Demystifying nursing research at the bedside

By: Esther Chipps, PhD, RN, NEA-BC, Clinical Nurse Scientist, Ohio State University Wexner Medical Center, and Associate Professor of Clinical Nursing, Ohio State University College of Nursing, Columbus, OH; Mary Nash, PhD, RN, NEA-BC, FAAN, FACHE, Chief Nursing and Patient Care Services Officer and Associate Vice President of Health Sciences, Ohio State University Hospital and Health System, and Assistant Dean, Ohio State University College of Nursing, Columbus, OH; Jacalyn Buck, PhD, RN, NEA-BC, Health System Nursing Quality, Research, Education, and EBP Administrator, Ohio State University Wexner Medical Center, and Assistant Clinical Professor, Ohio State University College of Nursing, Columbus, OH; and Brenda Vermillion, DNP, RN, ACNS-VC, ANP-BC, CCRN, Director of Nursing Education, Ohio State University Wexner Medical Center, and Assistant Professor of Practice, Ohio State University College of Nursing, Columbus, OH

Nursing research is no longer solely the purview of nursing faculty in academia. Inquiry and science are fundamental to raising the bar in nursing practice, improving the patient experience, and enhancing patient outcomes. Acute care hospital environments provide excellent settings for clinical nurses to conduct research that improves quality and patient safety. Magnet® recognition is one approach frequently used to develop a culture that promotes scientific inquiry. Magnet model components require that organizations have a successful and sustainable robust nursing research program.

Delivering excellent patient care is a high priority for nurses, yet this value is often viewed in isolation from the importance of empirical evidence. The barriers to clinical staff members conducting research have been well reported in the literature.^1-3 However, with strategic vision and nurse leader support at all organizational levels, building nursing research capacity is achievable.

Evidence-based practice (EBP) has taken a strong hold in nursing curricula and among frontline nurses across the country. Is it a reasonable expectation that every nurse at the bedside has integrated EBP into their daily work? Yes! Nurses who are becoming familiar with searching the literature to find answers to clinical questions are no longer satisfied with the “this is the way we’ve always done it” approach. Is it a reasonable expectation that every nurse at the bedside should conduct research? No! However, frontline nursing staff members who express interest in research are instrumental for any organization to build research capacity.

So, what does it take for clinical nurses to successfully execute a research project? Equally important, what does the nurse leader of today need to have in place to support nursing research?

Checklist for conducting a research study on a clinical nursing unit

1. Identify the clinical question.
2. Conduct a literature review.
3. If evidence supports a practice change, integrate the evidence into practice (no additional research needed).
   • If the literature review doesn’t provide substantial research studies to answer the clinical question, conduct research.
4. Examine and evaluate your organization’s strategic plan and organizational chart.
5. Review organizational policies/procedures regarding research in the clinical setting.
6. Review potential study settings/nursing units and the unit culture of the potential study unit.
7. Form the research team.
   • Identify the:
     • Nurse research mentor
     • Team members
     • Study PI
     • Unit nursing staff
     • Interdisciplinary team members
     • Academic partner (if applicable)
8. Identify administrative support, including senior nursing leadership and key stakeholders.
9. Complete the research proposal.
10. Apply for IRB approval.
    • Review organizational IRB guidelines.
    • Submit the proposal to the IRB.
    • Obtain IRB approval.
11. Assess and seek all other institutional approval as required by your organization (for example, nursing research council, hospital quality council, or HIPAA council).
12. Conduct the research study after obtaining all required approvals.
13. Disseminate research findings.
    • Submit a manuscript to a peer reviewed journal.
    • Present a poster at a national conference.

Clinical nursing research projects usually evolve in one of two ways: 1) a staff member or group of staff members identifies a clinical problem, creates a PICOT (population/patient problem, intervention, comparison, outcome, time) question, and finds no literature to support the inquiry; or 2) a group of staff members decides to get involved in research and brainstorm potential projects. Less frequently in the practice setting, research projects may develop from a publicly released funding agency request that addresses a specific area of interest.

The decision of a clinical staff member and/or team to pursue a research project marks a major step in moving the research agenda forward for an institution. Success of a bedside clinical research project requires that the researcher(s) follow a detailed step-by-step process. It begins with identifying a clinical problem and continues with conducting an extensive literature review, developing and writing a proposal, implementing the project, analyzing and reporting conclusions, and disseminating the findings at the unit level (if appropriate).

Evaluating infrastructure and identifying key stakeholders

The nurse leader can support the research team by leading an effort to assess and evaluate organizational structures and processes, and key stakeholders who support research. The first step begins with a review of your organizational chart. Most organizations have a designated nurse leader who’s responsible for EBP, nursing innovations, and/or nursing research. If there’s a nurse scientist/nurse researcher either on staff or serving in a consultant role, this is likely the first person you’ll engage in discussion. If there isn’t a designated nurse researcher, your discussion can start with the senior nurse administrator who’s responsible for quality, education, innovation, and EBP.

Assessment of your organization’s research capacity should begin with a review of the nursing strategic plan. At the Ohio State University Wexner Medical Center (OSU WMC), the nursing strategic plan outlines the goals of integrated innovations and best practices for clinical care, along with the importance of EBP and nursing research. In addition, our strategic plan emphasizes the importance of building a collaborative relationship with the Ohio State University College of Nursing (OSU CON), which promotes participation in both delivery and discovery through shared projects and joint appointments.

Some organizations have clear policies regarding nursing research. In our organization, “Research Conducted by a Nurse in a University Staff Title Position” clearly outlines the steps required for conducting research. Specifically, the policy should include information regarding the proposal development, nursing approval process, Institutional Review Board (IRB) submission process, role of the university research office, and role of clinical nurses who are caring for a patient in a nurse-directed study.

Unit culture is intimately linked to the success of a research project. Initiating a research project begins with an extensive assessment of the clinical unit to determine whether the group shares similar passions related to the topic of interest. Research questions that bear little interest to unit staff members won’t engage them and will struggle to move forward. Furthermore, the team must assess if there’s a spirit of inquiry.⁴ Overall, a unit culture that embraces an interest in clinical advancement and innovation, quality improvement, and scholarly projects is more likely to support a unit-based research project.

Mentorship is essential. A national study examining facilitators of and barriers to nursing research identified the presence of a nursing research mentor as the most important factor for success.⁵ For those institutions that have a dedicated nurse scientist/researcher, mentorship usually falls to this individual, who must be an expert in research methods and feel comfortable in multiple clinical specialty areas. At OSU WMC, our research program includes a nurse scientist who assists in the management of the research program, along with promoting clinical nurses to develop research studies.

Academic-service-practice partnerships provide another opportunity to pursue research mentors. These partnerships can enhance the research capacity of both small and large hospitals. In our organization, we developed a practice partner model as part of the strategy to develop innovative models for translational research and increase collaboration between academe and clinical practice. In this model, a faculty member with a specific clinical interest works with a designated advanced practice registered nurse (APRN).

The APRNs in our organization are given clinical release time to work collaboratively for a designated number of hours per week with an OSU CON faculty member. This model also works in reverse when the clinical nurse scientist at our organization engages nursing faculty with specific research expertise on clinical research teams. This has resulted in numerous collaborative manuscripts and national/international presentations, which represent our academic-practice partnership. Most recently, we’ve given four OSU CON faculty members a 5% clinical appointment in our medical center. Additionally, many of our medical center staff members have appointments in OSU CON.

Organizations vary in the support services provided to researchers across the entire enterprise. Research-intensive environments have an office of research that handles grants and research contracts. Even in the case of unfunded research, it’s critical to explore the role of this department in your organization and determine what services and support it can provide. In the case of funded research, this department is responsible for assisting with grant budgets, submissions, and contracts, as well as housing the research funds.

Increasingly, researchers are being encouraged to move away from paper data collection to web-based systems that provide greater data security. A variety of commercial systems are available. An inventory of data management tools at your organization, the associated educational and technical requirements, and the required costs should be investigated.

Garnering the research team

Research has truly become a team science; it’s nearly impossible to conduct a clinical study without the support of a research team. The composition of the team is largely dictated by the research question and the related clinical and research expertise required. In general, a well-rounded team should include a PhD-prepared nurse or another PhD-prepared academician and several expert clinicians, including, but not limited to, clinical nurses and APRNs. As hospitals add nurses prepared with clinical practice doctorates, research teams should seek their collaboration.

Statistical consulting services are almost always necessary. Engagement with other interdisciplinary team members who have clinical expertise relevant to the research question should be a high priority. Funding agencies look favorably upon research teams that are well rounded with a mix of skills. For example, research conducted at our organization on oral care in post mechanically ventilated patients included a diverse team. Our critical care clinical nurse specialists developed the proposal in collaboration with our hospital-based nurse scientist and served as the study interventionists, an OSU CON faculty member with expertise in epidemiology was involved in managing our oral bacterial cultures, a College of Dentistry faculty member developed the oral care protocol, a College of Veterinary Medicine faculty member processed our oral cultures, and a statistician provided statistical support.⁶

Determining who will be the principal investigator (PI), along with team member roles, is a discussion that needs to occur in the very early phases of the project. The PI is the team member who assumes overall responsibility for the preparation, conduct, and administration of a research project. This individual is ultimately accountable for regulatory compliance, data management, budget, deadline management, communication with funding agencies, and all ethical aspects of the project. Some organizations have very specific criteria for the PI role related to either job title and/or educational level.⁷

At our organization, the university requirement is that the PI either has a PhD or is employed at the director level. The inability to be a PI was a source of frustration to many of our clinical nurses who wanted to pursue a research project. The university’s policy required that they have another individual serve as the PI. The work of an appointed nursing subcommittee resulted in a new policy allowing nursing staff prepared at the master’s level and above to request a waiver from the university’s office of research to obtain PI status. This policy requires that the nurse requesting a waiver work closely with a designated research mentor who provides mentorship and oversight.

Developing the proposal and budget

There are multiple ways to approach the writing of research proposals. Some research teams divide the process up among the team members, others choose to work together in group sessions, and others select one individual to lead the effort with group feedback at designated intervals. No matter what the strategy taken to write the proposal, it’s a time-intensive effort. Generally, efforts are more effective when larger chunks of time are allocated (such as eight hours) versus smaller time increments. Numerous iterations of the proposal are often needed as each research team member provides input.

Research is always associated with costs. The major cost is staff time; additional personnel expenditures may result from consultant costs, such as a statistician. Other costs include the software program necessary to manage the data, any equipment, and incentives/compensation for study participants. Also consider the cost of postage and office supplies, as well as the costs of dissemination, such as charges associated with posters and travel to professional meetings. When writing a research budget, each line item should have a justification statement.

Conducting reviews and getting approval

First and foremost, the research team must assess the feasibility of its proposed research project. Feasibility issues include, but aren’t limited to, the project’s alignment with organizational standards of care/policies; type of patients to be included; project timeline; competing clinical projects; impact on nursing workflow and nursing staff time; additional unit expenses; equipment needs; and ability to disseminate, implement, and sustain associated practice changes. Feasibility reviews vary by organization but often involve a designated interdisciplinary committee, such as the chief medical officer’s administration; a designated nursing committee; and/or unit leaders. The result of the feasibility review should be a clear understanding between hospital/nursing leadership and the research team of the resources required, additional approvals needed, and approximate timelines. Additionally, a letter of support for the research project from either the CNO or the nursing director to submit with the IRB application is recommended.

If not already part of the feasibility review, additional consultation with and approval by the clinical staff from the specific unit(s) where the research will take place are essential. Specific details, such as unit staff training and education related to the research project and start dates, must be negotiated. All expectations of the unit staff related to the research project need to be clearly outlined. In addition, the unit’s medical team should be consulted. It’s recommended that a letter of support be obtained from the senior medical team member who directs the medical care of the study population of interest.

Shared governance and nursing research councils have an increasing presence at both Magnet and non-Magnet hospitals. The role of the research/EBP council varies, but most require that the research project undergo peer review before submission to the IRB.⁷ Many research councils provide peer review for scientific merit and also examine protocols for feasibility issues.

It’s recommended that all organization internal reviews are conducted and the requisite letters of support obtained before submission to the IRB. Larger hospitals generally have internal IRB boards; smaller hospitals often contract this service out. Irrespective, all human subject research must have IRB approval before initiating enrollment of subjects. IRB approval requires that all research team members are certified through the national Collaborative Institutional Training Initiative course. This is a several-hour, web-based training that provides an extensive overview of human subject protection and research ethics.

Managing patient data, particularly protected health information (PHI), is complex and can be easily overlooked by the novice researcher. Staff members must be clear about the type of data they’ll be accessing and collecting. A designated hospital committee closely monitors data requests, especially PHI, and appropriate approvals must be obtained. These approvals are separate from the IRB and may include committees/individuals, such as the hospital quality committee, the Health Insurance Portability and Accountability Act (HIPAA) committee, and the privacy officer. With the advent of the electronic medical record, most hospitals now have data warehouses that have distinct policies and timelines for requesting medical data. Nurse managers should assist staff members in obtaining the proper approvals.

Managing time

Experienced researchers note that managing one’s time is perhaps the greatest challenge in the research process. Time has two dimensions: the work time that’s needed to manage the research process, which means release time from other clinical duties, and the time needed for the approval processes required for research. The latter can be the most challenging to manage because it’s often unpredictable; IRB approval and grant negotiations between funding agencies are often delayed for reasons out of the research team’s control.

Subject enrollment rarely moves along as quickly as the research team anticipates. Often, there are inclusion and exclusion criteria that need to be altered (even minimally) once the study gets started. A common challenge in research-intensive organizations is that there are many ongoing research projects within the same clinical domain. This results in a situation in which research teams may compete for subjects. These situations require that the respective PIs of each research team delineate a process for either co-enrollment of subjects or another process to allow reasonable access to the study population.

Disseminating findings and sustaining practice changes

An often-overlooked aspect of nursing research is the dissemination of findings and the implementation/sustainment of practice changes. Too often, nurses disseminate findings locally at hospital fairs and conferences, but fail to present their findings at national conferences or through manuscript submission to a peer reviewed journal.⁸ Rapid dissemination is highly recommended; once the data have been analyzed, it’s common for the research team to disperse and move on. Many experienced researchers recommend initiating the first paper before the final data are analyzed. Much of the initial manuscript is embedded in the proposal; outlining the data tables, discussion, and conclusions can jumpstart the dissemination process.

The final phase is the implementation and sustainment of a practice change if supported by the research. As part of the primary manuscript, the research team outlines how its work contributes to the present body of evidence. This is the time to gather the organization’s EBP experts and determine if a practice change is warranted.

Innovation and research translation can be best executed when there’s an expert EBP practitioner on the research team or a designated EBP team to foster research translation. The ultimate reward for a research team is to have its work implemented in the clinical setting and witness the impact on patient outcomes.

Cultivating a culture of excellence

Developing a culture of excellence through the application of nursing research is a long journey requiring a nursing research program that’s visible to and attainable by clinical nurses. Evidence demonstrates that a professional practice culture focused on research provides clinical nurses with the opportunity to harness their individual potential to impact patient outcomes and achieve excellence.

References

1. Akerjordet K, Lode K, Severinsson E. Clinical nurses’ attitudes towards research, management and organizational resources in a university hospital: part 1. J Nurs Manag. 2012;20(6):814-823.
2. Leasure AR, Stirlen J, Thompson C. Barriers and facilitators to the use of evidence-based best practices. Dimens Crit Care Nurs. 2008;27(2):74-84.
3. Chan GK, Barnason S, Dakin CL, et al. Barriers and perceived needs for understanding and using research among emergency nurses. J Emerg Nurs. 2011;37(1):24-31.
4. Melnyk BM. Culture eats strategy every time: what works in building and sustaining an evidence-based practice culture in healthcare systems. Worldviews Evid Based Nurs. 2016;13(2):99-101.
5. Kelly KP, Turner A, Gabel Speroni K, McLaughlin MK, Guzzetta CE. National survey of hospital nursing research, part 2: facilitators and hindrances. J Nurs Adm. 2013;43(1):18-23.
6. Chipps EM, Carr M, KearneyHenry R, et al. Outcomes of an oral care protocol in post-mechanically ventilated patients. Worldviews Evid Based Nurs. 2016;13(2):102-111.
7. McLaughlin MK, Gabel Speroni K, Kelly KP, Guzzetta CE, Desale S. National survey of hospital nursing research, part 1: research requirements and outcomes. J Nurs Adm. 2013;43(1):10-17.
8. Mazurek Melynyk BM. Disseminating evidence by turning presentations into publications: key strategies for success. Worldviews Evid Based Nurs. 2016;13(4):259-260.

Reprinted from Nursing Management: April 2017, Vol. 48, No. 4, p. 28-35.