Beyond Innovation: Research in Practice

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Beyond Innovation Research in Practice

• Pat Quigley, Ph.D., ARNP, CRRN
• Deputy Director, VISN 8 Patient Safety Center
  Chair, Nursing Research Committee, JAHVAMC

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Purpose

• To stimulate and enhance your interest in nursing
  research.

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Objectives

• Reflect on at least two historical milestones of
  nursing research.
• Associate at least two myths with your
  perceptions.
• Illustrate at least three examples of Research at
  the Point of Care.
• Examine Professional Nurses Responsibility
  related to Research by level of expertise.

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Travel Back Into History

• Florence Nightingale
• (1820-1910)

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Objective 1.

• Reflect on at least two historical milestones of
  nursing research.

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History of Nursing

• Florence Nightingale - 1950s
• Miss Nightingale - 1st Statistician
• Published Notes on Nursing (1859)
• First School of Nursing
• the Nightingale Training School for Nursing

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American Nurses Association (1896)Sigma Theta
Tau (1922)Storga - LoveTharos - CourageTima -
Honor
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Milestones Birth of Theory 1950s-1960s

• ANA - First Position Paper on Nursing Research
  Need for Research- Based Practice
• Southern Research Board
• Columbia Teachers College collective effort to
  have theory
• Nursing Research (1952)

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Hildegard Peplau (1956)

• Theory on Nursing
• patient nurse
• patient environment

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Theory Development 1960s-1970s

• National Goal Theory Development
• Concept gtgtgtTheory
• Orlando, Henderson
• Levine, Roy, King
• Rogers, Orem, Neuman

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Theory Syntax1970-1975

• Nursing Process was defined
• Goal to have Nursing Diagnosis
• Move to Scientific Basis for Nursing
• Nursing Theorists Conceptual Models

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Time of Reflection 1975-1980

• Nurses Critiqued Nursing Theory
• Research Quantitative Surveys- Minimize
  Complications, Some experimental designs
• 1975-College of Nursing - USF
• 1978 - Graduate College of Nursing - USF

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Theory Revival 1980-1985

• Western Journal of Nursing
• Advances in Nursing Science
• Image
• Nursing and Health Care
• Evolution of research in union with evolution of
  theory

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The last Decade EBP

• Evidence based Practice
• Concept from medicine
• Wide variations in practice clinical focus
• Resources for EBP
• Cochrane Collaboration
• Agency for Healthcare Research and Quality
  http//www.ahrq.gov/
• Centre for Evidence-Based Nursing
  http//www.evidencebasednursing.com/

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Critical Factors for EBN

• Sufficient research on a specific topic
• Skill in accessing and critically analyzing
  research
• Nurses area of practice must allow her/him to
  implement changes based on the evidence
• (University of Minnesota Evidence-Based Health
  Care Project, 2002)

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Research

• Explanatory gtgtgt Descriptive
• Nursing Conferences to articulate theory Goal
  for theory to be a part of practice
• Michigan Nurses Association (1983) CURN Project
• Nursing Research Committees
• Participant Research
• Other Research Designs?

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Models for Research

• Research in Practice

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The PDSA Cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who,
• what, where, when)

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Hunches Theories Ideas
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Overall Aim Decrease Falls Rate by 40 in 7
months
Staff and Patient Education
Develop Envron.- mental Assess.
Develop specific interventions for fallers
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Tips for Successful Tests of Change

• Stay a cycle ahead.
• Scale down the scope of tests.
• Pick willing volunteers.
• Pick changes that dont require a lengthy
  approval process.
• Dont reinvent the wheel.

• Pick easy changes to try.
• Avoid technical slowdowns.
• Reflect on the results of every change.
• Be prepared to end a test of change.

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Accident Theory
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Schematic of Case-Crossover Design for Studying
Falls
X
Control Day
Case Day
Control Day

Control Day
Fall Day
-7 -6 -5 -4
-3 -2 -1
Days Before Fall Day
Adapted from Mittleman et al. 1995
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2 X 2 Table
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Relative Risks
RR
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Diagnostic Measures
Sensitivity (a/ac) (proportion of those who fall
and identified at risk by test) Specificity
(d/bd) (proportion of those who are free of fall
and identified not at risk by test) PPV
(proportion of those with risk who fall) NPV
(proportion of those with no risk who are free of
fall) Odd Ratio a/b ad
c/d bc
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Objective 2.

• Associate at least two myths with your
  perceptions.

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Reality Testing Myth Vs. Reality

• Research is part of our history?
• We live in a world of misperceptions and
  mechanical malfunctioning?
• We examine IMBALANCES?
• Only nurses can conduct nursing research?

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More Myths?

• We know what we are doing and why?
• Our future is plentiful?
• You will have time for research?

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Reality Nursing Makes a Difference

• Quality
• Outcome
• Cost

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Objective 3.

• Illustrate at least three examples of Research at
  the Point of Care.

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Wheelchair-Related Falls

• Current Fall-Risk Assessment tools not effective
• Features of Wheelchairs contribute to risk
• Most common site of injury is NOT hip, but rather
  fractures of extremities

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Research Agenda

• Falls
• Safe Patient Handling and Movement
• Patient Outcomes
• RN Satisfaction
• Restraint Reduction

• Research Teams
• RD
• IRB
• HSRD
• RRD

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Nursing Rituals

• What are your rituals?
• Vital Signs
• Toileting Patterns
• Discharge Preparation
• Ask Why?

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Objective 4.

• Examine Professional Nurses Responsibility
  related to Research by level of expertise

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ANA Standards of Professional Performance

• Basis for VA Qualification Standards
• Appointment
• Position statements
• Performance appraisal
• 9 Dimensions of practice

• Practice
• Quality of care
• Performance
• Education/career development
• Collegiality
• Ethics
• Collaboration
• Research
• Resource Utilization

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Benners Model of Patient Care
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Bruner (1986) Learner Model Novice to Expert

• Premise It begins with the premise that if you
  want to find out about learning, ask first about
  what is to be learned, find an expert who does it
  well, and then look for at the novice and figure
  out how he or she can get here Bruner, 1986, p.
  199.
• Bruner, J. (1986). Models of the learner. Educ
  Horizons, 64(4). 197-200.

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Organizational Structures

• Role of Nursing Research in QI
• Role of Nursing Research Committees
• Role of Nursing Research in Shared Governance
  Models

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S H A R E D G O V E R N A N C E
Quality Council
Practice Council
M O D E L
Unit Based Councils
Advocacy Council
Professional Development Council
Coordinating Council
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Strategies to Build Research Capacity

• Involvement
• Budget
• Time
• Nurse Researchers
• Unilateral Assignments
• Vision and Mission

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Reality Who Resists Change?

• All of us!
• Change is not easy
• Who effects change?
• What is planned change?

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Reality

• Practice must be evidenced-based
• Nurses must operate from a body of knowledge
• Nurses must collect reliable data
• Nurses must base decisions on sound data

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Together WE make a Difference

• Process Outcomes
• Structure Outcomes
• Clinical Outcomes

• Report Cards/Dash Boards
• Shared Performance - Success and Near Success

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Our Future is Our Present

• Research Teams
• Research Programs
• Centers for Nursing Research
• Disseminate Findings

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References, plus

• Fawcett, J. (2000). Analysis and evaluation of
  contemporary nursing knowledge Nursing models
  and theories. Philadelphia F.A. Davis.
• www.ualberta.ca/jrnorris/nt/theory.html
• Chinn, P.L., Kramer, M.K. (1999). Theory and
  nursing Integrated knowledge development. (5th
  ed). St. Louis Mosby.
• Barnum, B.S. (1998). Nursing theory Analysis,
  application, evaluation. (5th ed.).
  Philadelphia J.B. Lippincott.