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Research Strategies for Clinicians
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Translating Research into Practice
Research Strategies for Clinicians Bradi B. Granger, MSN, RN
Why did you choose to be a nurse? Most nurses would not answer, "for the opportunity to do research ." In spite of this, nurses have historically been asked to play a lead role in process improvement activities, policy and procedure implementation , and, increasingly, in the implementation and documentation of evidence-based practice. 8· 10· 11• 13· 14 All these are research-related activities in that they require one to obtain and analyze data so as to make good decisions about patient care. Evidence-based practice is researchbased practice, yet nursing has not as of yet fully integrated research language, application concepts, and implementation strategies into everyday nursing practice . Most nurses practicing in a clinical setting do not claim to be experienced researchers. If we take a closer look, however, the activities and responsibilities that nurses perform in delivering, documenting, and evaluating patient care are the steps necessa1y to track and measure patient outcomes and care (Fig. 1). Assessme nt, measurement, trending, and tracking of patient response to care and patient outcome are clone on a number of levels and at many different points throughout a course of treatment. As represented in From the Duke University Medica l Center and Health Systems and Duke University School of Nursing, D urham, North Ca ro lina
Figure 1, patients may experience any munber of "bumps" during care that are identified, evaluated, and managed by nurses. In this way, nurses are central figures in the management of patient outcomes, and as such, they are expected to know and apply the best evidence available for each particular situation. Yet even in academic medical centers, all espousing a similar triune mission, that is, to provide excellence in patient care, education, and research , the responsibilities and expectations for nurses are only indirectly linked to research. Exposure to and preparation for research activities are not typically part of nursing orientation. Clinical opportunities, time, and financial resources for research are not usually built into unit budgets o r staffing plans . In addition, expectations for performance and annual performance evaluations do not usually address research or require d irect evaluation of nurse participation in the research utilization processes. As a result the nurse's research role is not visible or rewarded. If evidence-based practice is synonymous with research-based p ractice and is universally understood as being that w hich is best for patient care and patient outcomes, how can we in the clinical setting "get there"? If nurses, present with the patient for longer periods of time than almost any other health care provider, do not learn to research the
CRITICAL CARE NURSING C LINI CS OF NORTH AMERICA I Volume 13 I Number 4 I December 200 1
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Outcomes:
Clinical: Mortality Comorbidity Complications Activity I Ambulation Psychosocial Self-care Learning
Poet-op Bleeding
Syncope
Financial: LOS Resource Utilization System Efficiencies
Patient Day1 Variance
Day3 Variance
Service: Satisfaction System Access System Process
Figure 1 Evaluating clinical outcomes. (From Granger B, Chulay M: Research Strategies for Clini cians. New York, Pearson Education, 1999, p 1O; with permission .)
problems we identify on a daily basis, who will? As clinicians, nurses are skilled at assessing, providing care and therapeutic intervention, and evaluating the outcome of that care. These are the underpinnings of the research process. How can we incorporate research-related activities so snugly into nursing practice that they are perceived as "ordinary, " that is , as being no different than taking a temperature or ambulating a patient after surge1y? In the twenty-first century, when research-based evidence is generally accepted as the driving force behind change across disciplines, the "why" embrace research should no longer be questioned. The following discussion, taken in part from the workbook Research Strategies for Clinicians, offers some practical insight into "how." 5
Research in the Service Setting Getting Started
Getting a research project started begins with an idea. Often, the idea comes from a patient concern or problem such as pain, discomfort, inability to sleep, or the desire to have a child
v1s1tor in a critical care setting. Sometimes, the idea originates from a failed intervention such as a specific approach to wound care or suctioning that resulted in a less than desirable outcome and caused you to question the practice. Any number of situations arise eve1y day during the delive1y of patient care that cause us to stop and ask ourselves, "Could that complication have been prevented?" or "Is there a better way?" Although a common tendency is to ask or "think" a question and move on, the evidence-oriented nurse might go one step further and look for an answer to the question. Because nurses are at the center of care, interacting directly on a daily basis with patients, families, and technologies that support their care, nurses are key players in the problem-solving game. As the primary coordinators and deliverers of care, nurses have the opportunity to identify problems and ask clinical questions eve1y day. Follow-through on these questions in a research-based process allows the nurse to be an active participant in evidence-based practice and thereby to improve patient outcomes by using and doing research (Fig. 2). Getting sta1ted on a research project requires continuously asking ourselves why we
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Generating Clinical Queetione; From Praatiae
" Pro'11eme Proaeeeore; 11
Staff Development
Policy& Procedure
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No Conaluelve Data Avalla'11e 11
Solution Generators
11
Praatlae Rsvleeel 6aeed on Literature
Research Team Formed
Research 5tudy Developed and Conduoted
•R---~ I Results I
Figure 2 Clinicians as solution generators. (From Granger B, Chulay M: Research Strategies for Clinicians. New York, Pearson Education, 1999, p 4; with permission.)
do things the way we do and could we be doing them better? Getting started is a matter of being open to ideas and thoughts that arise in the clinical setting each day. Capturing Clinical Questions Once the idea or thought arises, how can it be "saved" for later or until you have time to address it? Two strategies have been used successfully in the clinical setting to capture clinical questions. These are the strategies to investigate clinical cost kinetics (STICK) method and the FOCUS method. 5 Your specific clinical setting and the preferences of coworkers influence which one works best for you. STICK Method for Capturing Clinical Questions
The STICK method refers to "the practice of investigating the 'kinetics' or the interactive, dynamic relationship that exists between clinical practice and outcomes, and the costs associated with those outcomes.'' 5 Using the
STICK method, clinicians can capture clinical questions as they occur during rounds, during patient-family conferences, or in the course of delivering patient care. Here is how it works. The first step in capturing clinical questions using this method is to adhere a pad of PostIt Notes (3-M, St. Paul, MN) at the patient bedside or at clinical workstations throughout the unit. Use the sticky notes to write down thoughts, problems, concerns, or ideas that arise during patient care delivety. Instruct the staff to use the notes for jotting down practice-related questions. The second step in the STICK method is to collect the notes in a central location such as a break room bulletin board, where other staff and colleagues can view and comment on the questions and concerns posted. Central display of the STICK notes serves to stimulate interest for involvement in upcoming studies and gives opportunity for group input. The third step is evaluation and "triage" of the STICK questions into one of four
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categories: educational issue, administrative decision, policy or procedural issue, or research. Typically, the questions that arise during the course of clinical practice fit easily into one of these four categories. As the categories imply, not all concerns or questions are necessarily destined for a research project. Many are not amenable to research, and some could be easily answered by an educational in-service session or an administrative decision. The fourth step in the STICK method is to prioritize questions and follow through with protocol development for the question selected as top priority by the group (Fig. 3). This process is the research process. From prioritization of questions through protocol development, implementation, and final analysis, the STICK method and FOCUS method are the same: both use the research
[
process to work through development of the clinical question. 5 FOCUS Method for Capturing Clinical Questions
The FOCUS method is a unique approach to brainstorming clinical questions in a group setting. 5 This method uses a focus group of staff nurses and a facilitator to brainstorm and then prioritize clinical questions. Here is how it works. Phase I in the FOCUS method entails gathering clinicians from the unit, identifying a facilitator, and obtaining a flip chart. Using the flip chart, the facilitator helps staff to generate characteristics or items in each of three categories: high-volume patients or problems in the clinical area, frequent nursing interventions employed in the clinical area,
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• Factors to Consider in Prioritizing Clinical I I I
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Formfng Research Teams
Reviewing the Literature ]
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Figure 3 Prioritizing clinical questions. (From Granger B, Chulay M: Research Strategies for Clinic ians. New York, Pearson Education , 1999, p 38; with permission.)
RESEARCH STRATEGIES FOR CLINICIANS
and common technologies used in the clinical area (Table 1). Table 1 is an example of items generated from a medical intensive care unit during phase I of the FOCUS method. Phase II in the FOCUS method occurs during a second meeting of the working group. In this phase, the group is encouraged to question their practice as it relates to the items and topics generated in phase I. As practice questions begin to emerge, the facilitator helps the group to focus and narrow the
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questions by identifying dependent variables associated with each practice question. These dependent variables are then used as the variables in the study (Table 2) As with the STICK method, the FOCUS method requires the group to prioritize the questions generated and choose one. The success of the project may hinge on this important selection process, as consensus and "buy in" from the whole group are necessa1y to ensure the project's completion.
Table 1 EXAMPLE OF PHASE I OF FOCUS METHOD IN A MEDICAL INTENSIVE CARE UNIT Phase I: Brainstorming High-volume patient populations and patient needs/problems Sepsis with/without shock Respiratory failure Renal failure Cardiac failure related to chemotherapy Cardiac arrhythmias related to chemotherapy, Taxol, suramin Pediatric human immunodeficiency virus: admissions to unit as well as for procedures Pancreatitis GCD patients with respiratory failure or sepsis Fever Tumor lysis syndrome Common/frequent nursing interventions Assisting/monitoring patients during short-term procedures (bone marrow biopsy, bronchoscopy, central venous catheter line insertions, lumbar punctures) Specimen collections for therapeutic or research purposes (e.g., urine, blood, stool, sputum) Endotracheal suctioning with/without normal saline instillation, open method only, manual resuscitation bag for hyperoxygenation Pain management, mainly intravenous drug administration (as needed or continuous infusion); some new approaches being seen (transcutaneous electrical nerve stimulator) Transports Medication administration (antibiotics, vasopressors, neuromuscular blockers, chemotherapy) Intravenous tubing and dressing changes Patient/family teaching (intensive care unit routines, admission information, procedures, transfer planning, visiting) Computer interventions (e.g., putting in orders) Temperature control measures Dressing changes Chest tubes Technologies commonly used Special beds different types Ventilators: common modes these days are pressure control with fairly normal positive end-expiratory pressure levels Physiologic monitoring: invasive and noninvasive (blood pressure, arterial blood saturation with oxygen, PaC0 2 ) Sequential compression devices Continuous venous-venous hemofiltration (and his uncles) Blood glucose monitoring Hypothermia units Smart needles Sonogram for catheter insertion Pacemakers Capnography 12-lead electrocardiogram Fluoroscopy Cardiac monitoring Portable suction Syringe pumps
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Table 2 LIST OF POTENTIAL RESEARCH TOPICS OR QUESTIONS GENERATED DURING PHASE II OF THE FOCUS GROUP METHOD IN A MEDICAL INTENSIVE CARE UNIT
1. What are the risks and benefits associated with the use of normal saline with endotracheal suctioning? Dependent variables: Amount of mucous Consistency of mucous Oxygen Arterial saturation, Pa02 Cost Patient comfort 2. Are portable glucose meters as accurate as plasma glucose levels for managing critically ill patients? Dependent variables: Serum glucose level Cost 3. Which method (manual or mechanical) is better for the delivery of hyperoxygenation breaths during endotracheal suctioning? Which patients benefit from closed system suctioning (e.g., high positive end-expiratory pressure, fraction of inspired oxygen)? Dependent variables: Arterial blood gas Mean arterial pressure Heart rate Peak airway pressure during delivery Patient comfort 4. Which methods of temperature control work best with fever? (as needed vs scheduled antipyretic medications vs hypothermia unit vs ice packs vs tep id baths)? Core temperature Dependent variables: Shivering Patient comfort
Prioritizing Clinical Questions
The STICK and FOCUS methods are risky in that they can potentially yield way too many questions. Be prepared to prioritize those questions that arise in an efficient manner so as not to lose momentum or fragment the group at this early stage. A clinical question that is most like ly to succeed as a research question is one that is of interest to most staff in the unit, is clinically important, bas potential financial implications for the institution, includes patients who are eligible to participate and are available in large numbers on the unit, has established tools for variable measurement, does not require additional funds for study completion , is aligned w ith institutional priorities, and allows data collection procedures to be incorporated into the daily nursing routine .5 One quick way to see how your questions measure up to these criteria is to rate them using a rating worksheet such as the one in Table 3.
you quickly identify the extent to w hich your question has been answered? Every good clinical question calls for a good review of the existing literature, but before you throw in the towel, try this quick algorithm for finding existing information on your topic (Fig. 4). By following the algorithm in Figure 4, a "quick look" at existing literature can be obtained. The quick look allows you to judge how much work has already been done on your topic of interest and then, based on that knowledge, to review a few key articles from the list and determine if an adequate answer has b een found. Regardless of how you came about finding a clinical question, the literature review step is imperative. Remember, the quick look is not an exhaustive review of existing literature; it simply informs you about the volume of research already done and helps to filter out the most recent work on the topic. Research Teams
Expediting a Review of Existing Literature
Now that you have some strategies for coming up with clinical questions to pursue, how do you know they have not already been answered? Or, more importantly, how can
Altho ugh finding a good clinical question and reviewing the literature related to that question may be done solo, the success of research done by staff nurses in a clinical setting requires teamwork. Without it, the burden of protocol development, patient
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Table 3
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RATING WORKSHEET FOR PRIORITIZING RESEARCH QUESTIONS: EVALUATION CRITERIA FOR POTENTIAL RESEARCH PROJECTS Criteria
Topic
Topic
Topic
Topic
Area of staff interest Staff have c linical expertise Important to clinical practice, patient outcomes Large number of patients eligible No political land mines Potential financial impact No additional funds required Measurement tools available Data collection fits with unit routines Data col lection could be fini shed quickly Miscellaneous Scoring system: O = not present,
+=
present/yes, ++ = highly present/strong yes .
enrollment, and data collection and manageme nt is simply too great. Buy-in of peers is crucial to success not only to get the work done but also to keep momentum high for identifying eligible patients, promoting the study's visibility over time, encouraging general appreciation for study findings , and, not least of all , having fun! Team Size and Composition
Research teams require anywhere from 3 to 10 people and should be reflective of the size and composition of the unit involved. Although large clinical areas may have more nurses to draw from , small teams ca n be equally effective . Research projects can b enefit from a rnultidisciplina1y team and are typically composed of those colleagues most directly affected by or interested in the study topic. Examples include respirato1y therapy representatives working on a suctioning study, nutritionists working on a tubefee ding study, or physical the rapists working on an early ambulation study. Inviting other disciplines broadens perspective, adds diversity, and is especially helpful for identifying pertinent related literature during the literature review. Functioning as a Team
Across disciplines, the issues surrounding the dynamics of group work have been a consistent topic for discussion and the focus of many confere nces, meetings, and publicationsL " 6 7 Much of the literature
about teamwork has focused on reducing or dealing w ith conflict o n the team, holding members accountable for responsibilities and follow-through, and improving communication among team members. Although all of these issues may or may not apply to your research team, if the potential for them is recognized and addressed up front, the actual rroblems that arise sho uld be few . The most consistent problems that arise among research teams are re lated to responsibilities and communication.4 5 Responsibilities for various roles and fun ctions througho ut the study are many. These responsibilities are most effectively carried out when they are clearly communicated up front and when the individuals chosen for va rious jobs are well suited, prepared for the position. and enthusiastic about their role .
Bulldozing Barriers in Clinical Practice Settings Protocol Development: Time Constraints, Writer's Block, and Support
Although the STICK o r FOCUS method can help you cut to the chase in identifying a research question that is interesting and feasible for your specific clinical area, a lot of work remains to be clone to develop the protocol. Protocol development can be a barrier to the progress of the study, particularly for first-time researchers. Common stumbling
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Want to do a Literature Search? Here's How! Click "Start" in the bottom left corner of main menu and choose each of the following selections:
''Programs"
"Netscape"
Enter address into blank address bar: http://www.mc.duke.edu/mcli
Choose "Research"
Choose "Library and Research Resources"
Choose "Ovid"
Choose "Medline"
Select "Generic access"
Select "CINAHL" or "Medline" depending on what your needs are. CINAHL lists nursing and allied health literature only. Figure 4 Performing a literature review.
blocks that make protocol development difficult include inexperience with the process, unfamiliarity with expectations for the written document such as what needs to be included and w here, time constraints for getting it done, and inaccessibility of necessary experts to help with study design or statistical support. Two strategies for addressing these common problems are as follows. First, to find help either with the overall research process or with statistical support, find a mentor or someone to walk through the process with you. This person could be a faculty member, a clinical nurse specialist at your facility with research experience, or a represen-
tative on the institutional review board (IRB) w ho is willing to spend some time going over your protocol or the research process with you. A second suggestion is to obtain a copy of a completed IRB proposal from your facility, most likely one for which the study has been completed, and review the format and requirements applied therein. Concerns with these barriers are legitimate and best addressed individually based on your clinical setting and the possibilities for expert consultation in your regional area. Other sources of assistance that may be able to offer suggestions, resources, or consultative services are professional nursing organizations, hospital administration, or local universities and community colleges. Regardless of the availability of outside resources, an alternative first step is replicating a study or participating as a study site in a nationally coordinated study before attempting one on your own. Replicate a Study
Typically, the review of literature on any topic yields a number of articles that are similar to but not exactly the same as what your team is interested in studying. Replicating the study in a different, or even the same, population of patients is an extremely valuable exercise. Not only does the second study serve to validate the findings of the first, but it also offers opportunity to discover something new or to broaden the study by looking at slightly different variables. The biggest advantage of replication for new researchers is the chance to model a protocol on one that has already been written and "tested." This approach takes some of the anxiety out of getting the details "right" and offers a "failure cushion," because the nurse can often contact the previous investigator by telephone and discuss any problems that presented during the original study. A number of articles have been published about replicating studies, and they represent a helpful place to start before moving forward with the project. 2• 4 Participate as a Study Site If an opportunity to participate in a nationally coordinated study is available, do it. This
RESEARCH STRATEGIES FOR CLIN ICIANS
is an excellent place to learn, and the advantages of working on such a project are many. Sponsored multisite clinical trials such as the American Association of Critical-Care Nurses Thunder Projects have allowed staff the chance to be mentored through the clinical trial experience in a positive and supportive fashion. Because these trials and others like them are designed by experienced nursing researchers, including statisticians and methodology experts, the encl result is a wellconceived trial designed to evaluate clearly defined and measurable outcomes. In addition, at the completion of the trial, the results are analyzed, compiled, and shared by that same group of experts. Commonly, the results and implications for practice are distributed to participation sites in the form of presentation materials and printed text, making it easy to communicate the final outcomes to other staff, the multiclisciplina1y team, and administrative leaders in the organization, thus completing the cycle of research-based practice.
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ishes. Celebrations help to remind the team that progress is being made, and they provide a forum for reflection, discussion, and rejuvenation. The research process has six inherently obvious points at w hich to celebrate: proposal preparation completed, IRB approval obtained, educational in-service training finished and enrollment begun, the "half-way" mark in enrollment reached, data analysis completed, and manuscript submitted for publication (Fig. 5). 5 Although any small success will do, these are points at which the team definitely deserves a pat on the back. Even though it may seem silly or unimportant, small-scale celebrations at the unit level not only motivate the team and publicize research progress but also serve to entice new recruits for current or future studies. Your headline on the announcement flyer might be, "Join us (when and where) for festivities to celebrate the (name) study." Why? "Because these things are fun, and fun is goocl!"12
Logistic Barriers in Data Collection Motivation for the Long Haul
Are you having a good time? Do not let the team be tempted to chicle, "Are we having fun yet?" Instead, ask yourself if you are having enough fun. Research is important and serious work that can be draining for eve1yone. For this reason, keep in mind the important act of celebrating at every opportunity. Every "finish" is a finale and deserves celebration. This includes small accomplishments along the way as well as the big fin-
Proposal Prepared
Encourage the ream with this sensational coffee cake for st.arters.
Coffee Cake for Starrers .,;:,
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IR6 Approved
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The design of data collection procedures is a common barrier that causes many studies to fall short of enrollment goals, yield insignificant or uninterpretable results, and frustrate data collectors (staff nurses) to the point of never wanting to do research again. Data collection can be time-consuming, burdensome in its rigor, and sometimes monotonous. For these reasons, most academic and exte rnally funded studies spend a large percentage of the funding budget to hire designated data Enrollmem: I ( Half-W~ Point
Pass the Review Board in style with a cheese board party!
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Semi-Chocolate Cheese Board Party Get your clinical area excited about Chips your study with a great guacamole.
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Keep momentum going with lots of sweet rewards !
Finally I Data Celebration Salsa collection is complete. Pass off to the statistician and serve " DataNut Bread" Data-Nut Bread
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~~
Celebrate the chance to publish with a " hats off ! " salsa party.
Figure 5 Steps to success: Opportunities to celebrate. (From Granger B, Chulay M: Research Strategies for Clinicians. New York, Pearson Education, 1999, p 78; with permission.)
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collectors. For staff invested in identifying and generating their own research based on clinical issues in their specific patient population, designing data collection around unit norms is efficient, inexpensive, and creates a positive team experience. 4· 5 When studies incorporate collecting pieces of information that nurses collect anyway, and structure measurement intervals in such a way that staff are not unduly burdened, the data collection process builds peer collegiality, teamwork, and a stronger appreciation for research and the research process. How can data collection be built effectively into unit routine? Some suggestions include
(1) designing time intervals for data collection during the usual assessment and vital sign time periods; (2) planning for patient enrollment to occur during hours of highest staffing and lowest patient care needs; (3) using equipment and materials already available in the patient care area; and ( 4) stocking enrollment instructions, consent forms, and data collection tools in an easily accessible area of the unit. Table 4 offers a summary of these suggestions and some practical examples of how each suggestion might play out in actual practice. If a designated time for focused data collection is necessary for the study, make sure
Table 4 LOGISTIC BARRIERS TO COMPLETION OF DATA COLLECTION Barrier
Example
Unit rou tines Data collection interferes with patient care Collection of data for study purposes does not coincide with time patient care data are normally obtained
Subject's completion of a long research questionnaire during admission would cause hospital staff to wait to assess patient Temperatures for a comparison study of different devices not done when temperatures are needed for patient care purposes Study requires a sample size of 100, but only 6 patients eligible per month Data collectors only available on day shift, but data also need to be collected at night
Patient flow patterns Low volume each month Not available when data collectors available
Communication patterns
Staff do not know when patients are eligible for or subjects in a study
Documentation patterns
Patient needs to sign consent preoperatively, but researchers do not see the patient unti l after surgery Not enough staff to do patient care and data collection at the same time Data collection complex, requiring 1-2 h of time.
Staffing patterns
Possible Solution Consider a shorter version of the questionnaire or change data collection times to occur after clinical care Redesign timing of data collection to coincide with usual activities
Consider broadening the types of patients who would be eligible for the study to include other diagnoses Consider having other units or institutions participate in the study to increase the number of eligible patients Reconsider the feasibility of the study at this time Enlist some of the night shift staff to join the study group Consider discussing on rounds or during the report which patients are likely candidates for which studies on the unit Assign an investigator each day to be responsible for identifying eligible subjects and to alert the staff Place some type of colorful or eye-catching sign or notation in the medical record or at the patient's bedside to alert staff that patient is a participant in a study Enlist some of the staff on the admitting unit to join the study group so they can obtain consent Rethink staffing pattern Redesign and simplify data collection to be done during patient care routines or in brief 10-min segments
Adapted from Granger B, Chulay M: Research Strategies for Clinicians , New York, Pearson Education, 1999, p 115; with permission .
RESEARCH STRATEGIES FOR CLINICIANS
it can be completed in a short time frame (15 to 20 minutes) and that the staff are willing to use the b uddy coverage system to allow nurses to complete research. Much like
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breaks and lunch time, the buddy system is an excellent way to accomplish important research, particularly when staff are invested in the project and its outcome.
SUMMARY If there is a story waiting to be told about nurses and research, it is this: research is part of our past, our present, and our future. Research gives "caring" a mental muscle that makes it stronger than caring would be without it. Since the Crimean War, research has been a foundational cornerstone of the profession. 9 Florence Nightingale espoused caring and human touch but not without also observing and measuring important patient outcomes that identified the spread of infection via human contact. As a new generation of nurses emerges, we who have come before might serve them well to role model what we know: that strong research is strong nursing and that obtaining and using evidence in nursing practice results in better outcomes for those patients and families we serve. Is the story waiting to be told your st01y? Part of the story of nursing waiting to be told is your story. Regardless of why you embarked on your career in nursing and regardless of where your journey has taken you to this point, you are a part of the twenty-first century body of nursing, and your individual contribution is an important one. Listen to your patients with an ear toward measuring and evaluating outcomes. Reflect on the care you provided, the interventions you had to offer, and why. Should something have been different? Could something have been better? Find out ... measure it.
REFERENCES 1. Brinkman R, Kirschne r R: Dealing w ith Peopl e You
2. 3. 4.
5. 6.
7.
Can 't Stand: How to Bring Out the Best in People at The ir Wo rst. New York , McGraw-Hill , 1994 Connelly C: Re plicating researc h in nursing. Int J Nurs Stud 23:71-77, 1986 Deets C: Whe n is e nough , e no ugh? .J Pro f Nurs 14:196, 1998 Fullwood J, G ra nge r B, Bride W, et al: Heart cente r nursing research: A team effort. Prog Cardiovasc Nurs 14:25- 29, 1999 Granger BB , Chu lay M: Research Strategies for Clinicians. Stamford , NY, Apple ton & Lange, 1999 Larson C, LeFasto F: Tea m Work: What Must Go Right , \X'ha t Can Go Wrong. Newbury Park, CA, Sage, 1989 Nelson B: 100 1 Ways to Energize Employees. New York, Wo rkman Publishing, 1998
8. Nelson E, Splaine M, Batald en P, et al: Building measureme nt and data collectio n into medica l practice. Ann Inte rn Med 128:460- 466, 1998 9. Nightingale F: Notes o n Nursing: What It ls and What It ls Not. Lo ndo n, Harrison a nd Sons, 1859 10. Sacke tt D: Ev ide nce-Based Medicine : How to Pra ctice and Teach Evid ence-Based Medicine . Lond on , Pearson Professio nal Limited , 1997 11. Sche re r A: Des igning Critical Pathways . Aliso Viejo, CA, Am e rica n Assoc iation of Critica l Care Nurses, 1997 12. Dr Seuss: One Fish, Two Fish. Bosto n, Ho ughto n Mifflin , 1957 13. White S, Bartrug B, Bride W: Suppo rting nursing inte rve ntio ns in a cost-conscious e n vironment. Crit Care Nurs Clin North Am 7: 399-406, 1995 14. Wojne r A: O utcomes manage ment: From theory to pract ice. Critica l Ca re Nursing Q uarterly 19:1- 15, 1997
Address reprint requesls lo Bracli B. Granger, MSN, RN 80 20 Willardville Statio n Road Bahama , NC 27503 e-ma il: Grang004@ rnc. duke .ed u
Translating Research into Practice
Research Strategies for Clinicians Bradi B. Granger, MSN, RN
Why did you choose to be a nurse? Most nurses would not answer, "for the opportunity to do research ." In spite of this, nurses have historically been asked to play a lead role in process improvement activities, policy and procedure implementation , and, increasingly, in the implementation and documentation of evidence-based practice. 8· 10· 11• 13· 14 All these are research-related activities in that they require one to obtain and analyze data so as to make good decisions about patient care. Evidence-based practice is researchbased practice, yet nursing has not as of yet fully integrated research language, application concepts, and implementation strategies into everyday nursing practice . Most nurses practicing in a clinical setting do not claim to be experienced researchers. If we take a closer look, however, the activities and responsibilities that nurses perform in delivering, documenting, and evaluating patient care are the steps necessa1y to track and measure patient outcomes and care (Fig. 1). Assessme nt, measurement, trending, and tracking of patient response to care and patient outcome are clone on a number of levels and at many different points throughout a course of treatment. As represented in From the Duke University Medica l Center and Health Systems and Duke University School of Nursing, D urham, North Ca ro lina
Figure 1, patients may experience any munber of "bumps" during care that are identified, evaluated, and managed by nurses. In this way, nurses are central figures in the management of patient outcomes, and as such, they are expected to know and apply the best evidence available for each particular situation. Yet even in academic medical centers, all espousing a similar triune mission, that is, to provide excellence in patient care, education, and research , the responsibilities and expectations for nurses are only indirectly linked to research. Exposure to and preparation for research activities are not typically part of nursing orientation. Clinical opportunities, time, and financial resources for research are not usually built into unit budgets o r staffing plans . In addition, expectations for performance and annual performance evaluations do not usually address research or require d irect evaluation of nurse participation in the research utilization processes. As a result the nurse's research role is not visible or rewarded. If evidence-based practice is synonymous with research-based p ractice and is universally understood as being that w hich is best for patient care and patient outcomes, how can we in the clinical setting "get there"? If nurses, present with the patient for longer periods of time than almost any other health care provider, do not learn to research the
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Outcomes:
Clinical: Mortality Comorbidity Complications Activity I Ambulation Psychosocial Self-care Learning
Poet-op Bleeding
Syncope
Financial: LOS Resource Utilization System Efficiencies
Patient Day1 Variance
Day3 Variance
Service: Satisfaction System Access System Process
Figure 1 Evaluating clinical outcomes. (From Granger B, Chulay M: Research Strategies for Clini cians. New York, Pearson Education, 1999, p 1O; with permission .)
problems we identify on a daily basis, who will? As clinicians, nurses are skilled at assessing, providing care and therapeutic intervention, and evaluating the outcome of that care. These are the underpinnings of the research process. How can we incorporate research-related activities so snugly into nursing practice that they are perceived as "ordinary, " that is , as being no different than taking a temperature or ambulating a patient after surge1y? In the twenty-first century, when research-based evidence is generally accepted as the driving force behind change across disciplines, the "why" embrace research should no longer be questioned. The following discussion, taken in part from the workbook Research Strategies for Clinicians, offers some practical insight into "how." 5
Research in the Service Setting Getting Started
Getting a research project started begins with an idea. Often, the idea comes from a patient concern or problem such as pain, discomfort, inability to sleep, or the desire to have a child
v1s1tor in a critical care setting. Sometimes, the idea originates from a failed intervention such as a specific approach to wound care or suctioning that resulted in a less than desirable outcome and caused you to question the practice. Any number of situations arise eve1y day during the delive1y of patient care that cause us to stop and ask ourselves, "Could that complication have been prevented?" or "Is there a better way?" Although a common tendency is to ask or "think" a question and move on, the evidence-oriented nurse might go one step further and look for an answer to the question. Because nurses are at the center of care, interacting directly on a daily basis with patients, families, and technologies that support their care, nurses are key players in the problem-solving game. As the primary coordinators and deliverers of care, nurses have the opportunity to identify problems and ask clinical questions eve1y day. Follow-through on these questions in a research-based process allows the nurse to be an active participant in evidence-based practice and thereby to improve patient outcomes by using and doing research (Fig. 2). Getting sta1ted on a research project requires continuously asking ourselves why we
RESEARCH STRATEGIES FOR CLINICIANS
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Generating Clinical Queetione; From Praatiae
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Staff Development
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11
Praatlae Rsvleeel 6aeed on Literature
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Research 5tudy Developed and Conduoted
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Figure 2 Clinicians as solution generators. (From Granger B, Chulay M: Research Strategies for Clinicians. New York, Pearson Education, 1999, p 4; with permission.)
do things the way we do and could we be doing them better? Getting started is a matter of being open to ideas and thoughts that arise in the clinical setting each day. Capturing Clinical Questions Once the idea or thought arises, how can it be "saved" for later or until you have time to address it? Two strategies have been used successfully in the clinical setting to capture clinical questions. These are the strategies to investigate clinical cost kinetics (STICK) method and the FOCUS method. 5 Your specific clinical setting and the preferences of coworkers influence which one works best for you. STICK Method for Capturing Clinical Questions
The STICK method refers to "the practice of investigating the 'kinetics' or the interactive, dynamic relationship that exists between clinical practice and outcomes, and the costs associated with those outcomes.'' 5 Using the
STICK method, clinicians can capture clinical questions as they occur during rounds, during patient-family conferences, or in the course of delivering patient care. Here is how it works. The first step in capturing clinical questions using this method is to adhere a pad of PostIt Notes (3-M, St. Paul, MN) at the patient bedside or at clinical workstations throughout the unit. Use the sticky notes to write down thoughts, problems, concerns, or ideas that arise during patient care delivety. Instruct the staff to use the notes for jotting down practice-related questions. The second step in the STICK method is to collect the notes in a central location such as a break room bulletin board, where other staff and colleagues can view and comment on the questions and concerns posted. Central display of the STICK notes serves to stimulate interest for involvement in upcoming studies and gives opportunity for group input. The third step is evaluation and "triage" of the STICK questions into one of four
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categories: educational issue, administrative decision, policy or procedural issue, or research. Typically, the questions that arise during the course of clinical practice fit easily into one of these four categories. As the categories imply, not all concerns or questions are necessarily destined for a research project. Many are not amenable to research, and some could be easily answered by an educational in-service session or an administrative decision. The fourth step in the STICK method is to prioritize questions and follow through with protocol development for the question selected as top priority by the group (Fig. 3). This process is the research process. From prioritization of questions through protocol development, implementation, and final analysis, the STICK method and FOCUS method are the same: both use the research
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process to work through development of the clinical question. 5 FOCUS Method for Capturing Clinical Questions
The FOCUS method is a unique approach to brainstorming clinical questions in a group setting. 5 This method uses a focus group of staff nurses and a facilitator to brainstorm and then prioritize clinical questions. Here is how it works. Phase I in the FOCUS method entails gathering clinicians from the unit, identifying a facilitator, and obtaining a flip chart. Using the flip chart, the facilitator helps staff to generate characteristics or items in each of three categories: high-volume patients or problems in the clinical area, frequent nursing interventions employed in the clinical area,
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Figure 3 Prioritizing clinical questions. (From Granger B, Chulay M: Research Strategies for Clinic ians. New York, Pearson Education , 1999, p 38; with permission.)
RESEARCH STRATEGIES FOR CLINICIANS
and common technologies used in the clinical area (Table 1). Table 1 is an example of items generated from a medical intensive care unit during phase I of the FOCUS method. Phase II in the FOCUS method occurs during a second meeting of the working group. In this phase, the group is encouraged to question their practice as it relates to the items and topics generated in phase I. As practice questions begin to emerge, the facilitator helps the group to focus and narrow the
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questions by identifying dependent variables associated with each practice question. These dependent variables are then used as the variables in the study (Table 2) As with the STICK method, the FOCUS method requires the group to prioritize the questions generated and choose one. The success of the project may hinge on this important selection process, as consensus and "buy in" from the whole group are necessa1y to ensure the project's completion.
Table 1 EXAMPLE OF PHASE I OF FOCUS METHOD IN A MEDICAL INTENSIVE CARE UNIT Phase I: Brainstorming High-volume patient populations and patient needs/problems Sepsis with/without shock Respiratory failure Renal failure Cardiac failure related to chemotherapy Cardiac arrhythmias related to chemotherapy, Taxol, suramin Pediatric human immunodeficiency virus: admissions to unit as well as for procedures Pancreatitis GCD patients with respiratory failure or sepsis Fever Tumor lysis syndrome Common/frequent nursing interventions Assisting/monitoring patients during short-term procedures (bone marrow biopsy, bronchoscopy, central venous catheter line insertions, lumbar punctures) Specimen collections for therapeutic or research purposes (e.g., urine, blood, stool, sputum) Endotracheal suctioning with/without normal saline instillation, open method only, manual resuscitation bag for hyperoxygenation Pain management, mainly intravenous drug administration (as needed or continuous infusion); some new approaches being seen (transcutaneous electrical nerve stimulator) Transports Medication administration (antibiotics, vasopressors, neuromuscular blockers, chemotherapy) Intravenous tubing and dressing changes Patient/family teaching (intensive care unit routines, admission information, procedures, transfer planning, visiting) Computer interventions (e.g., putting in orders) Temperature control measures Dressing changes Chest tubes Technologies commonly used Special beds different types Ventilators: common modes these days are pressure control with fairly normal positive end-expiratory pressure levels Physiologic monitoring: invasive and noninvasive (blood pressure, arterial blood saturation with oxygen, PaC0 2 ) Sequential compression devices Continuous venous-venous hemofiltration (and his uncles) Blood glucose monitoring Hypothermia units Smart needles Sonogram for catheter insertion Pacemakers Capnography 12-lead electrocardiogram Fluoroscopy Cardiac monitoring Portable suction Syringe pumps
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Table 2 LIST OF POTENTIAL RESEARCH TOPICS OR QUESTIONS GENERATED DURING PHASE II OF THE FOCUS GROUP METHOD IN A MEDICAL INTENSIVE CARE UNIT
1. What are the risks and benefits associated with the use of normal saline with endotracheal suctioning? Dependent variables: Amount of mucous Consistency of mucous Oxygen Arterial saturation, Pa02 Cost Patient comfort 2. Are portable glucose meters as accurate as plasma glucose levels for managing critically ill patients? Dependent variables: Serum glucose level Cost 3. Which method (manual or mechanical) is better for the delivery of hyperoxygenation breaths during endotracheal suctioning? Which patients benefit from closed system suctioning (e.g., high positive end-expiratory pressure, fraction of inspired oxygen)? Dependent variables: Arterial blood gas Mean arterial pressure Heart rate Peak airway pressure during delivery Patient comfort 4. Which methods of temperature control work best with fever? (as needed vs scheduled antipyretic medications vs hypothermia unit vs ice packs vs tep id baths)? Core temperature Dependent variables: Shivering Patient comfort
Prioritizing Clinical Questions
The STICK and FOCUS methods are risky in that they can potentially yield way too many questions. Be prepared to prioritize those questions that arise in an efficient manner so as not to lose momentum or fragment the group at this early stage. A clinical question that is most like ly to succeed as a research question is one that is of interest to most staff in the unit, is clinically important, bas potential financial implications for the institution, includes patients who are eligible to participate and are available in large numbers on the unit, has established tools for variable measurement, does not require additional funds for study completion , is aligned w ith institutional priorities, and allows data collection procedures to be incorporated into the daily nursing routine .5 One quick way to see how your questions measure up to these criteria is to rate them using a rating worksheet such as the one in Table 3.
you quickly identify the extent to w hich your question has been answered? Every good clinical question calls for a good review of the existing literature, but before you throw in the towel, try this quick algorithm for finding existing information on your topic (Fig. 4). By following the algorithm in Figure 4, a "quick look" at existing literature can be obtained. The quick look allows you to judge how much work has already been done on your topic of interest and then, based on that knowledge, to review a few key articles from the list and determine if an adequate answer has b een found. Regardless of how you came about finding a clinical question, the literature review step is imperative. Remember, the quick look is not an exhaustive review of existing literature; it simply informs you about the volume of research already done and helps to filter out the most recent work on the topic. Research Teams
Expediting a Review of Existing Literature
Now that you have some strategies for coming up with clinical questions to pursue, how do you know they have not already been answered? Or, more importantly, how can
Altho ugh finding a good clinical question and reviewing the literature related to that question may be done solo, the success of research done by staff nurses in a clinical setting requires teamwork. Without it, the burden of protocol development, patient
RESEARCH STRATEGIES FOR CLINICIANS
Table 3
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RATING WORKSHEET FOR PRIORITIZING RESEARCH QUESTIONS: EVALUATION CRITERIA FOR POTENTIAL RESEARCH PROJECTS Criteria
Topic
Topic
Topic
Topic
Area of staff interest Staff have c linical expertise Important to clinical practice, patient outcomes Large number of patients eligible No political land mines Potential financial impact No additional funds required Measurement tools available Data collection fits with unit routines Data col lection could be fini shed quickly Miscellaneous Scoring system: O = not present,
+=
present/yes, ++ = highly present/strong yes .
enrollment, and data collection and manageme nt is simply too great. Buy-in of peers is crucial to success not only to get the work done but also to keep momentum high for identifying eligible patients, promoting the study's visibility over time, encouraging general appreciation for study findings , and, not least of all , having fun! Team Size and Composition
Research teams require anywhere from 3 to 10 people and should be reflective of the size and composition of the unit involved. Although large clinical areas may have more nurses to draw from , small teams ca n be equally effective . Research projects can b enefit from a rnultidisciplina1y team and are typically composed of those colleagues most directly affected by or interested in the study topic. Examples include respirato1y therapy representatives working on a suctioning study, nutritionists working on a tubefee ding study, or physical the rapists working on an early ambulation study. Inviting other disciplines broadens perspective, adds diversity, and is especially helpful for identifying pertinent related literature during the literature review. Functioning as a Team
Across disciplines, the issues surrounding the dynamics of group work have been a consistent topic for discussion and the focus of many confere nces, meetings, and publicationsL " 6 7 Much of the literature
about teamwork has focused on reducing or dealing w ith conflict o n the team, holding members accountable for responsibilities and follow-through, and improving communication among team members. Although all of these issues may or may not apply to your research team, if the potential for them is recognized and addressed up front, the actual rroblems that arise sho uld be few . The most consistent problems that arise among research teams are re lated to responsibilities and communication.4 5 Responsibilities for various roles and fun ctions througho ut the study are many. These responsibilities are most effectively carried out when they are clearly communicated up front and when the individuals chosen for va rious jobs are well suited, prepared for the position. and enthusiastic about their role .
Bulldozing Barriers in Clinical Practice Settings Protocol Development: Time Constraints, Writer's Block, and Support
Although the STICK o r FOCUS method can help you cut to the chase in identifying a research question that is interesting and feasible for your specific clinical area, a lot of work remains to be clone to develop the protocol. Protocol development can be a barrier to the progress of the study, particularly for first-time researchers. Common stumbling
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Want to do a Literature Search? Here's How! Click "Start" in the bottom left corner of main menu and choose each of the following selections:
''Programs"
"Netscape"
Enter address into blank address bar: http://www.mc.duke.edu/mcli
Choose "Research"
Choose "Library and Research Resources"
Choose "Ovid"
Choose "Medline"
Select "Generic access"
Select "CINAHL" or "Medline" depending on what your needs are. CINAHL lists nursing and allied health literature only. Figure 4 Performing a literature review.
blocks that make protocol development difficult include inexperience with the process, unfamiliarity with expectations for the written document such as what needs to be included and w here, time constraints for getting it done, and inaccessibility of necessary experts to help with study design or statistical support. Two strategies for addressing these common problems are as follows. First, to find help either with the overall research process or with statistical support, find a mentor or someone to walk through the process with you. This person could be a faculty member, a clinical nurse specialist at your facility with research experience, or a represen-
tative on the institutional review board (IRB) w ho is willing to spend some time going over your protocol or the research process with you. A second suggestion is to obtain a copy of a completed IRB proposal from your facility, most likely one for which the study has been completed, and review the format and requirements applied therein. Concerns with these barriers are legitimate and best addressed individually based on your clinical setting and the possibilities for expert consultation in your regional area. Other sources of assistance that may be able to offer suggestions, resources, or consultative services are professional nursing organizations, hospital administration, or local universities and community colleges. Regardless of the availability of outside resources, an alternative first step is replicating a study or participating as a study site in a nationally coordinated study before attempting one on your own. Replicate a Study
Typically, the review of literature on any topic yields a number of articles that are similar to but not exactly the same as what your team is interested in studying. Replicating the study in a different, or even the same, population of patients is an extremely valuable exercise. Not only does the second study serve to validate the findings of the first, but it also offers opportunity to discover something new or to broaden the study by looking at slightly different variables. The biggest advantage of replication for new researchers is the chance to model a protocol on one that has already been written and "tested." This approach takes some of the anxiety out of getting the details "right" and offers a "failure cushion," because the nurse can often contact the previous investigator by telephone and discuss any problems that presented during the original study. A number of articles have been published about replicating studies, and they represent a helpful place to start before moving forward with the project. 2• 4 Participate as a Study Site If an opportunity to participate in a nationally coordinated study is available, do it. This
RESEARCH STRATEGIES FOR CLIN ICIANS
is an excellent place to learn, and the advantages of working on such a project are many. Sponsored multisite clinical trials such as the American Association of Critical-Care Nurses Thunder Projects have allowed staff the chance to be mentored through the clinical trial experience in a positive and supportive fashion. Because these trials and others like them are designed by experienced nursing researchers, including statisticians and methodology experts, the encl result is a wellconceived trial designed to evaluate clearly defined and measurable outcomes. In addition, at the completion of the trial, the results are analyzed, compiled, and shared by that same group of experts. Commonly, the results and implications for practice are distributed to participation sites in the form of presentation materials and printed text, making it easy to communicate the final outcomes to other staff, the multiclisciplina1y team, and administrative leaders in the organization, thus completing the cycle of research-based practice.
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ishes. Celebrations help to remind the team that progress is being made, and they provide a forum for reflection, discussion, and rejuvenation. The research process has six inherently obvious points at w hich to celebrate: proposal preparation completed, IRB approval obtained, educational in-service training finished and enrollment begun, the "half-way" mark in enrollment reached, data analysis completed, and manuscript submitted for publication (Fig. 5). 5 Although any small success will do, these are points at which the team definitely deserves a pat on the back. Even though it may seem silly or unimportant, small-scale celebrations at the unit level not only motivate the team and publicize research progress but also serve to entice new recruits for current or future studies. Your headline on the announcement flyer might be, "Join us (when and where) for festivities to celebrate the (name) study." Why? "Because these things are fun, and fun is goocl!"12
Logistic Barriers in Data Collection Motivation for the Long Haul
Are you having a good time? Do not let the team be tempted to chicle, "Are we having fun yet?" Instead, ask yourself if you are having enough fun. Research is important and serious work that can be draining for eve1yone. For this reason, keep in mind the important act of celebrating at every opportunity. Every "finish" is a finale and deserves celebration. This includes small accomplishments along the way as well as the big fin-
Proposal Prepared
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The design of data collection procedures is a common barrier that causes many studies to fall short of enrollment goals, yield insignificant or uninterpretable results, and frustrate data collectors (staff nurses) to the point of never wanting to do research again. Data collection can be time-consuming, burdensome in its rigor, and sometimes monotonous. For these reasons, most academic and exte rnally funded studies spend a large percentage of the funding budget to hire designated data Enrollmem: I ( Half-W~ Point
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Finally I Data Celebration Salsa collection is complete. Pass off to the statistician and serve " DataNut Bread" Data-Nut Bread
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Celebrate the chance to publish with a " hats off ! " salsa party.
Figure 5 Steps to success: Opportunities to celebrate. (From Granger B, Chulay M: Research Strategies for Clinicians. New York, Pearson Education, 1999, p 78; with permission.)
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collectors. For staff invested in identifying and generating their own research based on clinical issues in their specific patient population, designing data collection around unit norms is efficient, inexpensive, and creates a positive team experience. 4· 5 When studies incorporate collecting pieces of information that nurses collect anyway, and structure measurement intervals in such a way that staff are not unduly burdened, the data collection process builds peer collegiality, teamwork, and a stronger appreciation for research and the research process. How can data collection be built effectively into unit routine? Some suggestions include
(1) designing time intervals for data collection during the usual assessment and vital sign time periods; (2) planning for patient enrollment to occur during hours of highest staffing and lowest patient care needs; (3) using equipment and materials already available in the patient care area; and ( 4) stocking enrollment instructions, consent forms, and data collection tools in an easily accessible area of the unit. Table 4 offers a summary of these suggestions and some practical examples of how each suggestion might play out in actual practice. If a designated time for focused data collection is necessary for the study, make sure
Table 4 LOGISTIC BARRIERS TO COMPLETION OF DATA COLLECTION Barrier
Example
Unit rou tines Data collection interferes with patient care Collection of data for study purposes does not coincide with time patient care data are normally obtained
Subject's completion of a long research questionnaire during admission would cause hospital staff to wait to assess patient Temperatures for a comparison study of different devices not done when temperatures are needed for patient care purposes Study requires a sample size of 100, but only 6 patients eligible per month Data collectors only available on day shift, but data also need to be collected at night
Patient flow patterns Low volume each month Not available when data collectors available
Communication patterns
Staff do not know when patients are eligible for or subjects in a study
Documentation patterns
Patient needs to sign consent preoperatively, but researchers do not see the patient unti l after surgery Not enough staff to do patient care and data collection at the same time Data collection complex, requiring 1-2 h of time.
Staffing patterns
Possible Solution Consider a shorter version of the questionnaire or change data collection times to occur after clinical care Redesign timing of data collection to coincide with usual activities
Consider broadening the types of patients who would be eligible for the study to include other diagnoses Consider having other units or institutions participate in the study to increase the number of eligible patients Reconsider the feasibility of the study at this time Enlist some of the night shift staff to join the study group Consider discussing on rounds or during the report which patients are likely candidates for which studies on the unit Assign an investigator each day to be responsible for identifying eligible subjects and to alert the staff Place some type of colorful or eye-catching sign or notation in the medical record or at the patient's bedside to alert staff that patient is a participant in a study Enlist some of the staff on the admitting unit to join the study group so they can obtain consent Rethink staffing pattern Redesign and simplify data collection to be done during patient care routines or in brief 10-min segments
Adapted from Granger B, Chulay M: Research Strategies for Clinicians , New York, Pearson Education, 1999, p 115; with permission .
RESEARCH STRATEGIES FOR CLINICIANS
it can be completed in a short time frame (15 to 20 minutes) and that the staff are willing to use the b uddy coverage system to allow nurses to complete research. Much like
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breaks and lunch time, the buddy system is an excellent way to accomplish important research, particularly when staff are invested in the project and its outcome.
SUMMARY If there is a story waiting to be told about nurses and research, it is this: research is part of our past, our present, and our future. Research gives "caring" a mental muscle that makes it stronger than caring would be without it. Since the Crimean War, research has been a foundational cornerstone of the profession. 9 Florence Nightingale espoused caring and human touch but not without also observing and measuring important patient outcomes that identified the spread of infection via human contact. As a new generation of nurses emerges, we who have come before might serve them well to role model what we know: that strong research is strong nursing and that obtaining and using evidence in nursing practice results in better outcomes for those patients and families we serve. Is the story waiting to be told your st01y? Part of the story of nursing waiting to be told is your story. Regardless of why you embarked on your career in nursing and regardless of where your journey has taken you to this point, you are a part of the twenty-first century body of nursing, and your individual contribution is an important one. Listen to your patients with an ear toward measuring and evaluating outcomes. Reflect on the care you provided, the interventions you had to offer, and why. Should something have been different? Could something have been better? Find out ... measure it.
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Can 't Stand: How to Bring Out the Best in People at The ir Wo rst. New York , McGraw-Hill , 1994 Connelly C: Re plicating researc h in nursing. Int J Nurs Stud 23:71-77, 1986 Deets C: Whe n is e nough , e no ugh? .J Pro f Nurs 14:196, 1998 Fullwood J, G ra nge r B, Bride W, et al: Heart cente r nursing research: A team effort. Prog Cardiovasc Nurs 14:25- 29, 1999 Granger BB , Chu lay M: Research Strategies for Clinicians. Stamford , NY, Apple ton & Lange, 1999 Larson C, LeFasto F: Tea m Work: What Must Go Right , \X'ha t Can Go Wrong. Newbury Park, CA, Sage, 1989 Nelson B: 100 1 Ways to Energize Employees. New York, Wo rkman Publishing, 1998
8. Nelson E, Splaine M, Batald en P, et al: Building measureme nt and data collectio n into medica l practice. Ann Inte rn Med 128:460- 466, 1998 9. Nightingale F: Notes o n Nursing: What It ls and What It ls Not. Lo ndo n, Harrison a nd Sons, 1859 10. Sacke tt D: Ev ide nce-Based Medicine : How to Pra ctice and Teach Evid ence-Based Medicine . Lond on , Pearson Professio nal Limited , 1997 11. Sche re r A: Des igning Critical Pathways . Aliso Viejo, CA, Am e rica n Assoc iation of Critica l Care Nurses, 1997 12. Dr Seuss: One Fish, Two Fish. Bosto n, Ho ughto n Mifflin , 1957 13. White S, Bartrug B, Bride W: Suppo rting nursing inte rve ntio ns in a cost-conscious e n vironment. Crit Care Nurs Clin North Am 7: 399-406, 1995 14. Wojne r A: O utcomes manage ment: From theory to pract ice. Critica l Ca re Nursing Q uarterly 19:1- 15, 1997
Address reprint requesls lo Bracli B. Granger, MSN, RN 80 20 Willardville Statio n Road Bahama , NC 27503 e-ma il: Grang004@ rnc. duke .ed u