Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Abstract

Nurse engagement in clinical inquiry is a key component of shared governance,1,2 professional development,3 and Magnet redesignation.4 Recent literature highlights the benefits of participation in clinical inquiry as fostering nurses’ leadership skills, autonomy, and decision-making skills, which in turn improve professional practice environments and patient care outcomes.5 At the same time, registered nurses (RNs) reportedly have low preparedness, knowledge, skills, and competence to undertake research and quality improvement (QI).6 In addition, the availability of nurse scientists to support RN research and QI project teams is limited; across the United States, less than 15% of hospitals employ nurse scientists who have dedicated time to support RN research teams.7,8 As a result, at the outset of clinical inquiry initiatives, nurses face a number of concerns and obstacles—not least of which is project design.An ongoing challenge for clinical inquiry in health system settings is the limited generalizability of the type of studies we do most often: single-site studies with relatively small convenience samples, observational designs, and a short follow-up duration that often evaluate educational programs or QI interventions throughout only a single cycle. Such studies are invaluable for establishing the baseline or “current state” of a high-priority problem and are often necessary for validating and characterizing the extent of a clinical problem in a local practice setting. When conducted in isolation, however, these designs fall short of the rigor required to advance the science of nursing in a statistically meaningful or substantive way.Nurse turnover contributes to the gap in robust design of clinical inquiry projects. Despite orientation and residency programs, new nurses practice at a novice level rather than an expert one,9 and they are less likely than experienced nurses to consider more complex or nuanced solutions for changes or improvements to care delivery processes. With increasing numbers of new nurses on local clinical inquiry teams, nurse turnover can contribute to a loss of continuity on unit-based research teams and may substantially affect the impact that could be made by designing longer follow-up timelines and including measures for sustainability at 12 and 24 months.Study designs for single sites—be they unit-level or hospital-level projects—can be limiting; however, nonrandomized, quasiexperimental designs and evaluations of educational programs or process improvement interventions should not be undervalued. These studies can be leveraged as building blocks that contribute to a larger research program with the power to contribute meaningful new knowledge that will advance nursing science. The purpose of this column is to describe one approach to designing site-based clinical inquiry that meaningfully advances nursing science, despite limitations of nurse staffing, time, and resources.Organizations undertake much health system science with an eye toward Magnet accreditation.3 This goal has served the nursing community well, as it sets a high standard for engagement in evidence-based practice and the development of new knowledge that improves care delivery and patient outcomes. Despite this high bar, current site-based research and QI topics are frequently generated and prioritized by using a process that may be short-sighted. Historical prioritization of clinical inquiry questions has been based on high-priority, high-value, unit-centric project ideas (Figure 1).10,11 These criteria, though necessary, may be insufficient for longer-term aims and end points that are nested within a bigger picture of patient experience; access to, equity of, and quality of care; and clinical outcomes. In other words, the use of historical criteria to prioritize clinical problems may inadvertently neglect the broader research agenda, which includes driving sustainable change for patient problems and improving care, care delivery, and care outcomes over time.The standard prioritization approach for generating QI and research at a single hospital or within one clinical unit can be used to generate clinical inquiry topics that reflect staff “favorites.” These preferences may, however, be prioritized without thorough consideration of work already done in the area. The priorities may be outdated, limited, and unable to serve as a foundation for a larger program of inquiry that can ultimately fill a gap; advancing nursing science beyond small, single-site studies to larger, more generalizable bodies of science can ultimately change the ways we as nurses practice and the outcomes and experiences of the patients for whom we care. In the end, if the scope of a given project is too big or the timeline too long, RNs’ interests or the tenure of the RNs themselves on the unit may have too short a half-life to generate meaningful science.One approach to shifting the clinical inquiry mindset is to consider building research and QI programs at the unit and patient population levels. Advantages of this approach are based on 3 key factors: improved patient outcomes and care delivery processes; improved quality and quantity of the nursing science being generated; and improved nurse learning related to methods and the variety of methods available for use. In addition, improved breadth and depth of clinical inquiry supports institutional efforts to attain or retain Magnet accreditation.4Designing clinical inquiry programs by using a prioritization pyramid approach is less about existing levels of evidence and more about examining and generating variety and breadth in the types of evidence that are available to support a given clinical problem. The pyramid can be used as a map that facilitates movement beyond project prioritization—based largely on nurse preferences and stand-alone, short-term study designs (Figure 1)—toward broader consideration of an array of smaller studies with varying designs that can serve as scaffolding for larger, more challenging clinical questions that could have far greater impact for patients (Figure 2).Building meaningful nursing science programs begins with reframing priorities at the nurse, unit, and health system levels, as we mentioned in the previous section. As outlined in Figure 2, in the first tier (tier 1), questions for the team to address are related to a review of the existing literature about the problem. Beyond simply evaluating how much literature exists and what level of evidence that literature represents,12 the pyramid approach also seeks to determine what is known about the periphery of the problem (eg, the cultural context, stakeholder views, costs). To evaluate the scope of a problem by using the pyramid approach is to undertake an analysis of the breadth and depth of existing science that not only assesses causal evidence but also critically evaluates the evidence behind key associations or contributing factors. Questions might include, What study designs are represented? Are the various designs adequate for the scope of the problem? What opportunities or methodological changes should be considered in order for new studies to address identified gaps?In tier 2, questions for the team to consider focus on the problem as it presents at the local level. The team should create a site-specific measurement table to clearly define each measure, the data element, data source, and data abstractionist (ie, who will collect each data element or measure). In addition, teams must consider eligibility criteria and the volume of patients, staff, and resources available. Specifying details of the problem and a proposed solution or intervention at the local level helps ensure that the team can complete each individual project proposed within the larger pyramid.In this same vein, determining the team’s bandwidth is critical to thinking through project prioritization. While developing the program, the team must identify the time and resources available to nursing staff, advanced practice providers, or clinical nurse specialist leaders, as these factors determine whether the individual projects or studies within a pyramid can take place in parallel (in the case of many units, team leaders, and mentors) or in sequence (in the case of only a few, or a single unit of, participants and mentors).Tier 3 addresses how to create a “map” or study pyramid blueprint (Figure 2). These questions facilitate thinking about the broad problem, gaps in existing evidence, and how your team might make a meaningful contribution to the existing science. In this context, a “meaningful contribution” refers to designing and executing studies that have equitable and unbiased sampling strategies, clearly defined objective and subjective measures, and appropriate durations of intervention and follow-up, and that are adequately powered to show any improvement or statistically significant difference in outcome. These principles are achievable even through small, single-site projects. The key to success is taking time to design a scientifically sound and logistically solid project and then to map how the next study will build on that foundation.Let’s use 2 examples to apply the stacking principle of these 3 tiers of considerations to design a clinical inquiry pyramid. The first example is a single-unit “program” of clinical inquiry that builds on a nurse-identified problem: the patient experience of pain and discomfort during cardiac catheterization. The second example is a program of clinical inquiry at the hospital or health system level to address the issue of preventing central line–associated bloodstream infection (CLABSI). Each example approaches the pyramid building from a different point, depending on the level of evidence available and the understanding of the problem at the local level.The patient experience during cardiac catheterization is a broad problem that is influenced by several unique factors and can be addressed through many avenues. Patients undergoing cardiac catheterization experience anxiety related to the unfamiliar hospital environment, unknown health outcomes, and anticipated pain and discomfort during the procedure. In the United States, procedural sedation is commonly used to help alleviate this discomfort and anxiety and to promote safe, effective completion of the procedure. Guidelines for sedation focus on preventing adverse hemodynamic and respiratory effects, but they do not address more patient-centric outcomes such as patients’ experience or comfort during, or satisfaction with, cardiac catheterization. In the absence of evidence-based guidelines, procedural sedation agents and approaches to timing of sedation are often dependent on the provider, and practices vary across institutions.With a paucity of data describing the patient experience, our primary research question was to explore and characterize patient- and procedure-specific factors associated with the patient experience during cardiac catheterization. In addition, we examined the influence of physician-ordered, nurse-administered sedation and whether the timing of initial administration was related to patient satisfaction, pain/discomfort, and repeat sedation administration. We conducted a retrospective, exploratory analysis of procedural pain/discomfort and overall satisfaction among adults undergoing outpatient cardiac catheterization.13The primary finding of the study was that patient-reported indicators of pain and the overall experience were not different before versus after the procedure, regardless of the wide variability of intraprocedural factors. Most notably, results indicated that a longer time interval between initial sedative administration and procedure start time was associated with a lower frequency of subsequent doses of procedural sedatives.13 Further evaluation of the problem through descriptive qualitative interviews of nursing staff confirmed that patients grimaced during the procedure, refuting the idea that adequate comfort measures are applied. These findings suggested the need to better characterize periprocedural sedation administration practices and interrater reliability of observational pain assessment in order to optimize the patient experience during cardiac catheterization (Mall et al, unpublished data, 2022).To develop the research question further, the team approached the next step in the clinical inquiry pyramid using a prospective, randomized controlled study to compare total sedative dosage, patient-reported and nurse-observed pain, and patient satisfaction across 2 time intervals. Previous work on interrater reliability was incorporated into the randomized controlled trial as the nurse-observed measure of pain. The primary outcomes showed no statistically different findings between time intervals, adding new knowledge to the literature and demonstrating that varying time intervals for sedation administration does not improve the patient experience (Mall et al, unpublished data, 2022).Again, however, a secondary analysis generated a hypothesis. Our inquiry pyramid expanded, and we are designing a new level of randomized controlled trial that will explore the impact of interventional procedure type and associated pain and discomfort during cardiac catheterization. Use of tier 3 considerations in mapping our clinical inquiry pyramid has allowed the team to build rigorous yet feasible studies that add incremental new knowledge to our understanding of the patient experience in our clinical area (Figure 3).Central line–associated bloodstream infections are a major preventable harm that the health care system seeks to avoid. Many evidence-based practices help prevent CLABSIs; one effective intervention is daily bathing with chlorhexidine gluconate (CHG) cloths. Upon retrospective chart reviews and audits, however, and after discussion with nursing staff, the clinical nurse specialist–led infection prevention team identified low compliance with CHG bathing. This poor compliance was contributing to high CLABSI rates in our large tertiary care health system. In what follows we outline how studies of CHG bathing helped inform one another, creating a wider evidence base about how to improve CHG bathing compliance.In 2016, our team conducted a small pilot study in the neuro–intensive care unit in order to examine the effects of strategies for implementing audit and feedback and educational outreach visits about CHG bathing compliance. Secondary outcomes included nursing knowledge and perceptions of CHG bathing and CLABSI rates. This study found statistically significant improvements in CHG bathing compliance, nurses’ knowledge and perceptions of CHG bathing, and CLABSI rates after the interventions.14Building on that pilot study, in 2019 in 2019 our team conducted a large cluster randomized stepped wedge implementation science study that was implemented among 14 units across 2 health care systems. The same implementation strategies of audit and feedback and educational outreach were used within the program. The main outcomes measured were CHG bathing documentation and process compliance. Secondary outcomes included nurses’ knowledge and perceptions of CHG bathing and CLABSI rates. The study found statistically significant improvements in CHG bathing process compliance and lower CLABSI rates during the 12 months after the interventions.15During the follow-up of the large cluster randomized stepped wedge study, we also conducted focus groups with infection prevention champions and with nurse leaders (who were also involved in the larger implementation science study) to better understand the strengths and weaknesses of the implementation science study and the evidence-based CHG bathing practice itself. Overall, unit-based infection prevention champions believed that the implementation strategies of audit and feedback and educational outreach were beneficial, and they identified barriers to and facilitators of using CHG for daily bathing, which helps inform sustainability efforts.16 This study indicated that being a part of the larger implementation science study allowed nurse leaders, including frontline leaders, to promote evidence-based practices,17 influence others, and grow in their professional roles.The larger implementation science study also showed us that it would be beneficial to conduct focus groups with patients in order to better understand barriers and facilitators from their perspectives. As such, in 2020, we conducted a focus group study with patients; we identified gaps in nursing care related to lack of assistance with completing CHG baths and inadequate patient education regarding the importance of CHG bathing.18 This information will be used for sustainability efforts at the unit level.In the first 2 studies, the main purpose was to improve compliance with CHG bathing. By partnering with a statistician and using data obtained from the larger implementation science study, we were able to complete a secondary analysis regarding how to best capture compliance data. In the study, data regarding CHG bathing process compliance were obtained through both direct observations and self-report. We conducted an analysis to determine whether significant differences existed between these 2 approaches. We found none, which indicates that self-report—through which data are much easier to obtain than with direct observation—may be a more realistic way to capture CHG bathing compliance data.19 We completed another secondary analysis to understand better how the context and culture of the unit affects the uptake of evidence-based practices.20Following the larger implementation science study and considering new published evidence, we used similar implementation strategies to implement CHG bathing in non-ICU areas for patients with a central catheter, with the goal of reducing CLABSI rates. That quality improvement study found that CLABSI rates were reduced as a result of this intervention.21As shown through these examples, each study built on the previous one and helped to inform the next study’s research questions. Building this type of clinical inquiry “pyramid” can have a wide impact on clinical practice and QI.How future clinical inquiry projects will contribute to changes in practice and clinical practice guidelines remains to be seen. Here we describe 3 opportunities to build better science by using prioritization pyramids. Implications for investigators in clinical practice settings include (1) extending historical “research prioritization criteria” to include additional, secondary research questions, which can broaden knowledge and understanding of the peripheral components of high-priority clinical problems; (2) creating a map for unit- or hospital-based research teams by using a “clinical inquiry pyramid” approach, which allows each new study to build on the one before it and to set the stage for the studies to follow; and (3) considering the broad clinical problem in the context of professional nursing organizations’ existing research priorities in order to provide continuity for unit-based study initiatives over time.In addition, realistic considerations and implications for the practice setting must anticipate and adjust for fluctuations in nursing resources, instability in the workforce, and varying access to research mentors. Nurse scientist mentors in practice settings are often pulled into educational programming, regulatory responsibilities, and a host of other, more centralized roles that detract from their ability to provide direct, one-on-one mentoring.22 How do these dynamics affect the quality of new knowledge being produced—not only for Magnet designation or redesignation but also, and more importantly, for patients? As professional nurses, how will we “advance the science” with fewer expert BSN-prepared nurses and fewer resources to support science in the clinical setting? Newer nurses practicing and fewer nurse scientists being readily available in clinical practice settings may deleteriously affect an organization’s Magnet preparedness and the evolving state of the science.6 A building-block approach to planning project development and study design provided stability in the incremental development of the CLABSI clinical inquiry pyramid (Figure 4).“Advancing the science” is defined by generating not only studies with increasing rigor and causal design but also a body of evidence that explores and explicates the wide realm of factors contributing to a given problem. Historical criteria for prioritizing clinical inquiry topics may be limited and unable to serve as a foundation for a larger program of inquiry. Designing a clinical inquiry pyramid may help advance nursing science beyond small, single-site studies to larger, more generalizable bodies of science that can change the way we practice and the outcomes and experiences of the patients for whom we care.