Clinician Involvement in Critical Care Research

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Critical Care Education

Clinician Involvement in Critical Care Research Marianne Chulay, DNSc, RN, FAAN

The

achievement of optimal patient outcomes requires critical care nursing to be research based, rather than a set of ritualistic practices. The attainment of evidencebased practice is a two-step process: first, the conduct of clinically meaningful research to guide critical care decisions and interventions and second, the integration of that "evidence" into bedside practice. Active involvement of clinicians in both the conduct of clinical research and the integration of research into practice is crucial if we are ever to know the best way to provide care to patients. 4 Because of clinicians' close involvement with patients and families, they have a unique vantage point to identify clinically important research questions and suggest research methods that are relevant to everyday patient care situations. Research studies that focus on clinically irrelevant problems or use methods that do not mimic the realities of clinical practice cannot describe the best practice in critical care nursing. 9 Critical care leaders have an important role in facilitating clinicians' involvement in both the conduct of clinical research and the integration of research into practice.3· 10 • 11 Most bedside clinicians have little practical From the Clinical Research and Critical Care Nursing , Chapel Hill, North Carolina

experience with research conduct or implementation and view research as something with little or no relevance to patient care. Moving clinicians into an active participant role in critical care research will require all of the talents of the critical care leadership team in teaching, mentoring, and facilitating. The first and most time-consuming step of the process is to arouse staff interest in critical care research and its importance to achieving optimal patient outcomes and the need for clinicians actually to conduct research on important clinical practice issues. The next step is to facilitate clinicians' ability to update their nursing practice with the latest research findings.

Getting Clinicians Interested in Critical Care Research Discussions about nursing research in the clinical setting are likely to elicit a less-thanenthusiastic response by most clinicians: blank looks or glazed-over eyes; groans; comments about the lack of relevance to real-life practice; negative experiences with research projects in school. It is important to recognize this less-than-enthusiastic attitude about research and to use strategies that will help clinicians view research positively, as relevant to their daily practice, and as a

CRITICAL CARE NURSING CLIN ICS OF NORTH AMER ICA I Volume 13 I Number 1 I March 2001

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Box 1 STRATEGIES TO FOSTER CLINICIAN INTEREST IN EVIDENCE-BASED CRITICAL CARE PRACTICE • "Walk the talk" of evidence-based practice. • Emphasize latest research in critical care education. • Challenge common practice routines. • Address practice questions with research. • Conduct a clinically relevant research study.

tool in providing optimal patient care. In the beginning, the "R" word, research, should be spoken infrequently, replaced with other phrases, or spoken softly until a more positive attitude or perspective exists about research. Another important principle to overcoming the clinician's negative attitude about research is to avoid situations that set research activities up as something apart from, or different from, day-to-day practice situations. For example, a commonly employed strategy to get staff interested in research is to start journal clubs, research committees, or research theory classes. These vehicles can be useful for gathering staff who already have an interest in nursing research but are unlikely to attract those with little interest. If not carefully planned, these approaches also can reinforce the common belief that research has little relevance to practice. For example, spending an hour in a journal club critiquing a study with little importance to dayto-day practice probably would not increase the clinician's interest in research. Using approaches that integrate research or research principles into practice situations is more likely to overcome the clinician's negative attitudes about research and foster evidencebased nursing practice (Box 1). "Walk the Talk" of Evidence-Based Practice

One strategy for getting clinicians to value research as an important ingredient of patient care is for the leadership of the unit to communicate its value in practice situations. 7 • 16 When assisting staff with patient care problem solving or helping with procedure revisions, encourage staff to question whether the routine for patient care at your institution really represents best practice in nursing.

When making decisions about equipment purchases for patient care, include gathering information from research studies as an important step in the procurement process. When untoward patient care events occur (e.g., concern over a seemingly high number of self-extubations), go to the literature to see if research has determined the incidence of the problem and what interventions, if any, have been shown to decrease the incidence. The key is to "walk the talk" of supporting research-based practice. It's not enough for staff to hear leadership say that nursing research is important to practice. They must see that you live by those words through your actions. So, as patient care is discussed, as critical care procedures are revised, as a new patient care protocol is developed, or as the use of a new technology is discussed, members of the leadership team must assist staff to incorporate the results of research into their decision-making process. The following strategies have examples of common critical care activities that provide opportunities for leadership to "walk the talk" of researchbased practice. Emphasize Latest Research in Critical Care Education

Another strategy to show that nursing research actually is important to practice is to highlight the latest research when teaching critical care concepts. Often, clinicians do not realize that many of the steps in our nursing care procedures or interventions are based on research studies that have shown one approach to be better than another. By briefly identifying where it has guided our nursing routines, clinicians can see that research has relevance to everyday practice. For example, this can occur when teaching about cardiac output determination. Without boring the learner with all the details, the educator can highlight how prior research has shown that injectate temperature (cold versus room temperature) does not affect the accuracy of cardiac output measurements. 2 In addition, the educator could draw attention to areas where more research is needed by mentioning that, although 5-mL or 10-mL injectate volumes can be used in most situations, more research is needed to determine if cardiac output measurements are accurate

CLINICIAN INVOLVEMENT IN CRITICAL CARE RESEARCH

when 5-mL volumes are used in patients with low cardiac output. Success with this technique is based on not boring the learner with too much detail about how the study was done and all its methodologic flaws. It's also not the time to impress the learner with your knowledge of research jargon. Try to translate research terms into language that a nonresearcher would not find intimidating. For example, describe a doubleblind placebo trial as a study that compared "X" technique with "Y" technique. The amount of emphasis on researchrelated information also should depend on the learner's level of clinical expertise. For neophyte critical care clinicians, it's probably best to keep the depth of information to a minimum. As the learner's clinical expertise increases, more detail can be included about the presence or absence of research findings to support the way patient care is provided. Whether teaching an inservice on a new piece of equipment or a class on weaning from mechanical ventilation, using the opportunity to "sneak" research into the content in a manner that emphasizes the practical utility of nursing research is a powerful vehicle to getting staff interested in research. Challenge Common Practice Routines

Another strategy for fostering interest in research is to assist clinicians to challenge their nursing practice routines and rituals. Make it acceptable and expected for staff to question why we do what we do in clinical practice. By encouraging clinicians to use the skills of clinical inquiry every day, in common patient care situations, you can help them to develop a natural tendency to question all that happens in their practice environment and to seek answers in the scientific literature. The first step is to get clinicians to stop assuming that just because they always have done a nursing procedure or intervention in a particular way does not mean that it is the best approach. An example is questioning the frequency of changing intravenous dressings, tubing, and solution that historically has been done to prevent nosocomial intravascular infections. By getting staff to ask, "Do we really need to be changing all this equip-

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ment every 24 hours?" and then helping them review the research-based guidelines on IV therapy, 17 they can answer the question, improve patient outcomes, and decrease cost for IV therapy supplies, if they implement the guidelines. Another area to challenge practice routines occurs in practice or procedure committees when clinical procedures are developed or revised. Help the staff learn how to verify that the procedure is based on the latest research by finding reviews of the literature articles or publications of expert consensus groups on the topic. These research summaries take some of the pain out of reading research, and staff need not become experts in the content area. For example, when reviewing the current enteral feeding procedure, obtaining the expert consensus guidelines on enteral nutrition8• 13• 15 and comparing those researchbased guidelines to your procedure will highlight that adding dye to tube feeding for the quick identification of aspiration is not recommended. This approach helps clinicians realize that reviewing clinical procedures every 1 to 3 years is more than putting a new date in the "reviewed" box or calling other institutions to see what they do and that nursing practice should be based on the latest scientific data. Address Practice Questions with Research

As clinicians discuss an individual patient's response to nursing interventions, questions logically arise about whether a different approach might avoid complications or be tolerated better by the patient. Interjecting suggestions to see what the research shows or actually bringing in a journal article of a study on the topic is another excellent way to highlight the relevance of research to patient care. For example, if a patient has repetitive bradicardic episodes during endotracheal suctioning, getting a review of the literature on suctioning can help staff sort out if the technique used for suctioning is appropriate or not and if other interventions could eliminate the complication. Research also should be used when making decisions about using a new technology or device for patient care. Typically, these decisions usually are based solely on the

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clinician's desire to use the technology and the availability of fiscal support to purchase the equipment. By encouraging clinicians to review the findings of research studies on safety and efficacy, clinicians will have a better perspective on whether the technology or medical device actually is appropriate for their patient population and would improve clinical decision making. For example, clinicians often believe pointof-care (POC) glucose monitoring is essential in caring for critically ill patients. A brief review of the research on these devices, however, would identify quickly that device accuracy in hypoglycemic and hyperglycemic conditions is not precise enough for drug titration purposes and would show that the conditions under which device use is contraindicated (i.e. , hematocrit less than 35% and greater than 50%; hyperlipidemia, during lipid infusions; hyperosmolar states) include many critically ill patients. Careful review of medical device research often leads to a less aggressive application of the technology. Conduct a Clinically Relevant Research Study

Another useful strategy for helping clinicians to see the value of research to their practice is to mentor the staff in the conduct of their own research study.5 If clinical questions that possess many of the characteristics of an ideal research question (see below) have arisen from practice situations, then moving forward to conduct the research study can be an ideal approach. Clinicians will see the value of research to practice and will learn much about the research process as they design, develop, and conduct their study. Given that staff likely will be inexperienced in the conduct of research, the role of the educator and other unit leadership members is to mentor clinicians as they journey through the research process for the first time.3• 14 Although it can seem that research experience or formal research theory classes are necessary for clinicians to conduct their own project, using the project so that staff can learn about research as they work on their own project can provide a richer learning experience. As long as the educator or other member of the unit leadership

is willing to serve as a research mentor to staff, experience or theory classes are not necessarily a prerequisite to conducting research. Selected suggestions for mentoring staff through research projects follow, with more in-depth information provided in other sources. 3• 7 Ideal Projects to Ensure Success for Clinicians

One of the most critical aspects of ensuring the success of a research project is to select one that will overcome or minimize the roadblocks to research completion (Fig. 1). Many of the roadblocks are unique to research that is conducted by relatively new researchers or individuals employed in the service setting rather than in an academic position. Criteria for research projects that avoid or overcome some of these roadblocks to research completion include the following: • Takes advantage of clinical expertise of the staff • Maintains the interest of the staff through a potentially lengthy period to project completion • Is important to clinical practice and patient outcomes • Has potential cost-saving impact for the institution • Includes large numbers of patients eligible for the study • Has established tools for variable measurement • Requires no additional funds for study completion • Allows data collection procedures to be incorporated easily into daily nursing practice routines From Granger B, Chulay M: Prioritizing clinical

questions. In Research Strategies for Clinicians. Stamford, CT, Appleton & Lange, 1999, p 41, with permission.

The "ideal" research project that meets all the criteria likely will never be found, but maximizing the number of criteria present in selected research projects can increase the likelihood of project completion. Finding Good Clinical Research Questions

When clinicians are at a loss to identify a good clinical research question, one of the

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CLINICIAN INVOLVEMENT IN CRITICAL CARE RESEARCH

• No clir1ical expertise in topic

•Funding required • No measurement tools

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• Few patients eligi111e • Data collection requires dedicated data collector •Not clinically important • No cost savings • No impact on outcomes

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Figure 1 Common roadblocks to research completion. (From Granger B, Chulay M: Prioritizing cl inical questions. In Research Strategies for Clinicians. Stamford, CT, App leton & Lange, 1999, p 40; with permission.)

following methods can be useful in helping clinicians to identify appropriate research topics: the STICK method and the Focus Group method. The STICK method is based on the principle that wonderful ideas for research projects come up every day as clinicians care for patients but are either forgotten or not appreciated as good research ideas. 7 With the

STICK method, clinicians are asked to jot down on a "sticky note," or self-adhering note pad, the clinical practice questions that occur as they take care of patients (Fig. 2). The sticky notes are left at a designated place near each patients's bed. The sticky note questions then are gathered from patients' bedsides by members of the unit's practice or research committee. The contents of the

Figure 2 Use of the STICK method at the patient's bedside to capture potential research questions. (From Granger B, Chu lay M: Clinical questions: Where do you find them? In Research Strategies for Clinicians. Stamford, CT, Appleton & Lange, 1999, p 17; with permission .)

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STICK, l'St.t~rd

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Qu~tione

•Could thi5 que5tion be ea5ily • Are the remaining que5tion5 re5olved by a 5imple of clinical importance? explanation, in5ervice or • If ye5, categorize a5 educational 5e55ion? potential clinical re5earch • If ye5, categorize a5 a 5taff que5tion5 and determine development i55ue and refer if pa5t re5earch ha5 to the clinical educator or addre55ed the que5tion5. appropriate committee I department.

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• 15 thi5 que5tion ea5ily • Could thi5 que5tion be re5olved by creating ea5ily re5olved by an a policy or procedure? admini5trative deci5ion ? • Doe5 it indicate a need for • If ye5, categorize a5 an a policy or procedure change? admini5trative i55ue and • If ye5, categorize a5 a policy I refer to the appropriate individual or committee. procedure and refer to the appropriate unit or ho5pital committee.

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Figure 3 STICK method algorithm for categorizing clinical questions. (From Granger B, Chulay M: Clinical questions: Where do you find them? In Research Strategies for Clinicians. Stamford, CT, Appleton & Lange, 1999, p 20; with permission.)

notes are reviewed and subjected to a series of questions to determine which ones are best addressed w ith research methods and which ones are best addressed by administrative staff, education, or existing policy or procedure documents (Fig. 3). For the questions that remain in the "research" pot, the practice or research committee then determines, by reviewing the literature, if the answer to the question already exists or if the question in fact would be a good research project. Those in the latter category are posted on the research bulletin board, and interest is solicited for team members to volunteer for a research project to address the question. Another method to identifying research questions is the Focus Group method.3• 7 · 12 In this method, in a series of 1-hour meetings, a facilitator leads staff members through brainstorming exercises to identify common patient care experiences and issues for their unit, followed by potential research questions.

Both the STICK and Focus Group methods can generate large numbers of clinically relevant research questions. It is important to use a process to determine which questions best meet the criteria for ideal research projects, as discussed earlier.3, 6• 7 Moving on with the Research Project

Through the many steps to complete the research study, the educator needs to provide a strong mentoring presence for the research team members. Writing the protocol, getting through the approval process, collecting data, and summarizing and presenting their findings all are aspects of the research p rocess with w hich most clinicians will have little to no experience. Updating Nursing Practice with the Latest Research Making sure that nursing practice reflects the latest research is an important and

CLINICIAN INVOLVEMENT IN CRITICAL CARE RESEARCH

time-consuming activity. Finding pragmatic approaches to this task is essential to ensuring that clinicians can take ownership for keeping their nursing practice up to date. Updating Critical Care Procedures

Given the overwhelming task of periodically reviewing the literature in all areas of critical care practice, helping staff to develop a systematic review process that occurs over 2 to 3 years might be a realistic strategy. Organizations typically set their policies for review of nursing department documents (e.g., policies, procedures, protocols) at once per year, but there is no external regulatory requirement (e.g., by ]CAHO) for frequency of the review. In fact, it is unusual for significant practice changes to occur more frequently than every 2 or 3 years, so setting the review policy at a 3-year interval probably would be more appropriate. By dividing the large volume of critical care procedures into six to ten logical categories, a Clinical Practice Committee or group of clinicians could establish a schedule of two or three categories for review each year (Box 2). This approach is more likely to allow clinicians to go to the literature to determine if the current procedure reflects the latest research on how best to provide care to the patient. Another approach is to adopt a procedure textbook as the main source of critical care procedures. Where you can identify a standardized textbook that has procedures based

Box 2 SCHEDULE OF CRITICAL CARE PROCEDURE REVIEW OVER A 3-YEAR CYCLE First Year

• Card iovascu lar procedures • Gastrointestinal procedures Second Year

• Respiratory procedures • Renal procedures • Muscu loskeletal procedures Third Year

• Neurologic procedures • Hematolog ic procedures • Safety procedures

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on the latest research available at the time of publication, you can save staff time (i.e., reviewing the literature on each procedure and writing or revising current procedures) by purchasing the textbook for your critical care procedure book. Any additional procedures needed (e.g., use of a technology just developed) can be added to the textbook procedures by placing them in a separate binder or interpolating them at the appropriate location in a procedure book that has been "unbound" and placed in a three-ring binder. Incorporating the Latest Research Into Clinical Pathways

Another important approach to keeping nursing practice up to date is to ensure that clinical pathways describing the care of patients with specific conditions reflect current research and practice guidelines. For example, the clinical pathway on acute respiratory distress syndrome should include interventions listed in guidelines for assessment of neuromuscular blockade and the latest research on endotracheal suctioning and artificial airway management. 1 When using guidelines from the literature, be sure that they are based on an analysis of research on the topic and are not just one individual's perspective on what should be done. Often, experts in a field are convened by professional associations to determine based on the available science, the best appr~ach to common patient care conditions or interventions. These guidelines can be invaluable to save staff the time of reviewing the literature themselves and having to become experts in every area of critical care practice. Solving Clinical Practice Questions or Issues with Research

As individual patient care questions or issues arise, some of them probably can be best addressed by finding out if any research has been done in the practice area. For example, when a question arises about whether in-line suctioning setups could be changed less frequently than the current hospital routine, going to the literature to search for research

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studies might provide a quick answer to this question. Or, if a physician is complaining that staff are not appropriately securing oral endotracheal tubes and believes this accounts for the number of unplanned extubations, finding the research this compared various techniques of tube fixation would be instrumental in addressing that practice issue. Sources for Easy Access to Critical Care Research

Many sources exist where critical care research is frequently published or easily accessed. Keeping abreast of publications in journals such as the American journal ofCritical Care, Heart and Lung, and Critical Care Medicine will provide clinicians with a good overview of new findings that relate to clinical practice. Especially helpful are review of the literature articles on narrow topics, allowing busy clinicians to avoid having to review numerous research studies on their own. Also, publication of abstracts of research presentations at annual meetings of professional associations, such as the American Association of Critical-Care Nurses, Respiratory Nursing Society, Society of Critical Care Medicine, or the American Heart Association, are another way to know about new research in the field. Most professional associations and governmental agencies are attempting to provide clinicians with useful summaries of the research basis for practice. Various titles exist for these documents (e.g., protocols, guidelines, review of the literature, consensus reports), but all have in common a strong basis of research to the recommendations. Calling the association or governmental agency or accessing their Internet Web site (Box 3) is usually an efficient method for determining what resources are available. Overcoming Roadblocks to Changing Practice

Once one has located the latest research indicating that clinical practice at your facility needs updating, the next step is to get the practice changed. Without going through the informal and formal steps to change people

Box 3 INTERNET RESOURCES FOR FINDING RESEARCH OR RESEARCHBASED GUIDELINES FOR PRACTICE

• http://www.nlm.n ih.gov (National Library of Med icine, with access to Medl ine from the Web page) • http://www.healthfinder.gov (Department of Health and Human Services) • http://www.aacn.org (American Association of Critical-Care Nurses, with access to Cl NAHL from the Web page) • http://www.nurs ingworld.org (American Nurses Association) • http://www.HELI X.com (Glaxo Wellcome site, with access to Medline from the Web page) • http://www.guidelines.gov (Agency for Health Care Policy and Research) • http://www.cinahl.com (CINAHL Information Systems) Adapted from Granger B, Chu lay M: Pragmatic approaches to reviewing the literature. In Research Strategies for Clinicians. Stamford , CT, Appleton & Lange , 1999, p 86.

Box 4 COMMON BARRIERS TO INTEGRATING RESEARCH INTO CLINICAL PRACTICE Reasons why individuals resist change:

Tendency to maintain the status quo Inadequate knowledge about the clinical practice due to: Lack of awareness of current state of the science Misconceptions about the practice area Fear of new techno logy or abi lity to acquire new skil ls/knowledge Ideas from outside the institution not acceptable (the "our patients are different" mindset) Reasons why the "system" resists change:

Group/individual with authority to make change not approached Incomplete picture of the financial and c linical outcomes associated with the change in practice because: Data not provided to group/individual Data provided are difficu lt to interpret by non experts "Politics" Outcomes from proposed change not proportional to the efforts required to institute the change Not a high enough priority No individual/group has taken responsibi lity for see ing the practice change through to completion

CLINICIAN INVOLVEMENT IN CRITICAL CARE RESEARCH

and the system's old approach to the issue, the new research-based practice change will never occur. Barriers to integrating research into practice are likely to occur at most clinical facilities at some time (Box 4). Mentoring staff on how to overcome these barriers to changing practice can require more time and energy of educators and unit leadership than assisting staff to determine the research basis for practice in the first place. Common approaches to overcoming some of the real or potential barriers to practice change include one or more of the following strategies: • Identify key stakeholders in the practice change and groups that will need to "approve" the practice change formally and informally. Determine a strategy for approaching each individual or group. • Help key stakeholders to "own" the proposed practice change by including them early in the discussions of the need

•

•

• •

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to change practice, keeping dialogue open about the pros and cons of practice change and soliciting their suggestions for getting others to accept the change. Consider putting together a brief written summary of the current practice, a review of the research, and suggested changes to practice. Educate others about the key concepts of the proposed change in practice. Include information about the current practice, the proposed research-based practice changes, and any clinical and fiscal implications of changing practice. If practice change requires new skills or knowledge for clinicians, plan educational sessions to develop staff confidence with the new skill or knowledge. Focus on the positive impact for patients and families. Build small successes first before tackling politically sensitive issues or practice changes that have significant institutional impact.

SUMMARY Clinician involvement in critical care research will be essential if we are ever to achieve optimal patient outcomes. Educators and unit leadership play a pivotal role in facilitating, mentoring, and coaching clinicians both to conduct research on important issues or problems in critical care and to ensure that practice routines are based on the latest research findings.

REFERENCES 1. AACN's Protocols for Practice: Care of the Mechanically Ventilated Patient. Aliso Viejo, CA, American Association of Critical-Care Nurse, 1998 2. AACN's Protocols for Practice: Hemodynamic Monitoring. Aliso Viejo, CA, American Association of Critical-Care Nurse, 1998 3. Campbell G, Chulay M: Establishing a clinical nursing research program. In Spicer ], Robinson MA (eds): Environmental Management in Critical Care Nursing. Baltimore, Williams & Wilkins, 1990, p 52 4. Chulay M, Guzzetta C, Dossey B: Caring for critically ill patients and families. In Chulay M, Guzzetta C, Dossey B (eds): AACN Handbook of Critical Care Nursing. Stamford , CT, Appleton & Lange, 1997, pp 3- 15 5. Chulay M, White T: Nursing research: Instituting changes in clinical practice. Critical Care Nurse 9(5): 106, 108, 110-113, 1987

6. Cronin S, Owsley V: Identifying nursing research priorities in an acute care hospital. ] Nurs Adm 23(11):58--62, 1993 7. Granger B, Chulay M: Research Strategies for Clinicians. Stamford, CT, Appleton & Lange, 1999 8. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. ]PEN] Parenter Enteral Nutr 17(4S):8S, 1993 9. Henry B: Useful research and applied methods too. Image] Nurs Sch 28(3):186, 1996 10. Hinds P, Gattuso], No1ville R, et al: Bedside nursing research. Clinical Nursing Research 1(2):169-179, 1992 11. Kacuba A: Turning tradition upside down: Staff nurses and clinical research. Am J Nurs Nov 5- 10, 1993 12. Krueger R: Focus Groups: A Practical Guide for Applied Research. Newbury Park, CA, Sage Publications, 1988

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13. Metheny N, St. John R, Clouse R: Measurement of glucose in tracheobronchial secretions to detect aspiration of enteral feedings. Heart Lung 27:285-292, 1998 14. O'Brien MB: Mentoring. In Cardin S, Rogers C (eds): Personnel Management in Critical Care. Baltimore, Williams & Wilkins, 1989, pp 107-123 15. Potts H: Comparison of blue dye visualization and glucose oxidase test strip methods for detecting

pulmonary aspiration of enteral feedings in intubated adults. Chest 103:117-121, 1993 16. Stetler C, Brnnnell M, Guilliano D, et al: Evidencebased practice and the role of nursing leadership. J Nurs Adm 28(7):45-53, 1998 17. Tabian 0, Anderson L, Arden N, et al: Guideline for prevention of nosocomial pneumonia. Infect Control Hosp Epidemiol 15(9):588-623, 1994b

Address reprint requests to Marianne Chulay, DNSc, RN, FAAN 505 North Boundaiy Street Chapel Hill, NC 27514 e-mail: [email protected]