ALIVE AND WELL THE "NO NEW IDEAS" MOTTO IS SEEN TO BE IN THE EYES OF AT LEAST ONE CARTOONIST! THE ANSWERS TO QUESTIONS ABOUT WHAT HAPPENED TO AND WHAT FOSTERS CURIOSITY IN CHILDREN PROVIDE SOME INSIGHTS ABOUT FOSTERING CURIOSITY IN NURSING AND ESTABLISHING THE KIND OF ENVIRONMENTS THAT CREATE A CLIMATE OF INQUIRY.
ALL OF US - REGARDLESS OF OUR ROLE IN NURSING - HAVE A RESPONSIBILITY IN CREATING A CLIMATE OF INQUIRY. WHAT ARE THE FEATURES OF SUCH A CLIMATE, AND HOW CAN WE ASSURE IT EXISTS? NURSES IN ALL POSITIONS - PRACTICE, EDUCATION, ADMINISTRATION, AND RESEARCH MUST BE HELD ACCOUNTABLE FOR THAT CLIMATE. I THINK THAT A CLIMATE OF INQUIRY ENABLES AND REWARDS ASKING QUESTIONS, SEARCHING FOR INFORMATION, USING RESEARCH IN PRACTICE, DOING RESEARCH, AND BEING INVOLVED IN RESEARCH IN ANY WAY.
WHAT ARE THE BARRIERS AND FACILITATORS TO ASKING QUESTIONS?
THE SHIFT IN EXPECTATIONS TO BE A REFLECTIVE AND QUESTIONNING PRACTITIONER IS A MAJOR ONE IN NURSING. THE STAFF NURSE MUST FEEL FREE TO RAISE IMPORTANT CLINICAL QUESTIONS - IT IS THE NURSE IN DIRECT AND EXTENDED CONTACT WITH PATIENTS OR CLIENTS, THEIR FA MILIES AND COMMUNITIES, AND THE SETTING IN WHICH THE CARE OCCURS WHO CAN SEE THE PATTERNS AND RESPONSES THAT NEED EXAMINATION. YET, OFTEN NURSES REPORT THAT THEY DO NOT HAVE TIME TO THINK ABOUT THE QUESTIONS THAT THEY MIGHT HAVE; THAT THEY DO NOT FEEL IT IS SAFE TO ASK QUESTIONS OR DO NOT FEEL THAT THEY HAVE THE POWER TO QUESTION TRADITIONS. EVEN IN EDUCATION PROGRAMMES, WE HAVE FOSTERED INSUFFICIENTLY THE ABILITY TO ASK GOOD QUESTIONS- WHILE WE PAY LIP SERVICE TO FOSTERING CRITICAL THINKING AND STRONG LY ENCOURAGE STUDENTS TO BE ADVOCATES FOR THEMSELVES AND THE FAMILIES THEY WORK WITH, IN MANY WAYS WE TELL THEM THAT THEY SHOULD BE "GOOD GIRLS" AND THEY MUST NOT QUESTION HOW " WE " DO THINGS.
IN CONTRAST, IN ENVIRONMENTS THAT ARE "RESEARCH FRIENDLY", NURSING ADMINISTATORS AND MANAGERS CREATE OPEN ENVIRONMENTS THAT ENCOURAGE QUESTIONS, REWARD THE RISK-TAKING ENTAILED IN CHALLENGING TRADITIONAL PRACTICES, AND CREATE STRUCTURES (SUCH AS DECENTRAL IZED AND PARTICIPATIVE DECISION-MAKING AND QUALITY IMPROVEMENT PROGRAMMES) THAT STIMULATE RELEVANT QUESTIONS ABOUT AND A SENSE OF RESPONSIBLITY FOR PRACTICE.
OUR EXPERIENCE AT THE IWK CHILDREN' S HOSPITAL HAS BEEN THAT TRYING TO ESTABLISH SUCH A CLIMATE ACTUALLY WORKS! A PROCESS OF DECENTRALIZATION AND PARTICIPATIVE MANAGEMENT HAS BEEN UNDERWAY FOR SEVERAL YEARS. STAFF ARE MAKING THEIR OWN DECISIONS ABOUT CA RE AND ABOUT MANAGEMENT ISSUES SUCH AS STAFFING.
THE QUALITY IMPROVEMENT PROGRAMME IS ALSO DECENTRALIZED AND STAFF ON INDIVIDUAL UNITS DECIDE WHICH STANDARDS THEY ARE TO FOCUS ON AND PURSUE THOSE PROJECTS. AS THESE PROCESSES HAVE EVOLVED, I SEE A CHANGE IN THE NURSES' SPIRIT OF INQUIRY. THE NURSING MA NAGER PLAYS A KEY ROLE - - THERE ARE DRAMATIC DIFFERENCES BETWEEN UNITS THAT CHANGE WITH A CHANGE IN MANAGER. MORE AND MORE NURSING MANAGERS ARE ENCOURAGING THEIR STAFF TO CHALLENGE TRADITIONAL WAYS OF DOING THINGS-
FOR EXAMPLE, A GROUP OF STAFF NURSES ASKED, ON THE BASIS OF SOME OF THEIR OBSERVATIONS OF PATIENT CARE PATTERNS IN RELATION TO ONE OF THEIR STANDARDS OF CARE, WHY SO MANY CHILDREN WITH ASTHMA HAD TO BE CARED FOR IN THE ICU - THEY BELIEVED THAT THE TRANSIT IONS WERE DISRUPTIVE FOR EVERYONE, MAY STIMULATE MORE RESPIRATORY DISTRESS, AND THAT THE ANXIETY OF POSSIBLE TRANSFER TO ICU WAS EXACERBATING THE DYSPNEA. THEY ASKED WHY COULD WE NOT CARE FOR THE CHILDREN IN AN ACUTE ASTHMA UNIT WITHIN THIS UNIT; HOW MANY OF THE CHILDREN WHO END UP HERE HAVE BEEN IN ICU AND WHY?
THEY FIRST UNDERTOOK A CHART REVIEW TO DEFINE THE SPECIFIC PATTERNS; THEY THEN DEVELOPED AND SHEPHERDED THROUGH THE MAZE OF MEDICAL APPROVAL COMMITTEES A PROPOSAL FOR AN ACUTE ASTHMA CARE UNIT ON THEIR OWN UNIT; THE PROCESS OF THE DEVELOPMENT OF THE PROPO SAL, LED TO SOME FUNDAMENTAL QUESTIONS ABOUT THE IMPACT OF SUCH A UNIT ON PARENTS AND THEIR CHILDREN AND THE APPROPRIATE ROLE OF PARENTS IN SUCH A UNIT. THOSE QUESTIONS HAVE LED TO A SERIES OF DISCUSSIONS OF RELATED RESEARCH LITERATURE BY THE HOSPITAL'S N URSING RESEARCH INTEREST GROUP, AND THE STAFF ARE CONSIDERING DEVELOPING A RESEARCH PROPOSAL TO TEST THE EFFECTIVENESS OF THEIR NEW APPROACHES TO CARE. STAFF NURSES ON SEVERAL OTHER UNITS HAVE ALSO BEEN STIMULATED TO PURSUE RESEARCH QUESTIONS BECAUSE OF DILEMMAS THAT AROSE IN THE PURSUIT OF QUALITY IMPROVEMENT PROJECTS.
OTHER STRATEGIES TO ENHANCE STAFF ASKING QUESTIONS ARE SETTING THE EXPECTATIONS THAT THEY WILL DO SO -- POSITION DESCRIPTIONS AND PERFORMANCE REVIEWS MAY MAKE THAT EXPECATION EXPLICIT. ANNUAL SACRED DINOSAUR OR NURSING RITUAL CONTESTS CREATE AN ACCEPTING ENVIRONMENT.
RESEARCH FRIENDLY ESIRONMENTS ENABLE AND REWARD THE SEARCH FOR INFORMATION ABOUT THE QUESTIONS
ONCE NURSES ASK IMPORTANT QUESTIONS THE NEXT CHALLENGE IS TO FIND THE ANSWERS! ONE OF THE FREQUENTLY CITED BARRIERS THAT NURSES FACE IN USING RESEARCH IN PRACTICE IS THE DIFFICULTY THEY FACE IN FINDING RESEARCH-BASED INFORMATION ABOUT THEIR QUESTIONS.
SOMETIMES THIS IS BECAUSE RESEARCHERS ARE NOT DOING RESEARCH THAT NURSES SEE AS RELEVANT TO THEIR PRACTICE. SOMETIMES IT IS BECAUSE THE NURSE DOES NOT HAVE THE SKILLS TO UNDERSTAND THE RESEARCH PAPERS. WHATEVER THE REASON FOR THE DIFFICULTY, A FRUITLESS OR FRUSTRATING SEARCH WILL SOON STIFLE THE EMERGENCE OF A SPIRIT OF INQUIRY. WHILE EACH OF US HAS A RESPONSIBLITY TO SEEK OUT CURRENT INFORMATION THAT IS RELEVANT TO OUR PRACTICE, RESEARCHERS, EDUCATORS AND ADMINISTRATORS HAVE A PARTICULAR ROLE IN ENABL ING STAFF TO FIND AND READ THE RESEARCH LITERATURE.
RESEARCHERS MUST FIND WAYS TO COMMUNICATE THAT ARE MORE CLEAR, --WE MUST STOP WRITING IN WHAT I CALL "RESEARCHESE" WE MUST ALSO BE CERTAIN THAT THE QUESTIONS WE ARE PURSUING IN RESEARCH ARE RELEVANT TO CLINICIANS. EDUCATIONAL PROGRAMMES (BOTH BASIC AND CO NTINUING EDUCATION) NEED TO FOCUS ON READING AND USING RESEARCH IN PRACTICE. FOR TOO LONG WE HAVE BORED STUDENTS WITH THE "HOW TO DO RESEARCH" APPROACH - WHEN THEY DO NOT HAVE THE BACKGROUND TO EVEN BE INTERESTED - AND WHEN THE SKILLS THEY NEED ARE HOW TO FIND, READ, AND MAKE USE OF THE RESEARCH THAT IS ALREADY COMPLETED. NURSES WHO ARE SEARCHING FOR RESEARCH-BASED INFORMATION REQUIRE RESOURCES THAT ARE ADDITIONAL TO THEIR OWN INQUIRING MINDS AND KNOWLEDGE OF RESEARCH. THEY MUST HAVE TIME TO READ, ACCESS TO LIBRARY FACILITIES - INCLUDING ACCESS TO COMPUTERIZED INDICES, AND OPPORTUNITY TO DISCUSS THE LITERATURE THAT THEY FIND.
ADMINISTRATIVE STRUCTURES AND EDUCATIONAL PRACTICES CAN BE OF GREAT ASSISTANCE IN THIS ARENA . SOME WORKLOAD MEASUREMENT SYSTEMS PERMIT ALLOCATION OF TIME FOR SPECIAL PROJECTS. IN OUR HOSPITAL, THE PRACTICE OF MANAGERS VARIES CONSIDERABLY, BUT MANY ARE FO STERING THEIR STAFF'S INQUIRIES BY ASSURING THAT THEY HAVE SOME PAID TIME TO PURSUE THEIR INTERESTS. THE CREATION OF RESEARCH INTEREST GROUPS OR JOURNAL CLUBS ENABLES GROUP DISCUSSION OF CURRENT RESEARCH; WE HAVE ESTABLISHED A PRACTICE WHERE THE HOSPITAL NURSING RESEARCH INTEREST GROUP LINKS WITH THE QUALITY PRACTICE COMMITTEE AND ASSISTS THEM WITH REVIEWING RESEARCH LITERATURE PERTINENT TO THE QUALITY ISSUES THEY ARE PURSUING. INDIVIDUAL UNITS HAVE ESTABLISHED JOURNAL CLUBS IN WHICH THE STAFF FIND AND CI RCULATE ARTICLES, USUALLY NOT YET RESEARCH ARTICLES, FOR DISCUSSION. THE STRUCTURE OF A JOINT APPOINTMENT MAKES LINKAGES WITH THE UNIVERSITY EASY AND HAS RESULTED IN SOME NEW WAYS OF FACILITATING STAFF FINDING ANSWERS TO THE QUESTIONS THEY RAISE.
FOR EXAMPLE, WE HAVE LINKAGES BETWEEN GRADUATE STUDENTS WHO ARE STUDYING NURSING OF YOUNG FAMILIES WITH ILL CHILDREN AND STAFF OR MANAGERS WITH PARTICULAR PRACTICE ISSUES. THE STUDENT FOCUSES HER ADVANCED CLINICAL PRACTICE IN THAT AREA, AND CAN PROVIDE TH E UNIT/ STAFF/MANAGER WITH LITERATURE AND ANALYSIS OF THE ISSUE, OR HELP WITH A PROJECT THEY MAY WISH TO CARRY OUT. A USEFUL STRATEGY IS TO DISTRIBUTE STUDENT PAPERS THAT SUMMARIZE CURRENT RESEARCH, AND THUS CREATE OPPORTUNITIES TO LEARN MORE ABOUT HOW T O READ AND THINK ABOUT RESEARCH ARTICLES. IN THE SITUATIONS WHERE WE HAVE DONE IT, BOTH STRATEGIES HAVE GENERATED EXCITEMENT AND STIMULATION OF MORE QUESTIONS ABOUT PRACTICE. GRADUATE STUDENTS IN THE AREA HAVE ALSO BEEN INSTRUMENTAL IN ENABLING STAFF TO ACCESS HELP IN FINDING LITERATURE IN THE HOSPITAL LIBRARY - AND SUBSEQUENTLY, THE STAFF NURSES HAVE ASKED FOR HELP IN DEVELOPING A RESEARCH PROJECT, OR HAVE PLANNED CHANGES IN THEIR PRACTICE.
IN ADDITION THE PRESENCE OF STAFF MEMBERS WHO HAVE SOME KNOWLEDGE OF RESEARCH CAN BE OF TREMENDOUS ASSISTANCE TO THOSE NURSES WHO HAVE "COLD SWEATS" WHEN THEY EVEN THINK ABOUT READING A RESEARCH ARTICLE - WITH THIS TYPE OF INVOLVEMENT REQUIRES EASY ACCESS TO A LIBRARY - AND IT IS THE JOB OF MANAGMENT TO ASSURE THAT NURSES HAVE READY ACCESS TO THE HOSPITAL AND UNIVERSITY HEALTH SCIENCE LIBRARIES, AND TO PROVIDE SUFFICIENT FUNDING TO PERMIT THE COPYING OF ARTICLES THAT THE NURSE NEEDS TO EXAMINE CAREFULLY.
EXPECTING, FACILITATING, AND REWARDING THE USE OF RESEARCH IN PRACTICE AND RESEARCH- BASED POLICIES
THE GAP BETWEEN CURRENT RESEARCH FINDINGS AND THEIR IMPLEMENTATION IN PRACTICE CAN BE DECREASED THROUGH A PLANNED AND MULTI-FACETED APPROACH TO THE PROBLEM. MANAGERS MUST CREATE EXPECTATIONS THAT PROCEDURES, POLICIES, AND STANDARDS WILL BE RESEARCH-BASED. THE EXPECTATIONS FOR USE OF RESEARCH IN PRACTICE CAN BE DETAILED IN POSITION DESCRIPTIONS FOR ALL LEVELS OF STAFF, AND STAFF CAN BE HELD ACCOUNTABLE DURING THE PERFORMANCE REVIEW OR POLICY APPROVAL PROCESSES FOR MEETING THOSE EXPECTATIONS. HOWEVER, SUCH EXPECTATIONS ALSO REQUIRE THE PROVISION OF SUPPORT SYSTEMS THAT ENABLE THEIR ENACTMENT. THESE INCLUDE REALISTIC TIME-FRAMES, TIME TO WORK ON THE PROJECT, EDUCATIONAL PROGRAMMES, LIBRARY SUPPORT, CONSULTATION WITH RESEARCHERS, AND OPPORTUNITIES TO COLLABOR ATE WITH ESTABLISHED RESEARCHERS ON RESEARCH UTILIZATION PROJECTS.
THE CREATION OF POSITIONS TO FACILITATE RESEARCH USE AND TO BE INVOLVED IN MANAGEMENT DECISIONS IN THE AGENCY WILL INCREASE SUCCESSES. IN TURN, STAFF HAVE THE RESPONSIBLITY TO MAKE OPTIMAL USE OF THE TIME AND RESOURCES AVAILABLE AND TO BE INVOLVED IN ACTI VITIES THAT ENHANCE THEIR CAPACITI ES TO CREATE SUCH RESEARCH-BASED PRACTICE.
SOME OF THESE STRATEGIES ARE EASIER TO ACHIEVE THAN OTHERS. MY OWN EXPERIENCE IS THAT THERE HAS BEEN GRADUALLY INCREASING AWARENESS OF THE NEED FOR ESTABLISHING A RESEARCH BASE - OR FAILING THAT, A DOCUMENTATION BASE - FOR PROCEDURES AND POLICIES.
TO DATE THAT AWARENESS IS CHIEFLY AMONG SENIOR NURSING MANAGEMENT AND THE CHAIR AND SOME MEMBERS OF THE QUALITY PRACTICE COMMITTEE. THE ADDITION OF RESOURCES IN NURSING RESEARCH HAS ACCELERATED THAT PROCESS, AND IT WOULD NOW BE RARE THAT ANY CHANGE WAS N OT DOCUMENTED WITH RATIONALE BASED IN RESEARCH (OR A REASON WHY IT WAS NOT) --- OF COURSE MANY OF THE ISSUES HAVE LITTLE RESEARCH BASE. IN THOSE INSTANCES, TITLER, ET AL. RECOMMEND SEEKING EXPERT CONSULTATIONS AND/OR USING SCIENTIFIC PRINCIPLES TO GUIDE P RACTICE.
THE MORE DIFFICULT STRATEGIES ARE THOSE RELATED TO TIME FRAMES AND TIME RELEASE TO WORK ON PROJECTS.
FACILITATING NURSING RESEARCH IN THE CLINICAL ENVIRONMENT
GETTING RESEARCH TO "WORK" IN CLINICAL SETTINGS REQUIRES EFFORTS BY CLINICIANS, MANAGERS, AND RESEARCHERS. THERE IS NO DOUBT IN MY MIND THAT HAVING NURSES INVOLVED IN DOING RESEARCH ENHANCES THE CLIMATE OF INQUIRY -- AND LEADS TO MORE USE OF RESEARCH IN P RACTICE. BUT TOO OFTEN RESEARCHERS AND CLINICIANS ARE LIKE TWO ISLANDS WITH NO CONNECTING BRIDGES. WE MUST FIND WAYS OF CREATING THOSE BRIDGES. WHILE RESEARCHERS HAVE MANY RESPONSIBILITIES IN THIS ARENA, TWO OF THE MOST CRUCIAL ARE THAT THE RESEARCH BE RELEVANT TO THE PRACTICE, AND THAT THE RESEARCHER REMAIN CLOSELY INVOLVED WITH STAFF THROUGH THE CONDUCT OF THE STUDY.
FOR MANY YEARS, RESEARCHERS HAVE BEEN BASED IN UNIVERSITIES - AND HAVE BEEN "RARE BIRDS". AS IN OTHER DISCIPLINES, THEY HAVE THE PRIVILEGE OF "ACADEMEMIC FREEDOM" THAT INCLUDES THE FREEDOM TO PURSUE QUESTIONS JUST BECAUSE THEY ARE INTERESTED. WHAT INTER ESTS THE ACADEMIC MAY NOT INTEREST THE CLINICIAN! HOWEVER, IN DEFENSE OF "ACADEMICS", THERE ARE OTHER REASONS WHY THE RESEARCH MAY NOT SEEM RELEVANT TO CLINICIANS. OFTEN, BEFORE THE CLINICALLY RELEVANT STUDY CAN BE DONE, MORE BASIC DESCRIPTIVE AND THEOR Y BUILDING STUDIES ARE NEEDED. THESE ARE UNLIKELY TO PROVIDE DIRECTION FOR PRACTICE. ANOTHER RESPONSIBILITY OF THE RESEARCHER IS TO STAY INVOLVED WITH CLINICIANS DURING THE STUDY.
FOR THE RESEARCH STUDY TO BE SUCCESSFUL, THE INVESTIGATOR MUST BE AWARE OF THE CONSTRAINTS THAT THE STAFF FACE, MUST KNOW THEIR ISSUES. IN DESIGNING THE STUDY, THE RESEARCHER MUST TAKE THOSE ISSUES INTO ACCOUNT, AND, OF COURSE, ALSO CONSIDER SUCH ETHICAL ISSUES OF IMPOSITION ON STAFF TIME, INTRUSIVENESS OF THE STUDY, INFRINGEMENTS ON PRIVACY, AND ASSURANCE OF SAFETY - FOR STAFF, CHILDREN, AND THEIR FAMILIES.
THERE ARE ALSO MANY RESPONSIBILITIES OF THOSE IN STAFF AND MANAGEMENT POSITIONS THAT "MAKE RESEARCH WORK INCLINICAL ENVIRONMENTS". THESE ARE RELATED TO SUCH ISSUES AS WELCOMING THE OPPORTUNITY FOR RESEARCH WITHIN THE AGENCY, ASSURING APPROPRIATE REVIEW P ROCESSES, FACILITATING ACCESS TO STUDY POPULATIONS - WHILE PROTECTING PATIENT AND STAFF RIGHTS. FOR EXAMPLE, THE AGENCY MUST HAVE A SYSTEM FOR ETHICAL REVIW OF PROJECTS - A RESEARCH ETHICS BOARD; WHATEVER THE REVIEW PROCESS IS, IT SHOULD NOT REQUIRE AN E XTRA TIER OF REVIEW FOR NURSING STUDIES. RESEARCH FRIENDLY CLINICAL ENVIRONMENTS OPERATE WITHIN A PHILOSOPHY TO FACILITATE AND SUPPORT RESEARCH (RATHER THAN TO REWARD ONLY VERY SKILLED RESEARCHERS). THESE ENVIRONMENTS DO NOT INSIST ON PERFECTION BUT FOST ER THE DEVELOPMENT OF GOOD PROPOSALS BY PROVIDING THE MEANS FOR CONSULTATION.
FOR EXAMPLE AT THE IWK, STAFF CONSULT EITHER WITH ME OR WITH BETH BRUCE, OUR RESEARCH ASSOCIATE, TO REFINE THEIR QUESTION AND HYPOTHESES, TO PLAN THE STUDY, TO WRITE THE PROPOSAL AND IN THE IMPLEMENTATION STAGES. ANOTHER FACILITATOR IS PROVIDING FUNDING T HAT ENABLES STAFF TO ATTEND PRESENTATIONS OR CONFERENCES ABOUT RESEARCH OR TO PRESENT THEIR OWN RESEARCH RESULTS. THE FUNDING OF ONE NURSE FROM OUR PICU TO PRESENT HER RESEARCH COMMUNICATED A VERY SUPPORTIVE MESSAGE TO OTHER STAFF. FINALLY, RESEARCH FRIE NDLY CLINICAL ENVIRONMENTS ENCOURAGE, MAKE VISIBLE, EVEN HERALD THE ACHIEVEMENTS OF RESEARCH AND RESEARCHERS. FOR EXAMPLE, DURING OUR NURSING DEPARTMENT'S ANNUAL MEETING LAST MONTH, THE AGENDA HIGHLIGHTS TWO STAFF NURSE RESEARCH PRESENTATIONS AND THE ANN OUNCEMENT OF THE WINNERS OF THE 1995 NURSING RITUAL CHALLENGE. AGENCY NEWSLETTERS CAN PROVIDE EVEN GREATER VISIBILITY AND CELEBRATION.
INFRASTRUCTURE SUPPORT -- ESSENTIAL!
NURSES IN UNIVERSITY SETTINGS HAVE CONSIDERABLE MOTIVATION TO DO RESEARCH -- IT IS A REQUIREMENT TO KEEP THEIR JOBS! EVEN IF THEY ARE IN POORLY FUNDED INSTITUTIONS, THEY HAVE TO FIND WAYS TO CONDUCT RESEARCH. TYPICALLY, AT LEAST IN THIS COUNTRY, THE UNIV ERSITY BASED RESEARCHER HAS GREATER SUCCESS IN OBTAINING RESEARCH GRANTS AND MAY EVEN HAVE SOME RESEARCH INFRASTRUCTURE SUPPORT. IF WE EXPECT NURSES IN CLINICAL SETTINGS TO DO RESEARCH, THEY MUST HAVE INFRASTRUCTURE SUPPORT. EVEN IN THESE TIMES OF INCRED IBLE BUDGET CONSTRAINTS, IT IS WORTH IT TO DEVOTE SOME RESOURCES TO THAT INFRASTRUCTURE. WHILE THE ACTUAL INVOLVEMENT OF STAFF IN DOING RESEARCH STUDIES MAY NOT ESSENTIAL TO HAVING A CLIMATE OF INQUIRY, THE "SPIN-OFF" EFFECT OF SUCH ACTIVITY GREATLY ENHAN CES SUCH A CLIMATE.
HAVING NURSE RESEARCHERS IN POSITIONS, SUCH AS NURSING RESEARCH CONSULTANT OR DIRECTOR, WILL PROVIDE AVENUES FOR STAFF TO SEEK THE CONSULTATION AND/OR COLLABORATION THEY NEED TO DEVELOP AND IMPLEMENT STUDIES THAT ARE RELEVANT TO THEIR OWN AREA OF PRACTICE OR TO THE AGENCY AS A WHOLE. IT HAS BEEN MY EXPERIENCE THAT NURSES FELT FREE TO CONSULT WITH ME ONLY WHEN THE HOSPITAL HAD CREATED A FUNDED POSITION -- SINCE I WAS NOW OFFICIALLY A PART OF THE STAFF THEY NO LONGER FELT THEIR CONSULTING ME WOULD BE AN IMP OSITION. SIX YEARS AGO, THE VICE-PRESIDENT CREATED THE POSITION OF DIRECTOR OF NURSTNG RESEARCH AT 30% OF AN FTE. THAT ENABLED CREATION OF RESEARCH AWARENESS, BEGINNING QUESTIONING OF PRACTICE, AND IMPLEMENTATION OF A FEW NURSING STUDIES.
HOWEVER, FOUR YEARS LATER, THE ADDITION OF THE 50% FTE RESEARCH ASSOCIATE POSITION ENABLED AN INCREDIBLE INCREASE IN THE NUMBER OF NURSING STUDIES IN THE AGENCY. NURSING NOW RANKS SECOND OF ALL DEPARTMENTS IN THE NUMBER OF APPLICATIONS FOR INTERNAL RESEA RCH FUNDING. I HAVE ALREADY DISCUSSED OTHER SUPPORTS THAT ARE REQUIRED. THESE INCLUDE APPROPRIATE ETHICS REVIEW BOARDS, INTERNAL FUNDING MECHANISMS, ACCESS TO COMPUTERS WITH WORDPROCESSING AND STATISTICAL ANALYSIS SOFTWARE PACKAGES.
STAFF INVOLVEMENT IN RESEARCH
WITHOUT SOME INVOLVEMENT IN RESEARCH, WHETHER THAT INVOLVEMENT BE READING AND DISCUSSING RESEARCH ARTICLES OR BEING THE PRINCIPLE INVESTIGATOR FOR A STUDY, NURSES MIGHT AS WELL BE CRYTAL BALL GAZING WHEN THEY ATTEMPT TO PREDICT THE OUTCOME OF THEIR INTERV ENTIONS, OR TO PREDICT THE FUTURE OF NURSING. INVOLVEMENT WILL ENABLE MORE ACCURATE PREDICTIONS, CREATION OF INNOVATIVE INTERVENTIONS, AND EVEN THE CREATION OF NURSING'S PREFERRED FUTURE. THE INVOLVEMENT OF NURSES IN ANY RESEARCH ACTIVITY IS DETERMINED, I N MY EXPERIENCE, NOT BY THEIR EDUCTION OR THEIR FORMAL POSITION IN AN AGENCY, BUT BY THEIR CURIOSITY, INTELLIGENCE, AND DRIVE, AND BY THE ENVIRONMENT IN WHICH THEY WORK. NURSING HAS HAD A LONG HISTORY OF DEBATE ABOUT WHO SHOULD "DO" RESEARCH.
IN A 1984 PRESENTATION, I SPOKE TO A SLIDE THAT DEPICTED STAFF NURSES' ROLES IN RESEARCH AS USUALLY LIMITED TO ASKING QUESTIONS, READING AND USING RESEARCH, OR PARTICIPATING AS RESPONDENTS IN STUDIES. BUT -- IN 1995 I HAVE QUITE A DIFFERENT VIEW. IT IS MY EXPERIENCE OVER THE PAST THREE YEARS, THAT INVOLVEMENT AS AN INVESTIGATOR, BOLSTER'S THE STAFF NURSE'S SPIRIT OF INQUIRY, STIMULATES FURTHER READING AND USE OF RESEARCH. SEVERAL OF THOSE WHO BEGAN BY PURSUING ANSWERS TO THEIR OWN CLINICAL QUESTIONS HA VE EMBARKED ON FURTHER NURSING EDUCAT I ON. BUT - TO REITERATE - THE CONDUCT OF RESEARCH IN CLINICAL SETTINGS REQUIRES EXPECTATIONS FOR RESEARCH ACTIVITY, ACCESS TO CONSULTANTS, MENTORING THROUGH ALL OF THE STAGES OF THE RESEARCH PROCESS INCLUDING IMPLEM ENTATION OF THE PROJECT, DATA ANALYSIS, AND WRITING OF REPORTS, ACCESS TO FUNDING - INCLUDING FUNDING OF RESEARCH ASSISTANTS FOR DATA COLLECTION AND DATA ENTRY, RELEASE TIME, SECRETARIAL SUPPORT, AND ACCESS TO SPACE AND A COMPUTER.
LET ME TAKE A FEW MOMENTS TO HIGHLIGHT JUST THREE OF THE MORE THAN 20 PROJECTS THAT ARE CURRENTLY AT SOME STAGE OF DEVELOPMENT OR IMPLEMENTATION BY NURSES AT OUR SMALL CHILDREN'S HOSPITAL. THIS TOTAL DOES NOT INCLUDE THE MANY QUALITY IMPROVEMENT PROJECTS THAT ARE UNDERWAY AS A RESULT OF REGULAR HEATED STAFF "DISCUSSIONS" AND CONSIDERATION OF A QUALITY PRACTICE ENDEAVOUR TO ASSESS STANDARDS ON VISITING IN OUR PICU.
ONE OF THE STAFF DECIDED TO DO A STUDY THAT COULD PROVIDE A RESEARCH BASE FOR THEIR DECISION MAKING. THE STUDY WHICH COMPARES PARENTS' AND PROFESSIONALS' VIEWS OF PICU VISITING POLICIES AND EXPERIENCES WAS THE FIRST PROJECT DONE BY A STAFF NURSE TO RECEIV E HOSPITAL FINANCIAL SUPPORT. THE STAFF NURSE INVESTIGATOR HAS PRESENTED HER PRELIMINARY RESULTS AT A RESEARCH CONFERENCE AND WILL USE THE RESULTS TO INFORM THE DEVELOPMENT OF NEW VISITING GUIDELINES FOR THE UNIT.
ANOTHER PROJECT COMPARES PARENTS' READINESS FOR DISCHARGE FOLLOWING TWO DIFFERENT NURSING APPROACHES TO PREPARATION. THIS QUESTION AROSE IN PART FROM THE NURSES' PERCEPTION THAT THEY HAD TO DEMONSTRATE THAT THEY WERE PROVIDING AN INDISPENSABLE AND COST-EF FECTIVE SERVICE. IN THIS STUDY STAFF NURSES AND THEIR NURSING MANAGER WORKED WITH THE RESEARCH ASSOCIATE TO DEVELOP AND IMPLEMENT THE STUDY, AND BASED ON THE RESULTS PLAN TO CONSIDER ANY NEEDED CHANGES IN THEIR APPROACH TO PREPARATION FOR DISCHARGE.
FINALLY, THE NURSES IN FOUR DIFFERENT AMBULATORY CLINICS HAVE UNDERTAKEN SURVEYS OF PARENTS TO DETERMINE THEIR NEEDS AND THE EXTENT TO WHICH THOSE NEEDS ARE BEING MET. IN ONE INSTANCE, THE RESULTS LED TO THE CREATION OF A CLINICAL NURSE SPECIALIST POSITIO N. IN THE SECOND, THE RESULTS LED TO CHANGES IN THE NURSES APPROACHES TO CARE.
WHY BOTHER? IS IS WORTH IT?
IS IT WORTH THE EFFORT AND THE EXPENSE TO HAVE RESEARCH IN CLINICAL ENVIRONMENTS AND TO HAVE STAFF INVOLVED IN DOING THAT RESEARCH?
IT IS OUR EXPERIENCE THAT SUCH INVOLVEMENT RESULTS IN ENERGIZED AND CREATIVE STAFF. THERE I S A CONTAGIOUS EXCITEMENT AND THERE ALSO SEEMS TO BE A SIGNIFICANT ENHANCEMENT OF THE SELF-CONCEPTS OF THE NURSES INVOLVED, AND THOSE UNITS WHOSE STAFF ARE INVOLV ED IN SUCH ACTIVITY. AS WE FACE THE DEMANDS OF THIS DECADE AND THE NEXT CENTURY TO DEMONSTRATE THE COST-EFFECTIVENESS AND BENEFITS OF OUR PRACTICE, RESEARCH WILL BE OF TRMENDOUS ASSISTANCE. THE CHANGES IN PRACTICE AND THE RESEARCH THAT FLOURISH WHEN THE RE IS A CLIMATE OF INQUIRY WILL ENABLE US TO "WORK SMARTER" AS WELL AS TO DEMONSTRATE WHY WE NEED THE RESOURCES TO PROVIDE GOOD QUALITY CARE. RESEARCH INCLINICAL ENVIRONMENTS PROVIDE THE EVIDENCE THAT ENABLE US TO MORE INTO THE NEXT ERA IN HEALTH CARE. THE FINDINGS OF SEVERAL NURSING STUDIES - BOTH ABOUT SPECIFIC NURSING PRACTICES AND ABOUT VERY BROAD NURSING CARE DELIVERY ISSUES - DEMONSTRATE THE PRACTICAL BENEFITS OF NURSING RESEARCH, THE COST-EFFECTIVENESS OF NURSING CARE, AND MODELS OF CARE THAT FIT WITH A REFORMED HEALTH CARE SYSTEM.
I CANNOT CLAIM THAT WE HAVE ACHIEVED THE LEVEL OF RESEARCH THAT CAN MEET THAT CRITERION - BUT OTHERS HAVE! CONSDIER FOR EXAMPLE, THE STUDIES BY GGODE AND COLLEAGUES THAT DEMONSTRATED THE EFFECTIVENESS OF SALINE RATHR THAN HEPARIN FLUSHES FO PERIPHERAL IN TRAVENOUS LOCKS - WITH ESTIMATED SAVINGS OF MORE THAN $1 MILLION U.S. DOLLARS ANNUALLY. PRESCOTT HAS REVIEWED A BEVY OF STUDIES THAT DEMONSTRATE THAT NURSE STAFFING LEVELS AND SKILL MIX MAKE SIGNIFICANT DIFFERENCS IN THE OUTCOMES OF HOSPITALIZED PATIENTS . BROOTEN REPORTS THAT HER MODEL OF SUBSTITUTION OF NURSING CARE FOR SOME PHYSCIAN VISITS HAS RESULTED IN SIGNIFICANT SAVINGS AND IMPROVED OUTCOMES IN SEVERAL VULNERABLE POPLULATIONS, INCLUDING THE HOSPITALIZED ELDERLY, VERY LOW BIRTHWEIGHT INFANTS, WOME N WITH UNPLANNED CAESAREAN BIRTHS, CHILD-BEARING DIABETICS, AND CHILDREN WITH HIV.
I THINK YOU MIGHT AGREE THAT CONDUCTING RESEARCH IN CLINICAL ENVIRONMENTS IS WORTH IT, AND WE MUST MAKE IT WORK !