- Email: [email protected]
Integrating clinical practice and research: A challenge for the pediatric nurse practitioner
Integrating Clinical Practice and Research: A Challenge for the 9 Pediatric Nurse Practitioner
9
Maureen R. Keefe, PhD, RN, PNP, and Anne Marie Kotzer, MS, RN, CPNP Nurse practitioners can contribute greatly to nursing science by identifying problems for investigation and using research findings in their practice. This article describes two approaches available to pediatric nurse practitioners for becoming involved in research. The role is described of two nurse researchers based in a research center in facilitating selected studies in ambulatory pediatric health care. An alternative approach is discussed for nurse practitioners who are in practice settings. Guidelines for initiating, conducting, and using research in practice are provided. Seven phases of clinical research are offered to assist the beginning researcher. J PEDIATR HEALTH CARE. (1988). 2, 275-280.
R
esearch is rapidly becoming a primary issue for the pediatric nurse practitioner (PNP), whether by choice or coercion. Oberst (1985) states that the development of a scientist-practitioner role in nursing is essential to the continued growth of nursing’s clinical science. The notion that the clinical practitioner provides care to patients and leaves the scientific endeavors to the academicians is obstructive to the growth of the nursing profession and to the individual professional. PNPs must decide how they will respond to the challenge of incorporating research into their practice. The nurse can approach this challenge in two ways; in one the nurse researcher addresses clinical problems and in the other the nurse practitioner focuses on research issues. n NURSE CLINICAL
RESEARCHER FOCUS
WITH
A
At The Children’s Hospital in Denver, the Kempe Research Center was established “to promote and
Maureen R. Keefe is Associate Director of Nursing for Research at The Children’s Hospital, Kempe Research Center and Assistant Professor at the University of Colorado School of Nursing, Denver, Colorado. Anne Marie Kotzer is Clinical Nurse Specialist for research dren‘s Hospital, Kempe Research Center, Denver, Colorado.
at The Chil-
Reprint requests: Maureen R. Keefe, PhD, RN, PNP, Associate Director of Nursing for Research, The Children’s Hospital, Kempe Research Center, 1056 E. 19th Ave., Denver, CO 80218.
JOURNAL
OF PEDIATRIC
HEALTH
CARE
facilitate high-quality, clinically relevant research to benefit children” (The Children’s Hospital, Kempe Research Center, 1985). A doctorally prepared clinical nurse researcher and PNP was appointed as associate director of the center. The primary responsibility of the associate director is to create a climate throughout the division of nursing that fosters nursing research as a valued activity for the professional nurse. Achievement of this goal involves identifying research resources and developing strategies for the application of research findings in practice.,The joint appointment of the associate director to the Univer-
P
NPs must decide how they will respond to the challenge of incorporating research into their practice.
sity of Colorado School of Nursing provides additional resources and promotes collaboration with academic colleagues. She also consults with other professionals within the institution to promote interdiscipJinary programs and research projects. Specific responsibilities include chairing the nursing research committee and serving as the nursing representative on the institutional review board. A master’s-prepared PNP also works in the re275
276
Volume 2, Number 6 November-December 1988
Keefe and Kotzer
search center and functions in the role of clinical nurse specialist. With the associate director, she is responsible for supporting and facilitating research activity throughout the hospital system. This includes initiating and conducting research independently and in collaboration with others; providing consultation for the development and review of research proposals; assisting in literature search, subject recruitment, data collection, data management, and analysis; and identifying funding sources. Several research-educational programs have been developed and offered by the nurse researchers. These programs have included a 2-day clinical research workshop covering the steps in the research process, a l-day workshop focusing on reading and critiquing the research literature relevant to clinical practice, and a regional conference on the unique challenges of collecting data from children. Avenues for research dissemination have included monthly research-based nursing grand rounds, research poster display cases, and a research column in the institution’s nursing newsletter. The transition from the traditional focus of the PNP on clinical practice to that of clinical research and research facilitation has been exciting and challenging. Two basic assumptions guiding the philosophy underlying this approach to research have been the belief that through clinical research the health of children and their families may be positively affected on a broader scale and that the skills required for excellence in clinical practice are also essential for the conduct of clinical research. Edmunds (1984) has identified the following components of health care that are unique to the role of the nurse practitioner (NP): (a) a holistic focus, (b) patient advocacy, (c) teaching, (d) skillful communication, (e) time and availability, (f ) empathy, and (g) personal involvement. These attributes, as well as a high level of clinical expertise, have been important in establishing credibility and functioning successfully in the role of clinical nurse researcher. Patient advocacy is reflected in the process of informed consent, which ensures the protection of the rights of subjects in clinical research studies. A high level of interpersonal and communication skills is necessary for gathering the in-depth qualitative data often used in nursing research. Nurse researchers are continually involved in teaching parents, patients, and staff about on-going and proposed research projects. The PNP in a research setting plays an important
role in identifying issues related to children’s health care that are conducive to clinical research as well as understanding the unique challenges that conducting research with children pose for the clinical investi-
A
high level of interpersonal and communication skills is necessary for gathering the in-depth qualitative data often used in nursing research.
gator. The problems and concerns related to children’s health and the family social structure are all part of the knowledge base of the PNP. As a provider of primary health care to pediatric clients, the PNP is in the foremost position to recognize those nursing actions and attitudes that uniquely define the role of the nurse. Clinical Research Studies
The following three studies in progress are examples of projects in which nurse researchers have focused on a clinical issue to improve and guide pediatric care. One research study being conducted by the nurses in the ambulatory care center, with consultation from the research nurses at The Children’s Hospital, involves the use of c‘pedipops” for fluid and electrolyte replacement in the dehydrated child. “Pedipops” consist of the oral electrolyte solution Pedialyte mixed with flavoring that is then frozen into Popsides. The hypothesis for the study is that the young child who will not drink adequate fluids will more readily accept a “pedipop,” thereby increasing fluid intake. This application could also be extended to the surgical patient after operation who requires a clear liquid diet and the inpatient with a gastrointestinal disorder who cannot tolerate a full diet. This study exemplifies the process of identifying a clinical problem and using research to explore alternative solutions. Another prospective, longitudinal study, conducted in collaboration with two pediatricians, investigated the relationship between illness and absentee rates of kindergarten children during their first year of school and the child’s prior day care experience (Gitterman, Kotzer, Luckey, Bitts, & Glode, 1988). The family of each child was contacted monthly for 10 months regarding signs and symptoms of illness in their child and the number of days
Journal of Pediatric Health Care
Integrating
missed from‘school because of the illness. These data were correlated with the child’s family characteristics and prior lifetime day care experience. This study attempted to answer an important epidemiologic question: does a child’s day care experience in preschool years impose an immunity on the child that will result in fewer illnesses during subsequent school years? The data were also analyzed to determine whether a child’s absenteeism from school could be predicted by the number of parent-reported illnesses. Exploring the relationship between early exposure and subsequent illness may help in making future recommendations regarding children and day care participation. A study that grew out of clinical practice is the “Irritable Infant Syndrome: Etiology and Management of Colic.” The theoretic basis for this study is the observation that infants with colic are different from other infants in terms of their sleep-wake cycles and clarity of behavioral cues (Keefe, 1988). The notion that the parents of these infants are simply too anxious or that these infants are just exhibiting a feeding intolerance has not proved useful in the clinical management of these infants. This project, designed to investigate the origins and management of infant colic from this new perspective, is funded by the National Institutes of Health National Center for Nursing Research. The research will be conducted in several phases: (a) the sleep-wake patterns of these infants will be studied with a new noninvasive infant monitoring system; (b) the clarity of infant cues and parent’s responsiveness will be eval-
M
aking the time integrate research conscious decision reprioritization of
and commitment to into practice requires a and often a activities.
uated; (c) a systematic investigation of the numerous gadgets, gimmicks, and folklore, as well as an alternative contingent care approach, will be conducted. NURSE PRACTITIONER WITH A RESEARCH FOCUS
l
Although it is interesting to describe the unique aspects of approaching pediatric primary care as a nurse researcher, most PNPs are practice-based and are struggling with the issue of integrating research into
Clinical
Practice and Research
277
their practice. For the practice-based PNP, incorporating research means learning to think about practice in new ways, challenging old assumptions, and accepting greater accountability, not just for one’s personal practice but for the development of more broadly applicable knowledge (Oberst, 1985). For the PNP who has not had a research course, the prospect of initiating a study may seem overwhelming. A list of selected readings is included on this page for those interested in updating their research skills. The following strategies for initiating, conducting, and using clinical research may be helpful. Initiating
Research
Getting started is often the most difficult part. Making the time and commitment to integrate research into practice requires a conscious decision and often a reprioritization of activities. The following list of questions described by Cronenwett (1986) will help the PNP focus on a level of commitment and motivation. n
Do I truly value nursing research?
Volume 2, Number 6 November-December 1988
27% Keefe and Kotzer
tivity for which nurses are well prepared. Acute observation and systematic assessment are key components within the research and nursing processes. The seven phases in applied or clinical research are illustrated in Figure 1. The process is cyclic in nature in that the research question arises from clinical practice and the results are then used to affect clinical practice.
A cute observation
and systematic assessment are key components within the research and nursing processes.
n
FIGURE 1 Clinical
research process.
Will participating in research activities help me accomplish my goals? What are the payoffs for doing nursing research in my work setting? What would motivate me to free up more time for research-related activities? What do my current activities say about my commitment to nursing research? Am I satisfied with my current research involvement? In addition to assessing one’s level of personal commitment, resources available for supporting research within one’s current work environment must be examined. l
n
n
l
n
l
Are other individuals conducting research in your setting? Will administration support research with time, money, or both? Are your clients receptive to being involved in research studies? Are there research consultants available at a nearby university or other health care agencies? Is it possible to form a network of PNPs interested in conducting research? Would it be possible to collaborate with a nursing faculty member or pediatrician on a study of mutual interest?
Conducting
Research
The word ‘%esearch” has a certain mystique that may intimidate PNPs who believe they are about to enter an unknown realm. In reality, the research process closely resembles the nursing process and is an ac-
Clinical research may be focused on describing a recognized pattern or phenomenon, testing those time-honored clinical axioms that were conceived out of tradition and folklore, or evaluating the effectiveness of a new nursing intervention. The very advice given to parents for anticipatory guidance can be a source of inquiry for the researcher.
Before
data collection begins, consultation with a methodologist or statistician is valuable and can prevent many of the frustrations of a fledgling researcher.
1
Whatever the focus, the next step in the process is to place the research question in context. The historical perspective, theoretic base, and previous empirical work must be reviewed and analyzed so that the current study can add a new piece to the knowledge base puzzle. Before data collection begins, consultation with a methodologist or statistician is valuable and can prevent many of the frustrations of a fledgling researcher. Data collection is often an exciting time for the’PNP. Interacting with the client and others in relation to the research project often reenforces our own enthusiasm for the project. However, advancing to this step too quickly without a well-thought-out and written research plan or protocol can lead to later discouragement when trying to make sense of one’s data. Data organization, management, and analysis may require a computer, but many clinical data sets are small and easily managed on a personal computer with a user-friendly statistics package. Other data, such as surveys and interviews,
Journal of Pediatric Health
Integrating
Care
are best analyzed and reviewed by hand. The next step of interpretation involves the fitting of the new piece of data back into the larger puzzle in a way that is logical and consistent with known facts. Dissemination of findings is as important a responsibility of the principal investigator as are proposal writing and data analysis. Too many nurses have stopped at this point and failed to share their experiences for lack of perfection or statistical significance. Overlooking this final important step has been a real hindrance to colleagues who could benefit from data of value in the previous work. Applying Research
The PNP scientist of the future will need to be a critical consumer of research-based knowledge and a producer of research ideas for clinical investigation. The usefulness of a research article or report to a
D
issemination of findings is as important a responsibility of the principal investigator as are proposal writing and data analysis.
PNP lies in its clinical applicability and its scientific merit. PNPs already bring a certain expertise to the research review or critique process in that they are able to evaluate the clinical appropriateness, relevance, and feasibility of the reported study. Clinical applicability can also be thought of as the generalizability or external validity of the study. The central issue is the extent to which the study subjects, setting, and interventions are similar to the conditions existing within the practitioner? current practice emironment.
T
he PNP scientist of the future will need to be a critical consumer of research-based knowledge as well as a producer of research ideas for clinical investigation.
The scientific merit of a research investigation rests on the internal validity of the study design. A study is internally valid if it was designed and conducted in such a way that the extraneous variables were well controlled so that the intervention was primarily responsible for the findings obtained. In other words,
Clinical
Practice and Research
279
a study has high internal validity if there is no other obvious explanation, or rival hypothesis, for the difference found in a particular group. PNPs who have had a recent research course or have been directly involved in the research process often are more comfortable in critically reviewing and using research in their practice, perhaps because of their familiarity with the terminology and demystification of the process. Even without an extensive methodologic and statistical background, a PNP can make several insightful observations about the scientific merit of a study. Study reports that are complex and cumbersome to follow are not more profound or scientific. It is the responsibility of the investigator to communicate in a clear and logical manner. If the report is not clear, the study may very likely be flawed in the conceptualization or the interpretation of findings. The method of data collection should be appropriate for addressing the question identified. The findings of the study should answer the original question as posed. Implications and conclusions drawn should not go beyond those supported by the data and clinical significance should always be balanced against any statistical significance that may have been reported in the study. The PNP should be able to find a clear, concise statement identifying a welldelineated research question, problem, or purpose. The research question then can be used as a reflective tool for evaluating the other components of the study.
C
learly there is a mandate to move from research focused on PNPs to research conducted by PNPs.
n
CONCLUSION
Previous research has been directed toward the study of PNPs, evaluating their competency and comparing their practice to that of physicians. Clearly there is a mandate to move from research focused on PNPs to research conducted L+JPNPs. It is the responsibility of the practicing PNP to respond to the challenge by generating the important patient-focused questions and conducting clinical investigations. PNPs can make significant contributions to pediatric health care through scientific inquiry and research-based practice. This practice orientation will have a signif-
T
November-December
icant impact on the growth and development of the nursing profession and will improve the quality of patient care. n REFERENCES The Children’s Hospital Kempe Research Center. (1985).Annzml rep” Denver: Author. Cronenwett, L. R. (1986). The research role of the clinical nurse specialist. The Journul ofNuvsin~Administration, 16(4), 10-11. F&tnmds, M. (1984). Do nurse practitioners still practice nursing?N#fmp?zcli~,47,5 1.
1988
Gitterman, B. A., Kotzer, A. M., Luckey, D. W., Bitts, M., & chilGlode, M. P. (1988). Does day care experience“‘immunid dren ~aimt subsequent ilhs? “The kindergarten study.” Unpublished manuscript. Keefe, M. R. ( 1988). Irritable infant syndrome: Theoretical perspectives and practice implications. Advance in Nursing Science,
16(5), 70-78. Oberst, M. T. (1985). Integrating research and clinical practice roles. Topicsin Clinicul Nutring, 7(2), 45-53.
Bound Volumes Available to Subscribers
Bound volumes of the JOURNAL OF PEDIATRIC HEALTH CARE are available to subscribers (only) for the 1988 issues from the Publisher, at a cost of $23.00 ($29.00 international) for Vol. 2 (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all O&QX Contact the C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800)325-4177, ext. 351. Subscriptions must be in force to qual@. Bound volumes are not available in place of a regular JOURNAL subscription.
9
Maureen R. Keefe, PhD, RN, PNP, and Anne Marie Kotzer, MS, RN, CPNP Nurse practitioners can contribute greatly to nursing science by identifying problems for investigation and using research findings in their practice. This article describes two approaches available to pediatric nurse practitioners for becoming involved in research. The role is described of two nurse researchers based in a research center in facilitating selected studies in ambulatory pediatric health care. An alternative approach is discussed for nurse practitioners who are in practice settings. Guidelines for initiating, conducting, and using research in practice are provided. Seven phases of clinical research are offered to assist the beginning researcher. J PEDIATR HEALTH CARE. (1988). 2, 275-280.
R
esearch is rapidly becoming a primary issue for the pediatric nurse practitioner (PNP), whether by choice or coercion. Oberst (1985) states that the development of a scientist-practitioner role in nursing is essential to the continued growth of nursing’s clinical science. The notion that the clinical practitioner provides care to patients and leaves the scientific endeavors to the academicians is obstructive to the growth of the nursing profession and to the individual professional. PNPs must decide how they will respond to the challenge of incorporating research into their practice. The nurse can approach this challenge in two ways; in one the nurse researcher addresses clinical problems and in the other the nurse practitioner focuses on research issues. n NURSE CLINICAL
RESEARCHER FOCUS
WITH
A
At The Children’s Hospital in Denver, the Kempe Research Center was established “to promote and
Maureen R. Keefe is Associate Director of Nursing for Research at The Children’s Hospital, Kempe Research Center and Assistant Professor at the University of Colorado School of Nursing, Denver, Colorado. Anne Marie Kotzer is Clinical Nurse Specialist for research dren‘s Hospital, Kempe Research Center, Denver, Colorado.
at The Chil-
Reprint requests: Maureen R. Keefe, PhD, RN, PNP, Associate Director of Nursing for Research, The Children’s Hospital, Kempe Research Center, 1056 E. 19th Ave., Denver, CO 80218.
JOURNAL
OF PEDIATRIC
HEALTH
CARE
facilitate high-quality, clinically relevant research to benefit children” (The Children’s Hospital, Kempe Research Center, 1985). A doctorally prepared clinical nurse researcher and PNP was appointed as associate director of the center. The primary responsibility of the associate director is to create a climate throughout the division of nursing that fosters nursing research as a valued activity for the professional nurse. Achievement of this goal involves identifying research resources and developing strategies for the application of research findings in practice.,The joint appointment of the associate director to the Univer-
P
NPs must decide how they will respond to the challenge of incorporating research into their practice.
sity of Colorado School of Nursing provides additional resources and promotes collaboration with academic colleagues. She also consults with other professionals within the institution to promote interdiscipJinary programs and research projects. Specific responsibilities include chairing the nursing research committee and serving as the nursing representative on the institutional review board. A master’s-prepared PNP also works in the re275
276
Volume 2, Number 6 November-December 1988
Keefe and Kotzer
search center and functions in the role of clinical nurse specialist. With the associate director, she is responsible for supporting and facilitating research activity throughout the hospital system. This includes initiating and conducting research independently and in collaboration with others; providing consultation for the development and review of research proposals; assisting in literature search, subject recruitment, data collection, data management, and analysis; and identifying funding sources. Several research-educational programs have been developed and offered by the nurse researchers. These programs have included a 2-day clinical research workshop covering the steps in the research process, a l-day workshop focusing on reading and critiquing the research literature relevant to clinical practice, and a regional conference on the unique challenges of collecting data from children. Avenues for research dissemination have included monthly research-based nursing grand rounds, research poster display cases, and a research column in the institution’s nursing newsletter. The transition from the traditional focus of the PNP on clinical practice to that of clinical research and research facilitation has been exciting and challenging. Two basic assumptions guiding the philosophy underlying this approach to research have been the belief that through clinical research the health of children and their families may be positively affected on a broader scale and that the skills required for excellence in clinical practice are also essential for the conduct of clinical research. Edmunds (1984) has identified the following components of health care that are unique to the role of the nurse practitioner (NP): (a) a holistic focus, (b) patient advocacy, (c) teaching, (d) skillful communication, (e) time and availability, (f ) empathy, and (g) personal involvement. These attributes, as well as a high level of clinical expertise, have been important in establishing credibility and functioning successfully in the role of clinical nurse researcher. Patient advocacy is reflected in the process of informed consent, which ensures the protection of the rights of subjects in clinical research studies. A high level of interpersonal and communication skills is necessary for gathering the in-depth qualitative data often used in nursing research. Nurse researchers are continually involved in teaching parents, patients, and staff about on-going and proposed research projects. The PNP in a research setting plays an important
role in identifying issues related to children’s health care that are conducive to clinical research as well as understanding the unique challenges that conducting research with children pose for the clinical investi-
A
high level of interpersonal and communication skills is necessary for gathering the in-depth qualitative data often used in nursing research.
gator. The problems and concerns related to children’s health and the family social structure are all part of the knowledge base of the PNP. As a provider of primary health care to pediatric clients, the PNP is in the foremost position to recognize those nursing actions and attitudes that uniquely define the role of the nurse. Clinical Research Studies
The following three studies in progress are examples of projects in which nurse researchers have focused on a clinical issue to improve and guide pediatric care. One research study being conducted by the nurses in the ambulatory care center, with consultation from the research nurses at The Children’s Hospital, involves the use of c‘pedipops” for fluid and electrolyte replacement in the dehydrated child. “Pedipops” consist of the oral electrolyte solution Pedialyte mixed with flavoring that is then frozen into Popsides. The hypothesis for the study is that the young child who will not drink adequate fluids will more readily accept a “pedipop,” thereby increasing fluid intake. This application could also be extended to the surgical patient after operation who requires a clear liquid diet and the inpatient with a gastrointestinal disorder who cannot tolerate a full diet. This study exemplifies the process of identifying a clinical problem and using research to explore alternative solutions. Another prospective, longitudinal study, conducted in collaboration with two pediatricians, investigated the relationship between illness and absentee rates of kindergarten children during their first year of school and the child’s prior day care experience (Gitterman, Kotzer, Luckey, Bitts, & Glode, 1988). The family of each child was contacted monthly for 10 months regarding signs and symptoms of illness in their child and the number of days
Journal of Pediatric Health Care
Integrating
missed from‘school because of the illness. These data were correlated with the child’s family characteristics and prior lifetime day care experience. This study attempted to answer an important epidemiologic question: does a child’s day care experience in preschool years impose an immunity on the child that will result in fewer illnesses during subsequent school years? The data were also analyzed to determine whether a child’s absenteeism from school could be predicted by the number of parent-reported illnesses. Exploring the relationship between early exposure and subsequent illness may help in making future recommendations regarding children and day care participation. A study that grew out of clinical practice is the “Irritable Infant Syndrome: Etiology and Management of Colic.” The theoretic basis for this study is the observation that infants with colic are different from other infants in terms of their sleep-wake cycles and clarity of behavioral cues (Keefe, 1988). The notion that the parents of these infants are simply too anxious or that these infants are just exhibiting a feeding intolerance has not proved useful in the clinical management of these infants. This project, designed to investigate the origins and management of infant colic from this new perspective, is funded by the National Institutes of Health National Center for Nursing Research. The research will be conducted in several phases: (a) the sleep-wake patterns of these infants will be studied with a new noninvasive infant monitoring system; (b) the clarity of infant cues and parent’s responsiveness will be eval-
M
aking the time integrate research conscious decision reprioritization of
and commitment to into practice requires a and often a activities.
uated; (c) a systematic investigation of the numerous gadgets, gimmicks, and folklore, as well as an alternative contingent care approach, will be conducted. NURSE PRACTITIONER WITH A RESEARCH FOCUS
l
Although it is interesting to describe the unique aspects of approaching pediatric primary care as a nurse researcher, most PNPs are practice-based and are struggling with the issue of integrating research into
Clinical
Practice and Research
277
their practice. For the practice-based PNP, incorporating research means learning to think about practice in new ways, challenging old assumptions, and accepting greater accountability, not just for one’s personal practice but for the development of more broadly applicable knowledge (Oberst, 1985). For the PNP who has not had a research course, the prospect of initiating a study may seem overwhelming. A list of selected readings is included on this page for those interested in updating their research skills. The following strategies for initiating, conducting, and using clinical research may be helpful. Initiating
Research
Getting started is often the most difficult part. Making the time and commitment to integrate research into practice requires a conscious decision and often a reprioritization of activities. The following list of questions described by Cronenwett (1986) will help the PNP focus on a level of commitment and motivation. n
Do I truly value nursing research?
Volume 2, Number 6 November-December 1988
27% Keefe and Kotzer
tivity for which nurses are well prepared. Acute observation and systematic assessment are key components within the research and nursing processes. The seven phases in applied or clinical research are illustrated in Figure 1. The process is cyclic in nature in that the research question arises from clinical practice and the results are then used to affect clinical practice.
A cute observation
and systematic assessment are key components within the research and nursing processes.
n
FIGURE 1 Clinical
research process.
Will participating in research activities help me accomplish my goals? What are the payoffs for doing nursing research in my work setting? What would motivate me to free up more time for research-related activities? What do my current activities say about my commitment to nursing research? Am I satisfied with my current research involvement? In addition to assessing one’s level of personal commitment, resources available for supporting research within one’s current work environment must be examined. l
n
n
l
n
l
Are other individuals conducting research in your setting? Will administration support research with time, money, or both? Are your clients receptive to being involved in research studies? Are there research consultants available at a nearby university or other health care agencies? Is it possible to form a network of PNPs interested in conducting research? Would it be possible to collaborate with a nursing faculty member or pediatrician on a study of mutual interest?
Conducting
Research
The word ‘%esearch” has a certain mystique that may intimidate PNPs who believe they are about to enter an unknown realm. In reality, the research process closely resembles the nursing process and is an ac-
Clinical research may be focused on describing a recognized pattern or phenomenon, testing those time-honored clinical axioms that were conceived out of tradition and folklore, or evaluating the effectiveness of a new nursing intervention. The very advice given to parents for anticipatory guidance can be a source of inquiry for the researcher.
Before
data collection begins, consultation with a methodologist or statistician is valuable and can prevent many of the frustrations of a fledgling researcher.
1
Whatever the focus, the next step in the process is to place the research question in context. The historical perspective, theoretic base, and previous empirical work must be reviewed and analyzed so that the current study can add a new piece to the knowledge base puzzle. Before data collection begins, consultation with a methodologist or statistician is valuable and can prevent many of the frustrations of a fledgling researcher. Data collection is often an exciting time for the’PNP. Interacting with the client and others in relation to the research project often reenforces our own enthusiasm for the project. However, advancing to this step too quickly without a well-thought-out and written research plan or protocol can lead to later discouragement when trying to make sense of one’s data. Data organization, management, and analysis may require a computer, but many clinical data sets are small and easily managed on a personal computer with a user-friendly statistics package. Other data, such as surveys and interviews,
Journal of Pediatric Health
Integrating
Care
are best analyzed and reviewed by hand. The next step of interpretation involves the fitting of the new piece of data back into the larger puzzle in a way that is logical and consistent with known facts. Dissemination of findings is as important a responsibility of the principal investigator as are proposal writing and data analysis. Too many nurses have stopped at this point and failed to share their experiences for lack of perfection or statistical significance. Overlooking this final important step has been a real hindrance to colleagues who could benefit from data of value in the previous work. Applying Research
The PNP scientist of the future will need to be a critical consumer of research-based knowledge and a producer of research ideas for clinical investigation. The usefulness of a research article or report to a
D
issemination of findings is as important a responsibility of the principal investigator as are proposal writing and data analysis.
PNP lies in its clinical applicability and its scientific merit. PNPs already bring a certain expertise to the research review or critique process in that they are able to evaluate the clinical appropriateness, relevance, and feasibility of the reported study. Clinical applicability can also be thought of as the generalizability or external validity of the study. The central issue is the extent to which the study subjects, setting, and interventions are similar to the conditions existing within the practitioner? current practice emironment.
T
he PNP scientist of the future will need to be a critical consumer of research-based knowledge as well as a producer of research ideas for clinical investigation.
The scientific merit of a research investigation rests on the internal validity of the study design. A study is internally valid if it was designed and conducted in such a way that the extraneous variables were well controlled so that the intervention was primarily responsible for the findings obtained. In other words,
Clinical
Practice and Research
279
a study has high internal validity if there is no other obvious explanation, or rival hypothesis, for the difference found in a particular group. PNPs who have had a recent research course or have been directly involved in the research process often are more comfortable in critically reviewing and using research in their practice, perhaps because of their familiarity with the terminology and demystification of the process. Even without an extensive methodologic and statistical background, a PNP can make several insightful observations about the scientific merit of a study. Study reports that are complex and cumbersome to follow are not more profound or scientific. It is the responsibility of the investigator to communicate in a clear and logical manner. If the report is not clear, the study may very likely be flawed in the conceptualization or the interpretation of findings. The method of data collection should be appropriate for addressing the question identified. The findings of the study should answer the original question as posed. Implications and conclusions drawn should not go beyond those supported by the data and clinical significance should always be balanced against any statistical significance that may have been reported in the study. The PNP should be able to find a clear, concise statement identifying a welldelineated research question, problem, or purpose. The research question then can be used as a reflective tool for evaluating the other components of the study.
C
learly there is a mandate to move from research focused on PNPs to research conducted by PNPs.
n
CONCLUSION
Previous research has been directed toward the study of PNPs, evaluating their competency and comparing their practice to that of physicians. Clearly there is a mandate to move from research focused on PNPs to research conducted L+JPNPs. It is the responsibility of the practicing PNP to respond to the challenge by generating the important patient-focused questions and conducting clinical investigations. PNPs can make significant contributions to pediatric health care through scientific inquiry and research-based practice. This practice orientation will have a signif-
T
November-December
icant impact on the growth and development of the nursing profession and will improve the quality of patient care. n REFERENCES The Children’s Hospital Kempe Research Center. (1985).Annzml rep” Denver: Author. Cronenwett, L. R. (1986). The research role of the clinical nurse specialist. The Journul ofNuvsin~Administration, 16(4), 10-11. F&tnmds, M. (1984). Do nurse practitioners still practice nursing?N#fmp?zcli~,47,5 1.
1988
Gitterman, B. A., Kotzer, A. M., Luckey, D. W., Bitts, M., & chilGlode, M. P. (1988). Does day care experience“‘immunid dren ~aimt subsequent ilhs? “The kindergarten study.” Unpublished manuscript. Keefe, M. R. ( 1988). Irritable infant syndrome: Theoretical perspectives and practice implications. Advance in Nursing Science,
16(5), 70-78. Oberst, M. T. (1985). Integrating research and clinical practice roles. Topicsin Clinicul Nutring, 7(2), 45-53.
Bound Volumes Available to Subscribers
Bound volumes of the JOURNAL OF PEDIATRIC HEALTH CARE are available to subscribers (only) for the 1988 issues from the Publisher, at a cost of $23.00 ($29.00 international) for Vol. 2 (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all O&QX Contact the C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800)325-4177, ext. 351. Subscriptions must be in force to qual@. Bound volumes are not available in place of a regular JOURNAL subscription.