| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Corresponding author: Anna Gawlinski, RN, DNSc, CS, ACNP, UCLA Medical Center, Room 14-176CHS, 10833 LeConte Ave, Los Angeles, CA 90095 (e-mail: AGawlinski{at}mednet.ucla.edu).
 |
Abstract |
|---|
 Top Abstract An Infrastructure for Advancing...Building a Foundation for...Structures to Advance Research...References |
|---|
|
Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
|
Institutions effective in involving clinicians have built a foundation of infrastructures that enable processes for engaging clinicians. What distinguishes effective from ineffective hospital nursing research and evidence-based practice programs is the presence of structures whereby processes can occur that
In this article, I describe infrastructures that can ensure and sustain research-based practices while unleashing the talent and creativity of clinicians as these health care providers question practice and ponder the merits of current research. Fostering participation in such clinical inquiry will summon professional growth, influence the lives of patients, and help each nurse develop a unique personal professional legacy.
| Research-based practices improve when staff nurses are involved with the research from the start.
|
|
An Infrastructure for Advancing Research and Evidence-Based Practice |
|---|
|
TopAbstractAn Infrastructure for Advancing...Building a Foundation for...Structures to Advance Research...References |
|---|
provides an organizational infrastructure based on the Donabedian model1–3 that can be used to advance research and evidence-based practice and shows the important relationships among structure, process, and outcome. Donabedian described the importance of structure, which first affects process and then results in desired outcomes. Donabedian initially introduced the triad model for use with quality assessment and improvement processes. This linear framework can be used to conceptualize a model for designing and implementing an infrastructure in which research and evidence-based care can flourish. Establishing structures (ie, having the right things in place) must occur so that processes can take place (doing things right) to achieve outcomes (having the right things happen).4 Thus, in a hospital institutional setting, well-planned implementation of these structures is likely to promote research and evidence-based practice in the delivery of good care and, consequently, produce better outcomes.
|
|
Building a Foundation for Research and Evidence-Based Practice |
|---|
|
TopAbstractAn Infrastructure for Advancing...Building a Foundation for...Structures to Advance Research...References |
|---|
lists the structures that have been implemented at the University of California, Los Angeles (UCLA) Medical Center to advance research and evidence-based care.
|
Implementing structures similar to those at UCLA Medical Center can position an institution to move its culture toward one in which nursing practice is based on the best available evidence and clinicians are fully engaged in the process.
|
Structures to Advance Research and Evidence-Based Practice Evidence-Based Practice Fellowship Program for Staff Nurses |
|---|
|
TopAbstractAn Infrastructure for Advancing...Building a Foundation for...Structures to Advance Research...References |
|---|
Program Description.
The evidence-based practice fellowship program is a 9- to 12-month mentored program. The fellows identify a clinical practice issue and solve it by using the latest research and other levels of evidence to implement a change in practice. The fellows are mentored through a series of steps:
During the 9 to 12 months of the program, each fellow is mentored by a researcher who has a doctoral degree (director of evidence-based practice) and a clinical mentor who is an advanced practice nurse (eg, a clinical nurse specialist) or, in some cases, the nurse educator or unit manager. The program includes didactic education and facilitated work on the evidence-based practice project. The didactic part of the program consists of six 8-hour classes (1 class per month) that provide both theory and practical information needed to facilitate completion of the fellow’s evidence-based practice project.
The director of evidence-based practice coordinates the fellowship projects and works with the fellows and their mentors (usually clinical nurse specialists) to assist in all phases of each fellow’s project, from fine-tuning the clinical practice issue to evaluating the evidence-based change in practice.
The clinical nurse specialist provides additional support for the fellowship program by working with the fellows to improve patient care by incorporating research findings into nursing practice. Clinical nurse specialists mentor fellows who work in specialties similar to the specialty of the mentoring nurse specialist. They provide expert clinical advice and assist the fellows in using appropriate communication channels when implementing an evidence-based practice change.5,7,15
Fellows increase their skills in finding pertinent literature via library MEDLINE searches, learning to critique and synthesize research, developing an evidence-based practice innovation, learning how to make a practice change, and measuring the outcomes of their project. In addition, fellows prepare educational sessions to share information at staff meetings. They disseminate the results of their projects internally to their units and departmental committees and, in some instances, externally through national presentations and/or publication. Each fellow integrates the practice change into his or her unit and/or department and develops processes to promote sustainability of the change in practice.
Selection Criteria.
Staff nurses are selected for the fellowship via a competitive application process. Applicants representing diverse clinical inpatient areas are desired. The competitive review is based on the content of the application, the number of applications received, and the applicant’s meeting criteria, which include the following:
Applications are evaluated and scored by the members of the nursing practice research council. Interest in the program has been high; for example, in one "call for applications," 14 applications were submitted and 7 staff nurses were chosen for the fellowship program.
Research Institute
Another structure that should be considered to help involve nurses in the conduct of research, advance the science of nursing, and improve patients’ outcomes is a research institute. At UCLA Medical Center, the research institute is a mentored program with a focus on the essential elements of designing and conducting a research study. The research institute is unique: the education and practicum associated with the design and conduct of research are incorporated into meetings of a unit-based research team, allowing the team to simultaneously develop a research proposal and learn the research process. The research institute teaches nurses to ask the right clinical research questions and, as a team, to use research methods to discover new knowledge that ultimately improves patients’ care.
Concepts and processes used in the research institute were adapted from a program developed and published by Chulay.16 In her program, research teams and focus groups are used to engage clinicians in the conduct of research; the program has been adapted several times to meet the organizational and departmental needs at UCLA Medical Center.
Program Description.
The research institute is designed for staff nurses to work collaboratively with advanced practice nurses (usually clinical nurse specialists) to form a unit-based research team that develops knowledge and critical skills in designing and conducting a research study. The institute is a 12-month research-intensive program in which participants focus on the essential elements of designing and conducting a research study to answer clinically relevant research questions. Staff and clinical nurse specialists (or a qualified clinical/administrative leader) learn to design a research study, test hypotheses, and answer research questions by using the scientific process. This institute stimulates innovative thinking about practice issues that require rigorous scientific investigation and expands the scientific foundations of nursing practice at UCLA.
During the 12-month institute, each research team meets twice a month for 2 hours to choose an appropriate research question, develop the research proposal, obtain appropriate approvals, conduct the study, and simultaneously learn how to conduct research. The education and practicum for the design and conduct of research are incorporated into the 2-hour meetings. In addition, at key points during the institute 4-hour meetings are held during which participants actively work on synthesizing the literature and pulling together the various parts of the research proposal they have been working on during the 2-hour sessions.
| Structures to support research must engage frontline clinicians.
|
The director of evidence-based practice, a researcher who has a doctorate, oversees the research institute and serves as the research mentor for staff nurses and the nurses’ paired clinical nurse specialists. Each clinical nurse specialist is also mentored in leading a research team and assisting in all phases of the design and conduct of a research project. The staff nurses and clinical nurse specialists on the research teams increase their knowledge and skills to do the following:
On the basis of the results of the study, each research team develops an action plan to effect changes in practice. Research findings are disseminated internally to divisional and departmental committees and councils and externally at professional meetings and through publication.
Selection Criteria. A total of 1 to 2 unit-based research teams are selected annually through a competitive application process. Each team ideally consists of 4 to 5 staff nurses, but a minimum of 2 staff nurses and 1 advanced practice nurse (or other qualified individual) from a unit and/or clinical practice area must submit the application.
| The evidence-based practice fellowship assists nurses in solving clinical practice issues in their own units.
|
Staff nurses must meet the following criteria to be selected for the research team:
The clinical nurse specialist (or a qualified clinical/administrative individual) who leads the research team must meet the following criteria:
| Each fellow is mentored by both a researcher and an advanced practice nurse.
|
In addition, the clinical nurse specialists must have skills to run a meeting effectively and move the research team and the team’s project along to completion. These team leaders facilitate group process and decision making or reaching consensus by group members. The leaders must be organized, able to develop a detailed agenda, and start and end a meeting on time. They should give recognition to the team members for accomplishments and successes, instead of to themselves. Above all, they must commit to the completion of the research project and the success of their research team.
Advanced Practice Institute
Clinical and administrative leaders have an important role in aligning hospital systems to ensure that evidence-based practices are consistently used at the bedside. Therefore, structures also are needed to educate and develop knowledge and skills of research and evidence-based practice among administrative and clinical leaders. Leaders make evidence-based practice a priority by investing in the structures and processes necessary to identify and implement evidence-based practices while holding staff accountable for using those practices.
Program Description. The advanced practice institute is an annual 8-hour workshop designed to develop the advanced skills necessary for administrative and clinical leaders to promote and mentor staff nurses and multidisciplinary teams in adopting evidence-based practices. The institute also provides leaders with strategies that assist evidence-based practice fellows in implementing and evaluating projects and facilitates completion of clinically relevant projects involving evidence-based practice and research. Additionally, the institute fosters networks for creative thinking and for resolution of issues that occur during the process of getting innovations into practice. Developing a scientific base for practice is important for nurses and is a requirement of many accreditation and regulatory agencies such as the Joint Commission.
Workshops and seminars at the advanced practice institutes at UCLA have addressed topics such as the following:
Selection Criteria. Any person in a position of leadership can attend the advanced practice institute. Nurse executives advance the agenda for research and evidence-based practice by clearly articulating the expectation for leaders to attend the institute. By encouraging involvement in the institute and other research and evidence-based practice activities, leaders give unwavering verbal support to these structures. Such vigilance from the executive level sends a clear message to the leadership and staff that patient care should be based on the best available evidence and should not vary illogically from practitioner to practitioner.
Clinical Practice Committee
In addition to structures that engage clinicians and leaders in advancing knowledge and building skills of research and evidence-based practice, several committee structures are important to put into place. An organization’s commitment and values related to research and evidence-based practice are reflected in the organization’s practice documents for the provision of patient care. Thus, practice documents such as policies, procedures, and guidelines must be written to reflect practices that are based on research and other levels of evidence. In addition, practice documents should include the agreed-upon grading scheme for the level and strength of evidence, along with supporting reference citations.
Committee Description. The purpose of the clinical practice committee is to foster exemplary patient care through the development, review, and dissemination of clinical nursing policies, procedures, and guidelines to ensure that these documents are based on the latest research or other levels of evidence. The committee is composed of staff nurses from each unit within the nursing department. Staff nurses representing their respective units on the committee participate in the development and review of delegated nursing policies, procedures, and guidelines.
In addition to reviewing key nursing policies of the medical center for clinical accuracy, staff nurses on the committee assess the incorporation of evidence, identifying gaps between research recommendations and practice. The nurses consult on practice issues that require clarification through the development of practice documents and, in some instances, may refer issues for performance improvement processes. Involvement of staff nurses on the clinical practice committee facilitates recognition of the nurses’ clinical expertise and influence to guide clinical practice. Moreover, the nurses’ involvement stimulates innovative thinking about practices that are efficient and effective in improving patients’ outcomes and facilitates ownership and promotion of unit policies, procedures, and guidelines. Participation fosters retention and recruitment of nurses and stimulates professional growth and development.
Collaboratively, all unit representatives engage in disseminating and communicating new and revised practice documents and changes in practice to their respective units and throughout the hospital. Strategies for dissemination include teaching staff nurse colleagues about selected clinical practice issues, reinforcing that information, and "leading by example" in areas specific to clinical practice. As a liaison between their units and the clinical practice committee, staff nurses bring information back to the committee about how new information and practice changes are being assimilated into the units. The nurses also keep their unit managers, clinical nurse specialists, and educators informed of new practice changes and committee activities.
Because of the many health care specialty areas, the clinical practice committee has 3 designated subgroups: critical care; medical-surgical intermediate care; and pediatrics, neonatal, and perinatal. Each subgroup is cochaired by a clinical nurse specialist or a clinical leader who is knowledgeable about evidence-based practice and able to work with groups to mentor staff in developing evidence-based practice documents. In addition, the director of evidence-based practice serves as the overall director of the clinical practice committee and as a mentor for research and evidence-based practice.
Appointment Criteria. Staff nurses from each hospital unit who have strong clinical knowledge and skills represent the unique needs of their specific units and help shape nursing practice in the units and throughout the hospital. A minimum of a 1-year commitment is needed. All unit representatives are expected to attend meetings regularly and participate fully in all activities during the meeting of the committee; they cannot miss more than 2 meetings per year. Attendance at the monthly committee meetings provides opportunities for training, development, and actual group and committee work in the following areas:
| This research institute focuses on the design and conduct of unit-based research.
|
Nursing Practice Research Council
One of the traditional structures for integrating research within an organization is a nursing research committee. Historically, these committees have focused on the review and approval of research studies; involvement of staff nurses has been limited. It is important to redesign such traditional committee structures to encompass nurses who practice at the bedside so that these nurses are involved and have a strong voice and representation on these committees.
Council Description. Refocusing traditional research committees to include involvement in activities for research and evidence-based practice can reinvigorate the practice environment and increase use of research at the bedside. For example, the purpose of the nursing practice research council at UCLA Medical Center is to increase the scientific foundation of practice by conducting and using research in 3 areas of work. For research development, the council provides consultation in the design, implementation, analysis, dissemination, and publication of nursing research. For research utilization, the council identifies and disseminates clinical research findings that are sufficient and appropriate to apply to nursing practice. For research education, the council develops workshops and seminars on generation and use of research results.
The agendas for the meetings of the research council include opportunities for interactive discussions of research intended to maximize staff participation in discussions. Nurses are encouraged to think critically about their practice and are asked if practices are aligned with research. Research that supports or negates current clinical practice is reviewed and discussed. Strategies are planned to decrease the gap between practice and research. Meetings close with detailed plans for implementation of strategies.
New research findings identified by council members also are discussed at meetings. Exploration of the applicability of the research to day-to-day practice is emphasized. Ideas are solicited for original research projects that might be conducted. This process generates clinically relevant research questions that arise from the bedside and can provide the committee with the subject for a good research project. Linking research to bedside practice always generates enthusiasm.
| Leaders make evidence-based practice a priority by investing in structures and processes necessary for using those practices.
|
Through their involvement in a research committee, many staff nurses become familiar and comfortable with research, research concepts, and terms related to research and evidence-based practice. The nurses learn by linking the terms to clinically relevant examples. This process helps generate and sustain enthusiasm for research and the work of the research council among staff nurses on the committee.
Other activities of a nursing research council might include the following:
Appointment Criteria. Staff nurses and clinical and administrative leaders participate in activities of the nursing practice research council to achieve the goals of the council. Annually, a "call for members" is electronically sent out to all staff nurses and the leadership group. The e-mail includes a description of the council and the responsibilities and activities of council members. Personal invitations are also issued at staff meetings and to individual nurses by the unit mangers and clinical nurse specialists. The director of evidence-based practice also discusses the council’s purpose and activities at the new graduate residency program. Nurses are invited to attend and observe a meeting to see if they would be interested in joining. All new and "visiting" members are introduced and are made to feel welcome by being asked to share something about themselves.
Administrative and clinical leaders often volunteer to become members, or are invited to serve, and subsequently are appointed to the council.
Processes for Engaging Clinicians
The conduct and use of research are powerful tools for advancing the science of nursing and for improving the quality of patients’ care and outcomes. Nurses play an integral role in research by asking relevant clinical questions. At UCLA Medical Center, clinicians are engaged in the structures just described via several strategies. E-mails and flyers are sent out to market the program or committee and to announce that applications are being accepted.
E-mails and flyers stress these structures as opportunities for staff to exert their clinical leadership and "influence over their practice," and this focus attracts clinicians to apply. Unit managers and clinical nurse specialists also announce these opportunities at staff meetings, answer questions that arise, and encourage staff to apply. If additional questions come up, staff nurses may also contact the director of evidence-based practice, who oversees these structures. Applications that include more detailed information about the responsibilities of staff nurses in these learning and committee structures are attached to e-mails and are accessible to staff via the intranet Web site.
For some structures, such as the fellowship program, staff nurses may have already identified a practice issue that they would like to address within the program. Other interested nurses may need suggestions from a clinical nurse specialist and manager for possible clinical issues that would be suitable to address within the program. A nurse manager and/or clinical nurse specialist can use this opportunity to discuss practice issues that can be addressed by the evidence-based practice fellowship program. Such practice issues are often on the "to do list" of a nurse manager and/or a clinical nurse specialist but have not been tackled because of other priorities and workload.
One-to-one dialogue may also engage staff nurses. In such dialogues, a nurse manager and/or clinical nurse specialist discusses the program with an individual staff nurse, suggests topics, and encourages the staff nurse to apply. This additional marketing strategy is important in engaging staff nurses who are ready to expand their knowledge and skills beyond day-to-day clinical care.
Written approval by the appropriate unit manager and/or clinical nurse specialist (or designee) must be obtained by staff nurses and included in the nurses’ application and/or letter of support. Using predetermined criteria, both the members of the nursing practice research council and the director of evidence-based practice review the applications. Staff nurses are notified of acceptance into the program or appointment to the committee/council.
Education about research conduct and/or evidence-based practice occurs while staff nurses are being involved in these structures. Opportunities are provided for clinicians to reflect on their practice, question whether they are providing care in the best possible way, and explore and evaluate other methods. Nurses develop insights into the depth and breadth of their practice and gain appreciation and pride for the work they do.16 They are empowered by the realization of their positive impact on patients’ lives. The nurses’ creativity is unleashed to investigate future practices, as the nurses engage in clinical inquiry and ponder the merits of past and present practices.19
For clinicians who are constantly busy "doing," involvement in these organizational structures creates genuine excitement and enthusiasm about research. Nurses are empowered and validated because they identify important questions to ask and address about patient care. Hospital-based "experts" on nursing research and evidence-based practice emerge from these structures prepared for future projects. Nurses continue to bring research findings to the bedside, while elevating accountability and sustainability for research and evidence-based practice throughout the hospital.
| Nurses who engage in research and evidence-based practice create a healing environment for patients and a healthy workplace for colleagues.
|
Improving Patients’ Lives
Conducting research and using the results of research have far-reaching benefits for patients. When care is improved, patients’ lives are improved. Compared with other nurses, nurses who engage in research and evidence-based practice are in much stronger positions to participate in teams to implement other research-based practices, create a healing environment for patients and patients’ families, and generate a healthy workplace for staff colleagues. Structures and processes for the evidence-based practice fellowship program and the research institute at UCLA Medical Center have resulted in improved care for patients with measurable benefits. Table 2 is a partial list of fellowship projects that had good outcomes, such as an increase in patients’ knowledge and preparedness for surgery, a decrease in medication errors, and lower rates of catheter-related bloodstream infections.
|
On the basis of the research-validated communication needs of these patients, the nurse then developed a lightweight board with preprinted words and pictures. The 2-sided communication board is now standard for patients receiving mechanical ventilation throughout the hospital, and the board is used for other types of patients who have impaired verbal abilities. Thus, the nurse helped solve a long-standing problem of many patients and had an impact that extended far beyond the unit where the study was done.
This comment from a former patient in the intensive care unit captures the importance of this nurse’s research intervention:
I had two major surgeries on the same day. When I awoke in the recovery room, I had tubes in my mouth and nose and could not speak. My daughter brought me an EZ Board, and I was able to communicate all my needs through it. . . . I think it was crucial to my time in the recovery room to have the board because it’s frustrating to be unable to express your needs.
The staff nurse presented his research findings internally via the aforementioned educational venues and externally at national meetings; his results were also published.20
The benefit of research discoveries generated by staff nurses may go beyond a patient’s current hospital admission and could improve the long-term health of many patients. Another nurse involved in research discovered that even short (12-minute) interactions between patients and dogs during animal-assisted therapy can reduce cardiopulmonary pressures, neurohormone levels, and anxiety in patients with advanced heart failure.21 These findings not only add to the knowledge about animal-assisted therapy but also indicate a new focus for studying the long-term improvement in these variables and the use of animal-assisted therapy as an effective adjunctive treatment for the health of patients.
Forging a Professional Legacy
Every nurse with an open mind and an open heart sees things that might be done better or thinks about changes that will improve patients’ care and outcomes. Involvement of staff nurses in the structures and processes that advance research and evidence-based practice provides an additional opportunity for professional growth and development far beyond the day-to-day clinical skills required at the bedside. Nurses’ professional growth and development are reflected by their comments:
It is amazing how through the classes and the structure, a light comes on. I can read articles now and advocate for evidence-based practice. I feel a lot more confident. It has been an amazing experience for me as a nurse.
I see the bigger picture. It changed my life entirely. I have the confidence to move up in my clinical ladder.
By learning the skills of research and evidence-based practice, nurses are empowered to individually and collectively bring about measurable improvements for patients in the health care environment:
Everyone has the responsibility to implement and make sure [an evidence-based practice change] is a success for each and every patient. Make it each one’s responsibility.
As nurses acquire new skills required for research and evidence-based practice, their roles are expanded. Their involvement broadens their scope of influence over practice as they make things even better for their patients. Staff nurses derive the greatest satisfaction when they actually make change happen with measurable positive results. This process of improving patient care fuels nurses’ spirit ("I am proud to say that I am a beacon [for evidence-based practice] on my unit") as they know that they have gone beyond their daily work assignments.
Nurses who engage in research and evidence-based practice are better prepared to participate in future research and on evidence-based practice teams, creating a healing environment for patients and patients’ families and a healthy workplace for staff colleagues. As one clinical leader stated:
This evidence-based practice program has changed the culture at UCLA. For the staff, it is so empowering. For me [as a clinical nurse specialist and mentor for staff], evidence-based practice is where nursing has arrived. We have our science and we have our knowledge. We want our practice to reflect the best practices. It allows the staff to think in the ozone ... the sky is the limit.
As nurses and their colleagues act as preceptors and mentors for new generations of nurses, they pass on the research discoveries and changes they have made. These discoveries and innovations become woven into the fabric of daily practice. Research-based changes in practice are thereby sustained and the lives of patients are improved. The impact of a nurse’s work lives on and creates a unique personal professional legacy.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
None reported.
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ajcconline.org and click "Respond to This Article" in either the full-text or PDF view of the article.
To learn more about evidence-based practice, visit http://ccn.aacnjournals.org and read the article by Carol A. Rauen and colleagues, "Seven Evidence-Based Practice Habits: Putting Some Sacred Cows Out to Pasture" (Critical Care Nurse, April 2008).
|
REFERENCES |
|---|
|
TopAbstractAn Infrastructure for Advancing...Building a Foundation for...Structures to Advance Research...References |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
