- Email: [email protected]
Community Medical Centers Elevate Nursing Professionalism
Community Medical Centers Elevate Nursing Professionalism Cindy Czplinski, MSN, Sally O’Toole Gerard, DNP, and Teresa Money McLaughlin, DNP
T
he landscape of nursing is changing quickly. Although advanced practice
nurses have distinguished themselves over the past decades, direct care nurses have begun to emerge as leaders and scholars also. The profession of nursing is no longer just about acquisition
and
development
of
clinical
skills. The level of professionalism, accountability, and leadership expected at the staff nurse level has grown considerably.
T
he professional growth of the nursing workforce growth can partially be attributed to skilled nursing leaders who provide the vision, support, and mentorship necessary to support achievement a higher level of performance. Leaders in this new environment need to be comfortable with taking risks, being vulnerable, and questioning the status quo, and they need to be able to coach nurses to develop these characteristics.1 This trajectory of the profession has been supported by the Institute of Medicine’s (IOM) Future of Nursing report, calling on nurses to be more educated, work to the fullest scope of practice, and be full partners in leading change.2 The concept of shared governance has become a nursing “buzz word” over the last 5 to 10 years. Healthcare organizations are setting out a model in which nurses at all levels have the ability to enact change and improve care. Although noble in theory, this level of staff involvement is a decided culture change that is not without obstacles. Nursing leaders in the organization, not only must support this model of empowerment, but may also need to form new relationships and challenge old bureaucratic organizational structures to facilitate the change.3 The purpose of this article is to share the challenges and learning opportunities experienced by nurses at a community medical center as they pursued a scholarly research project and the role of nursing leaders in paving the way for a new way of thinking about nurses as professionals. www.nurseleader.com
LEADERS SUPPORTING NURSING RESEARCH At the organization level, a nursing shared governance model had recently been put into place. In addition to several department-wide councils such as the professional practice council and the nursing research council (NRC), each patient care unit had formed a unit practice council (UPC). The function of a UPC is to allow staff to understand professional and performance issues on their own unit and to empower the staff to enact change. The oncology unit was challenged with reducing falls and pressure ulcers, the oncology unit nurse manager charged the UPC with identifying and implementing interventions that would improve outcomes for their oncology patients. The council collaborated with the newly formed NRC to conduct a literature review which revealed no nursing evidence in the acute care setting related to the topic of deconditioning of oncology patients in acute care hospitals As a community hospital just beginning their Magnet Journey, nursing research had never been done. The director of oncology saw this as an opportunity to educate nurses
Nurse Leader
45
about nursing research, as well as advance the professional image of nursing within the institution. Thus, the director of oncology and the oncology clinical nurse specialist challenged the council to develop a research protocol to support the development of new knowledge in this area. The director of oncology services and the oncology clinical nurse specialist, in addition to the support of the various councils, provided education, guidance, and oversight for the group.
UNANTICIPATED BARRIERS Protection of human subjects is a priority in research and requires the approval of the organization to proceed. This process can be challenging for experienced researchers and especially vexing for staff nurses venturing into research. At this community hospital, institutional review board (IRB) approval is a 2-step process: administrative approval and final IRB review. The administrative approval process is intended to clear the path for a smooth IRB approval and ensure that studies are not in conflict with the mission and values of the medical center. It was in this preliminary process of administrative review that it was discovered that the policy required the principal investigator (PI) be a physician. This presented a challenge, as the PI for this research proposal was a master’s prepared registered nurse. Research conducted by registered nurses was not a familiar concept to the IRB chairperson because there had never been a nursing research study submitted to this IRB. At this point, the registered nurse PI met with the chairperson of the IRB to discuss nursing research and why it is appropriate for registered nurses to conduct studies. Although there was a nurse on the IRB, the IRB chair did not truly understand nursing practice or nursing research. In this community hospital, nursing practice at the time was seen as an extension of the physician rather than an independent field. This is not dissimilar to what is reported in the literature. Research done by Weierbach et al.4 found distinct differences between community and academic hospitals in relation to IRB approval, regulations and recruitment. Some professional publications were available to support this situation by providing keys to breaking down barriers and doing nursing research in a community hospital.5 After continued discussion, the IRB chair proposed that the group find a physician to be co-investigator and then resubmit the proposal. Although this was an interesting compromise, the group felt strongly that nursing research should be led by nurses. Having a physician as co-investigator would undermine the intent to demonstrate to the hospital that nursing is a unique science with its own body of knowledge. Completing this study would be beneficial on many levels and raise the standard of nursing practice at the hospital. The team found themselves in the unexpected position of breaking ground in the area of nursing research for the institution and regarded that role with great esteem. The nursing leaders involved with the project took this opportunity to meet with top-level administrators to explain the details of the situation and also the philosophical virtue of supporting the professional growth of nursing. Although this
46
Nurse Leader
had become an uncomfortable situation, the project team felt strongly that there was a need for nurses to assert itself if they were to share the vision of the organizations culture change and the IOM’s vision for nursing. The nursing administration fully supported the project team’s objection to a mandated physician on the study and validated the need to push the organization out of its established comfort zone. After multiple meetings and discussion over a number of months, a compromise was reached in which the study was approved with nurses in the role of principle investigators.
LEADERSHIP OPPORTUNITIES IN A CHANGING NURSING CULTURE It is obvious that nursing leaders are integral in developing strategic plans for their organizations, maintaining oversight of major initiatives, and fostering a positive culture for change to occur. Although these qualities are necessary for leaders, some of the most valuable opportunities may come from unexpected situations that force leaders to “walk the walk” not just “talk the talk.” Leaders must be willing to think in new ways and try new approaches despite the barriers to change that they confront. The leaders in this project were put in the unanticipated situation of challenging the established norm in an effort to validate to direct care staff /UPC that indeed nurses can elevate their professional roles in valuable ways. Key components to nurses as change agents were utilized in the success of this situation, including vision, collaboration, and credibility. Leaders demonstrate a vision for the change they seek. Without success for nurses in this situation, the change culture would have been significantly inhibited. Leaders must network with key colleagues and involved members. Multiple meetings and conversations were conducted at all levels to share facts and seek solutions. A major asset to this situation was the credibility of the project team. The staff nurses and leaders were very knowledgeable about the evidence around the research initiative, had developed a well prepared protocol and had involved a multidisciplinary team in the development of the project. The excitement around this project was a driving force for the leaders who took on the unexpected challenge of being advocates of change. There was a strong dedication to maintain the integrity of the project, to validate the hard work and enthusiasm of the team, and to elevate the image of nursing within the hospital.
RESOURCES TO SUPPORT NURSING PROFESSIONALISM A shared governance model has also evolved in the last 2 years at the organization and now provides nurses with a variety of professional interests with support and opportunities for growth. At the time the first study was initiated, the model was just developing. The research arm of this council structure has now matured and can now offer resources, guidance, and education to nurses or groups of nurses interested in pursuing research and evidence based practice activities. In addition, a member of the nursing research committee was invited to join the organization’s IRB. This invitation was seen as a huge victory from a group who previously did not
October 2014
know that NRC or the nursing research committee existed. This shared membership between the NRC and the IRB has proven very beneficial in bridging the communication and knowledge gap that previously existed.
POSITIVE RESULTS The nurse leaders and staff nurses involved in the study played a major role in advancing professional activity and opened the door for future scholarly activities. Key nursing leaders were able to convey to IRB members and administration that, in fact, nursing is a science, which utilizes appropriate research methods to build a body of scientific knowledge that grounds nursing practice. These efforts in networking, education, and opening lines of communication with the IRB and administration was an evolving process over time and eventually well received. The increased awareness and exposure to nursing research paved the way for subsequent nursing research projects to move through the IRB process without the requirement of physician involvement. Aside from breaking ground for nurse researchers regarding the IRB process, the organization also identified and mobilized additional resources to support future success. The concurrent culture change added great strength to the development of resources through the shared governance council model, the allocation of resources to support academic research liaisons and consultants. Additionally, nurses who are pursuing research projects in the organization are supported financially to spend time outside of patient care hours to supervise and complete the research process. Resources, particularly human resources, are key elements recommended for the success of nursing research.5 The inclusion of nursing research in this community medical center is no longer an area of uncharted territory. As nurses who are interested in research, we must recognize the importance of nursing research and persevere to reach our goals. Nurses must play a role in the development of research teams and must be able to foster relationships with all the disciplines who play a role in our research projects. These relationships include the IRB, physicians and other members of the multidisciplinary team. These relationships are critical in terms of educating the healthcare team about nursing research, as well as representing nursing as a scientific-based profession that plays a vital role in the healthcare arena.
supported to gather new knowledge in a scholarly way, and apply those finding to improve patient care. The publication of this research was later highlighted by the president of the medical center in a correspondence to all employees as an example of nursing excellence. Considering the challenges in the origins of this project, this public accolade to the nursing research team held special significance for the organizations nurse leaders. NL References 1. Porter-O’Grady T, Malloch K. Quantum Leadership. 3 ed. Sudsbury, MA: Jones & Bartlett; 2011. 2. Institute of Medicine. The Future of Nursing: Leading Change. Advancing Health. Washington, DC: National Academies Press; 2012. 3. Grossman S, Valiga T. The New Leadership Challenge. 4 ed. Philadelphia, PA: F.A. Davis; 2013. 4. Weierbach FM, Glick DF, Fletcher K, Rowlands A, Lyder CH. Nursing research and participant recruitment: organizational challenges and strategies. J Nurs Adm. 2010;40(1):43-48. 5. Beyerman K. Keys to nursing research within a community hospital. Nurs Manag. 2005;36(8):35-40. 6. Mclaughlin TM, Wittstein ER, White TH, Czaplinski CA, Gerard SO. Moving to wellness: a pilot study examining a nurse-driven exercise program in acutely ill patients with cancer. Clin J Oncol Nurs. 2012;16:E105-E110.
Cindy Czplinski, MSN, is clinical vice president, Oncology/ Maternal Child Health/Nursing Operations at St. Vincent’s Medical Center in Bridgeport, Connecticut. Sally O’Toole Gerard, DNP, is an associate professor at Fairfield University, Connecticut. She can be reached at [email protected]. Teresa Money McLaughlin, DNP, is an oncology clinical coordinator in Trumbull, Connecticut. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl. 2013.12.009
CONCLUSION If nurses at all levels are to aspire to the recommendation of the Future of Nursing report, organizations must mature in their view of interprofessional collaboration and allocation of resources. As a result of the first nurse research project in this community medical center, there have been several positive changes and growth of the profession. Some of these changes are a direct result of the project and some are associated with the overall culture change around nursing’s professional scope of practice. Most importantly, the research project described, had positive outcomes for patients and was later incorporated into the standards of care for oncology patients to minimize deconditioning during acute illness.6 In essence, nurses were www.nurseleader.com
Nurse Leader
47
T
he landscape of nursing is changing quickly. Although advanced practice
nurses have distinguished themselves over the past decades, direct care nurses have begun to emerge as leaders and scholars also. The profession of nursing is no longer just about acquisition
and
development
of
clinical
skills. The level of professionalism, accountability, and leadership expected at the staff nurse level has grown considerably.
T
he professional growth of the nursing workforce growth can partially be attributed to skilled nursing leaders who provide the vision, support, and mentorship necessary to support achievement a higher level of performance. Leaders in this new environment need to be comfortable with taking risks, being vulnerable, and questioning the status quo, and they need to be able to coach nurses to develop these characteristics.1 This trajectory of the profession has been supported by the Institute of Medicine’s (IOM) Future of Nursing report, calling on nurses to be more educated, work to the fullest scope of practice, and be full partners in leading change.2 The concept of shared governance has become a nursing “buzz word” over the last 5 to 10 years. Healthcare organizations are setting out a model in which nurses at all levels have the ability to enact change and improve care. Although noble in theory, this level of staff involvement is a decided culture change that is not without obstacles. Nursing leaders in the organization, not only must support this model of empowerment, but may also need to form new relationships and challenge old bureaucratic organizational structures to facilitate the change.3 The purpose of this article is to share the challenges and learning opportunities experienced by nurses at a community medical center as they pursued a scholarly research project and the role of nursing leaders in paving the way for a new way of thinking about nurses as professionals. www.nurseleader.com
LEADERS SUPPORTING NURSING RESEARCH At the organization level, a nursing shared governance model had recently been put into place. In addition to several department-wide councils such as the professional practice council and the nursing research council (NRC), each patient care unit had formed a unit practice council (UPC). The function of a UPC is to allow staff to understand professional and performance issues on their own unit and to empower the staff to enact change. The oncology unit was challenged with reducing falls and pressure ulcers, the oncology unit nurse manager charged the UPC with identifying and implementing interventions that would improve outcomes for their oncology patients. The council collaborated with the newly formed NRC to conduct a literature review which revealed no nursing evidence in the acute care setting related to the topic of deconditioning of oncology patients in acute care hospitals As a community hospital just beginning their Magnet Journey, nursing research had never been done. The director of oncology saw this as an opportunity to educate nurses
Nurse Leader
45
about nursing research, as well as advance the professional image of nursing within the institution. Thus, the director of oncology and the oncology clinical nurse specialist challenged the council to develop a research protocol to support the development of new knowledge in this area. The director of oncology services and the oncology clinical nurse specialist, in addition to the support of the various councils, provided education, guidance, and oversight for the group.
UNANTICIPATED BARRIERS Protection of human subjects is a priority in research and requires the approval of the organization to proceed. This process can be challenging for experienced researchers and especially vexing for staff nurses venturing into research. At this community hospital, institutional review board (IRB) approval is a 2-step process: administrative approval and final IRB review. The administrative approval process is intended to clear the path for a smooth IRB approval and ensure that studies are not in conflict with the mission and values of the medical center. It was in this preliminary process of administrative review that it was discovered that the policy required the principal investigator (PI) be a physician. This presented a challenge, as the PI for this research proposal was a master’s prepared registered nurse. Research conducted by registered nurses was not a familiar concept to the IRB chairperson because there had never been a nursing research study submitted to this IRB. At this point, the registered nurse PI met with the chairperson of the IRB to discuss nursing research and why it is appropriate for registered nurses to conduct studies. Although there was a nurse on the IRB, the IRB chair did not truly understand nursing practice or nursing research. In this community hospital, nursing practice at the time was seen as an extension of the physician rather than an independent field. This is not dissimilar to what is reported in the literature. Research done by Weierbach et al.4 found distinct differences between community and academic hospitals in relation to IRB approval, regulations and recruitment. Some professional publications were available to support this situation by providing keys to breaking down barriers and doing nursing research in a community hospital.5 After continued discussion, the IRB chair proposed that the group find a physician to be co-investigator and then resubmit the proposal. Although this was an interesting compromise, the group felt strongly that nursing research should be led by nurses. Having a physician as co-investigator would undermine the intent to demonstrate to the hospital that nursing is a unique science with its own body of knowledge. Completing this study would be beneficial on many levels and raise the standard of nursing practice at the hospital. The team found themselves in the unexpected position of breaking ground in the area of nursing research for the institution and regarded that role with great esteem. The nursing leaders involved with the project took this opportunity to meet with top-level administrators to explain the details of the situation and also the philosophical virtue of supporting the professional growth of nursing. Although this
46
Nurse Leader
had become an uncomfortable situation, the project team felt strongly that there was a need for nurses to assert itself if they were to share the vision of the organizations culture change and the IOM’s vision for nursing. The nursing administration fully supported the project team’s objection to a mandated physician on the study and validated the need to push the organization out of its established comfort zone. After multiple meetings and discussion over a number of months, a compromise was reached in which the study was approved with nurses in the role of principle investigators.
LEADERSHIP OPPORTUNITIES IN A CHANGING NURSING CULTURE It is obvious that nursing leaders are integral in developing strategic plans for their organizations, maintaining oversight of major initiatives, and fostering a positive culture for change to occur. Although these qualities are necessary for leaders, some of the most valuable opportunities may come from unexpected situations that force leaders to “walk the walk” not just “talk the talk.” Leaders must be willing to think in new ways and try new approaches despite the barriers to change that they confront. The leaders in this project were put in the unanticipated situation of challenging the established norm in an effort to validate to direct care staff /UPC that indeed nurses can elevate their professional roles in valuable ways. Key components to nurses as change agents were utilized in the success of this situation, including vision, collaboration, and credibility. Leaders demonstrate a vision for the change they seek. Without success for nurses in this situation, the change culture would have been significantly inhibited. Leaders must network with key colleagues and involved members. Multiple meetings and conversations were conducted at all levels to share facts and seek solutions. A major asset to this situation was the credibility of the project team. The staff nurses and leaders were very knowledgeable about the evidence around the research initiative, had developed a well prepared protocol and had involved a multidisciplinary team in the development of the project. The excitement around this project was a driving force for the leaders who took on the unexpected challenge of being advocates of change. There was a strong dedication to maintain the integrity of the project, to validate the hard work and enthusiasm of the team, and to elevate the image of nursing within the hospital.
RESOURCES TO SUPPORT NURSING PROFESSIONALISM A shared governance model has also evolved in the last 2 years at the organization and now provides nurses with a variety of professional interests with support and opportunities for growth. At the time the first study was initiated, the model was just developing. The research arm of this council structure has now matured and can now offer resources, guidance, and education to nurses or groups of nurses interested in pursuing research and evidence based practice activities. In addition, a member of the nursing research committee was invited to join the organization’s IRB. This invitation was seen as a huge victory from a group who previously did not
October 2014
know that NRC or the nursing research committee existed. This shared membership between the NRC and the IRB has proven very beneficial in bridging the communication and knowledge gap that previously existed.
POSITIVE RESULTS The nurse leaders and staff nurses involved in the study played a major role in advancing professional activity and opened the door for future scholarly activities. Key nursing leaders were able to convey to IRB members and administration that, in fact, nursing is a science, which utilizes appropriate research methods to build a body of scientific knowledge that grounds nursing practice. These efforts in networking, education, and opening lines of communication with the IRB and administration was an evolving process over time and eventually well received. The increased awareness and exposure to nursing research paved the way for subsequent nursing research projects to move through the IRB process without the requirement of physician involvement. Aside from breaking ground for nurse researchers regarding the IRB process, the organization also identified and mobilized additional resources to support future success. The concurrent culture change added great strength to the development of resources through the shared governance council model, the allocation of resources to support academic research liaisons and consultants. Additionally, nurses who are pursuing research projects in the organization are supported financially to spend time outside of patient care hours to supervise and complete the research process. Resources, particularly human resources, are key elements recommended for the success of nursing research.5 The inclusion of nursing research in this community medical center is no longer an area of uncharted territory. As nurses who are interested in research, we must recognize the importance of nursing research and persevere to reach our goals. Nurses must play a role in the development of research teams and must be able to foster relationships with all the disciplines who play a role in our research projects. These relationships include the IRB, physicians and other members of the multidisciplinary team. These relationships are critical in terms of educating the healthcare team about nursing research, as well as representing nursing as a scientific-based profession that plays a vital role in the healthcare arena.
supported to gather new knowledge in a scholarly way, and apply those finding to improve patient care. The publication of this research was later highlighted by the president of the medical center in a correspondence to all employees as an example of nursing excellence. Considering the challenges in the origins of this project, this public accolade to the nursing research team held special significance for the organizations nurse leaders. NL References 1. Porter-O’Grady T, Malloch K. Quantum Leadership. 3 ed. Sudsbury, MA: Jones & Bartlett; 2011. 2. Institute of Medicine. The Future of Nursing: Leading Change. Advancing Health. Washington, DC: National Academies Press; 2012. 3. Grossman S, Valiga T. The New Leadership Challenge. 4 ed. Philadelphia, PA: F.A. Davis; 2013. 4. Weierbach FM, Glick DF, Fletcher K, Rowlands A, Lyder CH. Nursing research and participant recruitment: organizational challenges and strategies. J Nurs Adm. 2010;40(1):43-48. 5. Beyerman K. Keys to nursing research within a community hospital. Nurs Manag. 2005;36(8):35-40. 6. Mclaughlin TM, Wittstein ER, White TH, Czaplinski CA, Gerard SO. Moving to wellness: a pilot study examining a nurse-driven exercise program in acutely ill patients with cancer. Clin J Oncol Nurs. 2012;16:E105-E110.
Cindy Czplinski, MSN, is clinical vice president, Oncology/ Maternal Child Health/Nursing Operations at St. Vincent’s Medical Center in Bridgeport, Connecticut. Sally O’Toole Gerard, DNP, is an associate professor at Fairfield University, Connecticut. She can be reached at [email protected]. Teresa Money McLaughlin, DNP, is an oncology clinical coordinator in Trumbull, Connecticut. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl. 2013.12.009
CONCLUSION If nurses at all levels are to aspire to the recommendation of the Future of Nursing report, organizations must mature in their view of interprofessional collaboration and allocation of resources. As a result of the first nurse research project in this community medical center, there have been several positive changes and growth of the profession. Some of these changes are a direct result of the project and some are associated with the overall culture change around nursing’s professional scope of practice. Most importantly, the research project described, had positive outcomes for patients and was later incorporated into the standards of care for oncology patients to minimize deconditioning during acute illness.6 In essence, nurses were www.nurseleader.com
Nurse Leader
47