- Email: [email protected]
Evidence-based practice: A role for nurse practitioners
Marilyn
D
Hockenberry-Elton,
CPNP,
FAAN,
Nancy
E. Kline,
Patrick
,PhD, Barrera,
PhD(c),
uring the past 20 years, the nurse pract&ioner(NP) has evolved from a continuing education-prepared role to an advanced practice specialty that has expanded the definition of practice to include research. The diversity with which the research role is currently being implemented in practice is similar to that seen in the educational preparation of the NP throughout the years. While the concept of researchbased or evidence-based practice is not new to advanced practice nurses, a focus on establishing outcome measures-based on research-that make a difference in improving clinical practice has been renewed recently. In this time of health care change, the NP will be required in the near future to demonstrate how cost-effective and quality care is being provided. International journals from Canada, Australia, and England have recently published articles related to the importance of stronger links between research and practice (Camiah, 1997; McGee, 1996; Pearson, 1997; Shorten & Wallace, 1996/1997; Shorten & Wallace, 1997; Simpson, 1996). Camiah (1997) discussed the inadequate use of nursing research findings to support clinical practice among senior nursing staff in England. The lack of collaboration between educators, researchers, and clinical staff was cited as the contributing factor to the lack of research dissemination that could influence nursing practice. In addition to recent publications discussing the lack of evidence-based
338
BS,
RN,
l?N-CS, &
CPNP
practice, several articles that discuss how evidence-based practice is being developed in the United States have been published. A recent journal article reviewed a project at Columbia University School of Nursing in which evidence-based practice was used to evaluate a community primary care clinic managed by NPs (Totten, Lenz, & Mundinger, 1997). Similarities and differences in the practices of physicians and advanced practice nurses were evaluated in relation to patient satisfaction, quality of care, functional health status, patient understanding of their chronic health conditions (ie, hypertension, asthma, and diabetes), cost of care, and utilization of health services. In Tennessee, a consortium of NT’s has been developed to serve as a network for the generation of research data regarding NT’s and their practice (Smith, Moody, Glenn, & Garmany 1996). The goal of this group is to collect large data sets that document how NT’s enhance the health of communities and deliver cost-effective, high-quality, and accessible care throughout the state. The projects at Co-
lumbia University and Tennessee exemplify the type of outcome measures that are essential to demonstrate how pediatric nurse practitioner (PNP) practice makes a difference in health care. An interesting discussion in a recently published nursing management journal presented the question of whether evidence-based practice should be established from successful interventions discovered when providing care or determined by scientific research inquiry (Flarey, 1997). Interest both in discoveries found in clinical practice and findings supported by scientific research studies would seem to be essential for a clinical environment that includes NPs. Totten, Lenz, and Mundinger (1997) believe that if NPs are to fulfill their potential as providers they must be involved in research, as well as the traditional role of educator and clinical expert. The concern arises that, in reality, few NT’s are adequately prepared to serve as investigators of traditional research studies and are much more likely to establish practice based on clinical experiences. Few PNP mentors are adequately pre-
Marilyn Hockenberry-Eaton is Associate Professor of Pediatrics, Baylor College of Medicine, and Director Pediatric Nurse Practitioners, Texas Children’s Cancer Center, Texas Children’s Hospital, Houston. Patrick Barrera is Research Coordinator
at Texas Children’s
Cancer Center, Texas Children’s
Nancy E. Kline is Assistant Professor of Pediatrics, Baylor College of Medicine, Texas Children’s Cancer Center, Texas Children’s Hospital, Houston. Reprint requests: Marilyn Hockenberry-Eaton, Fannin, MC3-3320, Houston, TX 77030. J Pediatr Health Care. (1998). Copyright
+ 0
Houston.
and Pediatric Nurse Practitioner,
PhD, RN-CS, CPNP, FAAN, Texas Children’s
Hospital,
6621
72, 338-339.
0 1998 by the National Association
0891-5245/98/$5.00
Hospital,
of
of Pediatric Nurse Associates
& Practitioners.
25/l/93756
November/December
1998
PROFESSIONAL
TABLE
Web
INSIGHTS
sites for nursing
Hockenberry-Eaton,
research
Organization
World
National Association of Pediatric Nurse Associates and Practitioners National Institute for Nursing Research Sigma Theta Tau Society of Pediatric Nurses American Holistic Nurses’ Association Community Association Health Electronic
of Science for the Care Nursing
funding
of Children’s
Ladder
Wide
Web
address
www.napnap.org/foundation.html www.nih.gov/ninr/lntramuralpage.htm www.stti.iupui.edu www.pednurse.org’benefits.htm www.ahna.org/f_assistance.htm www.cos.com www.acch.org www3.uchc.edu/-uchclib/eduoff/nngr.html
pared for scientific inquiry Membership statistics of the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) reveal that of the active members in 1997, only 1.9% held a doctorate in nursing (Dunn, 1998). While master’s-prepared NPs now complete formal coursework in research design and methodology, their skills are more appropriate for evaluating research studies than for developing them. How then does the NP establish a clinical practice that is measured by evidence-based outcomes? NPs have several options to pursue, the most effective model being one of collaboration among clinicians, researchers, and educators. Collaboration permits different types of nursing expertise to be used in the development of research questions relating to practice. Valuable expertise is brought to the research project by persons in each nursing role. NPs, with their clinical role, have the experience
to ask essential questions that will ultimately make a difference in practice. Researchers have expertise in research methods and data analysis. Educators are often able to assist with nursing student involvement by providing the opportunity for students to participate in data collection as a project for school. Schools of nursing are also an avenue for increased collaboration, especially through PNP program faculty who may be clinically involved in their own practice. Collaborative efforts promote excitement and increase strategies for evidence-based practice. Hospitals with research departments or research directors are often looking for clinical research opportunities and may have doctorally prepared nurses available as resources for staff. Although time and research expertise may be the most prevalent stumbling block for the development of evidencebased practice, financial constraints are just as much a concern for NPs. Today,
Availability
Barrera,
& Kline
perhaps more than any other time in the history of nursing, funding sources are available for innovative and creative projects developed to improve patient care. For example, NAPNAP provides numerous funding opportunities for members and is currently funding research to improve care in the areas of immunizations and pain management. The Table lists the names and Web sites of some of the organizations that have grants available for NPs who care for children.
REFERENCES Car&h, S. (1997). Utilization of nursing research in practice and application strategies to raise research awareness amongst nurse practitioners: A model for success. Journal of Advanced Nursing, 26,1193-1202. Dunn, A. M. (1998). 1997 NAPNAP membership surrey. Journal ofPediatric Health Care, 12,203.210. Flarey, D. L. (1997). Does evidence-based practice make a difference in outcome? Seminars jar Nurse Managers, 5,160-161. McGee, P. (1996). The research role of the advanced nurse practitioner. British Journnl of Nursing 5,290-292. Pearson, A. (1997). Basing practice on the evidence. Australian Nursing Journal, 5,22. Shorten, A., &Wallace, M. (1996/1997). Evidence based practice: The future is clear. Austmlian Nursing Journal, 4,22-24. Shorten, A., & Wallace, M. (1997). Evidence based practice: When quality counts. Australim Nursing Journal, 4,26-27. Simpson, B. (1996). Evidence-based nursing practice: The state of the art. The Cmadian Nurse, 92, 22-25. Smith, l’., Moody, N., Glenn, L., & Garmany, J. D. (1996). Nurse practitioner research network: Patterns of practice in northeast Tennessee. Tennessee Nurse, 59,25-26. Totten, A. M., Lenz, E. R., & Mundinger, M. 0. (1997). Differentiated primary care and evidence-based practice: The Columbia nursing equipment. Advanced Practice Nursing Quarferly, 3,9-16.
of JOURNAL Back Issues
As a service to our subscribers, copies of back issues of Journal of Pediatric Health Cave for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $12.00 per issue. The following quantity discounts are available: 25% on quantities of 12 to 23, and 33% on quantities of 24 or more. Please write to Mosby, Inc, Subscription Services, 11830 Westline Industrial Dr, St Louis, MO 63146-3318, or call (800) 453-4351 or (314) 453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues are available from UMI, 300 N Zeeb Rd, Ann Arbor, MI 48106, phone (313) 761-4700.
JOURNAL
OF PEDIATRIC
HEALTH
CARE
November/December
1998
3 3 9
D
Hockenberry-Elton,
CPNP,
FAAN,
Nancy
E. Kline,
Patrick
,PhD, Barrera,
PhD(c),
uring the past 20 years, the nurse pract&ioner(NP) has evolved from a continuing education-prepared role to an advanced practice specialty that has expanded the definition of practice to include research. The diversity with which the research role is currently being implemented in practice is similar to that seen in the educational preparation of the NP throughout the years. While the concept of researchbased or evidence-based practice is not new to advanced practice nurses, a focus on establishing outcome measures-based on research-that make a difference in improving clinical practice has been renewed recently. In this time of health care change, the NP will be required in the near future to demonstrate how cost-effective and quality care is being provided. International journals from Canada, Australia, and England have recently published articles related to the importance of stronger links between research and practice (Camiah, 1997; McGee, 1996; Pearson, 1997; Shorten & Wallace, 1996/1997; Shorten & Wallace, 1997; Simpson, 1996). Camiah (1997) discussed the inadequate use of nursing research findings to support clinical practice among senior nursing staff in England. The lack of collaboration between educators, researchers, and clinical staff was cited as the contributing factor to the lack of research dissemination that could influence nursing practice. In addition to recent publications discussing the lack of evidence-based
338
BS,
RN,
l?N-CS, &
CPNP
practice, several articles that discuss how evidence-based practice is being developed in the United States have been published. A recent journal article reviewed a project at Columbia University School of Nursing in which evidence-based practice was used to evaluate a community primary care clinic managed by NPs (Totten, Lenz, & Mundinger, 1997). Similarities and differences in the practices of physicians and advanced practice nurses were evaluated in relation to patient satisfaction, quality of care, functional health status, patient understanding of their chronic health conditions (ie, hypertension, asthma, and diabetes), cost of care, and utilization of health services. In Tennessee, a consortium of NT’s has been developed to serve as a network for the generation of research data regarding NT’s and their practice (Smith, Moody, Glenn, & Garmany 1996). The goal of this group is to collect large data sets that document how NT’s enhance the health of communities and deliver cost-effective, high-quality, and accessible care throughout the state. The projects at Co-
lumbia University and Tennessee exemplify the type of outcome measures that are essential to demonstrate how pediatric nurse practitioner (PNP) practice makes a difference in health care. An interesting discussion in a recently published nursing management journal presented the question of whether evidence-based practice should be established from successful interventions discovered when providing care or determined by scientific research inquiry (Flarey, 1997). Interest both in discoveries found in clinical practice and findings supported by scientific research studies would seem to be essential for a clinical environment that includes NPs. Totten, Lenz, and Mundinger (1997) believe that if NPs are to fulfill their potential as providers they must be involved in research, as well as the traditional role of educator and clinical expert. The concern arises that, in reality, few NT’s are adequately prepared to serve as investigators of traditional research studies and are much more likely to establish practice based on clinical experiences. Few PNP mentors are adequately pre-
Marilyn Hockenberry-Eaton is Associate Professor of Pediatrics, Baylor College of Medicine, and Director Pediatric Nurse Practitioners, Texas Children’s Cancer Center, Texas Children’s Hospital, Houston. Patrick Barrera is Research Coordinator
at Texas Children’s
Cancer Center, Texas Children’s
Nancy E. Kline is Assistant Professor of Pediatrics, Baylor College of Medicine, Texas Children’s Cancer Center, Texas Children’s Hospital, Houston. Reprint requests: Marilyn Hockenberry-Eaton, Fannin, MC3-3320, Houston, TX 77030. J Pediatr Health Care. (1998). Copyright
+ 0
Houston.
and Pediatric Nurse Practitioner,
PhD, RN-CS, CPNP, FAAN, Texas Children’s
Hospital,
6621
72, 338-339.
0 1998 by the National Association
0891-5245/98/$5.00
Hospital,
of
of Pediatric Nurse Associates
& Practitioners.
25/l/93756
November/December
1998
PROFESSIONAL
TABLE
Web
INSIGHTS
sites for nursing
Hockenberry-Eaton,
research
Organization
World
National Association of Pediatric Nurse Associates and Practitioners National Institute for Nursing Research Sigma Theta Tau Society of Pediatric Nurses American Holistic Nurses’ Association Community Association Health Electronic
of Science for the Care Nursing
funding
of Children’s
Ladder
Wide
Web
address
www.napnap.org/foundation.html www.nih.gov/ninr/lntramuralpage.htm www.stti.iupui.edu www.pednurse.org’benefits.htm www.ahna.org/f_assistance.htm www.cos.com www.acch.org www3.uchc.edu/-uchclib/eduoff/nngr.html
pared for scientific inquiry Membership statistics of the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) reveal that of the active members in 1997, only 1.9% held a doctorate in nursing (Dunn, 1998). While master’s-prepared NPs now complete formal coursework in research design and methodology, their skills are more appropriate for evaluating research studies than for developing them. How then does the NP establish a clinical practice that is measured by evidence-based outcomes? NPs have several options to pursue, the most effective model being one of collaboration among clinicians, researchers, and educators. Collaboration permits different types of nursing expertise to be used in the development of research questions relating to practice. Valuable expertise is brought to the research project by persons in each nursing role. NPs, with their clinical role, have the experience
to ask essential questions that will ultimately make a difference in practice. Researchers have expertise in research methods and data analysis. Educators are often able to assist with nursing student involvement by providing the opportunity for students to participate in data collection as a project for school. Schools of nursing are also an avenue for increased collaboration, especially through PNP program faculty who may be clinically involved in their own practice. Collaborative efforts promote excitement and increase strategies for evidence-based practice. Hospitals with research departments or research directors are often looking for clinical research opportunities and may have doctorally prepared nurses available as resources for staff. Although time and research expertise may be the most prevalent stumbling block for the development of evidencebased practice, financial constraints are just as much a concern for NPs. Today,
Availability
Barrera,
& Kline
perhaps more than any other time in the history of nursing, funding sources are available for innovative and creative projects developed to improve patient care. For example, NAPNAP provides numerous funding opportunities for members and is currently funding research to improve care in the areas of immunizations and pain management. The Table lists the names and Web sites of some of the organizations that have grants available for NPs who care for children.
REFERENCES Car&h, S. (1997). Utilization of nursing research in practice and application strategies to raise research awareness amongst nurse practitioners: A model for success. Journal of Advanced Nursing, 26,1193-1202. Dunn, A. M. (1998). 1997 NAPNAP membership surrey. Journal ofPediatric Health Care, 12,203.210. Flarey, D. L. (1997). Does evidence-based practice make a difference in outcome? Seminars jar Nurse Managers, 5,160-161. McGee, P. (1996). The research role of the advanced nurse practitioner. British Journnl of Nursing 5,290-292. Pearson, A. (1997). Basing practice on the evidence. Australian Nursing Journal, 5,22. Shorten, A., &Wallace, M. (1996/1997). Evidence based practice: The future is clear. Austmlian Nursing Journal, 4,22-24. Shorten, A., & Wallace, M. (1997). Evidence based practice: When quality counts. Australim Nursing Journal, 4,26-27. Simpson, B. (1996). Evidence-based nursing practice: The state of the art. The Cmadian Nurse, 92, 22-25. Smith, l’., Moody, N., Glenn, L., & Garmany, J. D. (1996). Nurse practitioner research network: Patterns of practice in northeast Tennessee. Tennessee Nurse, 59,25-26. Totten, A. M., Lenz, E. R., & Mundinger, M. 0. (1997). Differentiated primary care and evidence-based practice: The Columbia nursing equipment. Advanced Practice Nursing Quarferly, 3,9-16.
of JOURNAL Back Issues
As a service to our subscribers, copies of back issues of Journal of Pediatric Health Cave for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $12.00 per issue. The following quantity discounts are available: 25% on quantities of 12 to 23, and 33% on quantities of 24 or more. Please write to Mosby, Inc, Subscription Services, 11830 Westline Industrial Dr, St Louis, MO 63146-3318, or call (800) 453-4351 or (314) 453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues are available from UMI, 300 N Zeeb Rd, Ann Arbor, MI 48106, phone (313) 761-4700.
JOURNAL
OF PEDIATRIC
HEALTH
CARE
November/December
1998
3 3 9