The Clinical Nurse Specialist and the Research Process

]OMS C L I N I C A L I S S U E S The Clinical Nurse Specialist and the Research Process Debbie Fraser Askin, RNC, MN, Kim Bennett, RN, MN, Carla Shapiro, RN, MN With the growing emphasis on clinically based research as the foundation for nursing practice, the clinical nurse specialist (CNS) is in an ideal position to identify problems within the clinical arena and use research methods to support and advance practice. In the case of the Transition of the Preterm Infant to an Open Crib project sponsored by the Association of Women s Health, Obstetric, and Neonatal Nurses (AWHONN), CNSs served as site coordinators at most of the 10 implementation sites. The educational background of the CNS, combined with a grounding in clinical experience, was ideal for this role. This article discusses the role of the CNS in the implementation of a research utilization project using two case studies as examples. R esearch utilization provides a unique opportunity or clinicians to become involved in the research process. Although research clearly is within the job description of most clinical nurse specialists (CNSs), the way in which this aspect of the job is woven into the fabric of day-to-day clinical activities varies. The role of the CNS has evolved during the past 2 decades in response to a burgeoning nursing knowledge base, greater complexity of patient care associated with an increased use of technology, and growing consumer demand for comprehensive health care. The nursing profession has responded to these forces and the need for more sophisticated practitioners through the development of specialists. Defining Characteristics of the CNS Role The American Nurses Association (ANA) has defined the CNS as a registered nurse who through study and supervised practice at the graduate level (master s or doctorate), has become expert in a defined area of knowledge and practice in a selected clinical area of nursing (ANA, 1980, p. 23). Similarly, the Canadian Nurses Association (1988) has stated that a CNS is a registered nurse with nursing education at the graduate level who has expertise in a clinical specialty. Within this broad definition of the CNS, four major subroles have been identified: expert practitioner, educator, researcher, and consultant. Other skills or competencies that the CNS uses in implementing these subroles are change agent, collaborator, clinical leader, role model, and patient advocate (Hamric & Spross, 1989). Regardless of the setting in which a CNS works, the focus of practice is on the patient, client, or family and the provision of quality nursing care. Involvement in research is generally accepted as one of the major components of the clinical nurse specialist (CNS) role and, indeed, is mandated by our major national professional organization [ANA] (McGuire & Harwood, 1989, p. 169). With the growing emphasis on clinically based research as the foundation for nursing practice, the CNS is in an ideal position to identify problems within the clinical arena and use research methods to support and advance practice. In the case of the Transition of the Preterm Infant to an Open Crib project sponsored by the Association of Women s Health, Obstetric, and Neonatal Nurses (AWHONN), the site coordinators for project implementation were expected to be prepared at the masters level and in most cases were CNSs. The education background of the CNS, combined with a grounding in clinical experience, was ideal for this role. At the meeting of the site coordinators and the research team, modifications were made to the protocol and the data collection forms based on the advice of the CNSs with regard to what was clinically practical. Implementation of the project was facilitated by the CNSs knowledge of the clinical area and the staff in that area. Problems could be anticipated and dealt with before they interfered with the implementation of the project. Depending upon an individual CNS s interests, Values, time constraints, and abilities, participation in research and research utilization can be performed at different levels (McGuire & Harwood, 1989). At the most basic level, a CNS can serve as a communicator of nurs- 336 J O G N N Volume 23, Number 4

The Clinical Nurse Specialist and the Research Process ing research (Hodgman, 1983). This can be achieved by keeping abreast of and evaluating the current research literature and facilitating the application of empirical knowledge into practice. The second level of research involvement for the CNS involves participation in clinical nursing research. This might take the form of replication of others research, participation in a collaborative study, or investigating the quality of nursing practice within the clinical setting. This level of involvement requires a higher level of skill and time commitment to the research aspect of the CNS role. The third (and most advanced) level of research entails the conduct of original research: developing the research question and design, implementation, and analysis. This level of research often is performed by individuals who are prepared at the doctoral level, although this is not always the case. The AWHONN research utilization project Transition of the Preterm Infant to an Open Crib falls into the realm of 2nd-level research involvement. In this collaborative study, the development of the research-based protocol, overall design, data analysis, and dissemination of the findings were performed by a group of doctorally prepared nursing research experts. CNS coordinators at the 10 sites were responsible for implementation of the protocol and for data collection, In summary, participation in the research process on some level is one of the essential components of the CNS role. One means of achieving the goal of using research to support and advance nursing practice is through participation in collaborative research-utilization projects at multiple sites. Professional specialty associations with large memberships, such as AWHONN, are in an ideal position to foster this goal Research Utilization as a Goal for Practice: Incorporating Research Findings into Practice The amount of clinically based nursing research being conducted is mushrooming as the nursing profession strives to generate an independent body of knowledge. Although knowledge is being generated, there is a gap between production and application (Keefe, 1993). What is research utilization and how does it differ from research conduct? Research utilization is the transferring of specific research-based knowledge into our practice (Briones & Bruya, 1990, p. 78). The CNS is in an ideal position to serve as a change agent by facilitating the transfer of existing nursing knowledge from research into daily practice in the clinical setting. The jump from reading and evaluating a research report to putting the findings into practice is not to be taken lightly. A great deal of effort is required in meeting this objective. Before changing practice, one must have confidence in the new approach. Bedside nurses, who have grown comfortable in providing care in a particular way often are hesitant to alter practice unless they are thor- oughly convinced that a change is for the better. One way to ensure reliability and verify findings is through multicenter trials in which a research-utilization project can be implemented at several locations. The utilization of research in practice continues to be a major nursing goal in the 1990s (Lindquist, Brauer, Lekander, e31 Foster, 1990, p. 342). The formation of nursing research planning committees that develop practicebased, research-utilization projects to be performed at multiple sites, as was the case with this project, helps CNSs in meeting this goal. The following case studies describe two of the institutions that participated in the AWHONN multicenter crib study. The case studies serve to illustrate the practical issues involved in incorporating research participation and utilization into the CNS role. Case Studies Site A is a tertiary care teaching hospital in central Canada with 10 neonatal intensive-care unit (NICU) beds, 16 intermediate care beds, and 8 convalescent beds. This hospital has a delivery rate of 4,300 births per year, 45% of which are high risk. Another 30-50 neonates are transported to the facility annually. Site B is an acute care community hospital. Its services include a 12-bed designated Level I1 NICU with two staff neonatologists. This unit admits approximately 250-300 neonates per year. Getting Started When contemplating involvement in research or research utilization, it is helpful to consider several questions to determine the level and type of commitment that is feasible within a particular department and the limits of ones job description. These questions are: 1. Is there support for research within the institution and the nursing department? 2. Does the project meet a need within the CNS clinical area? 3. Is there time available for the CNS to participate in the project? With respect to the commitment to research, if the conduct of nursing research is not part of the mandate of nursing administration within the institution, the first task may be to convince nursing leadership of the potential value of this process for nursing staff, patients, and the institution. Within the department of maternal/child nursing at Site A, there was and remains a strong commitment to clinically based nursing research, the development of standards of practice, and the provision of quality nursing care. This research-utilization project was seen as valuable because it allowed staff nurses in the department to actively participate in nursing research and play a role in the development of standards of practice. The project also received the support of the staff neonatologists. Similarly, at Site B, research is a critical component May 1994 J O G N N 337

C L I N I C A L I S S U E S of the nurse s professional responsibility. This institution s Department of Nursing expects staff nurses to become involved in research in some capacity. Nurses are evaluated and promoted in a clinical ladder system that incorporates research as one of the criteria for evaluation. This project received strong support from nursing and neonatology. The second question focuses on whether or not the proposed study meets a need within the CNS s clinical area. At site A, the NICU/intermediate care nursery had no formal written protocol for the procedure of transferring infants from isolettes to cribs. Thus, this multisite project provided an opportunity to develop a researchbased protocol that it was hoped would result in standardized quality care throughout the department of maternal/child nursing. Traditionally, premature neonates were transferred from isolettes to open cribs when they reached a weight of approximately 2,000 g. This move was generally ordered by a physician, rather than left to the discretion of the nursing staff caring for the neonate. With the move toward earlier hospital discharge and increased individualization of care based on the physiologic maturity and wellness of each infant, the weight of 2,000 g for transfer to a crib needed to be evaluated in a formal way. Before the crib project, transferring neonates from heated isolettes to open cribs at Site B was based upon a physician s order. The order was based on the medical condition and weight of the infant but was not consistent from infant to infant. This process did not consider how to dress the infant or how many blankets to use. Little consideration was given to environmental factors that could affect the success of the transfer. The third, and most pragmatic question to be considered with respect to the multiplicity of the CNS role is availability of time. At Site A, two part-time CNSs shared the role of site coordinator. This division of labor ensured that one or the other CNS was available to speak with parents, troubleshoot equipment problems, and assist the staff in carrying out the study protocol. A large amount of time was spent in the setup phase for the study. This time was spent on meetings and information sharing with staff and administration. Once the study was under way, days in which there were infants in the study required 20-45 minutes of time for obtaining consents, troubleshooting, and assisting the staff. Data collection required approximately 30 minutes per infant. At Site B, the CNS was expected to facilitate and implement research. This individual was viewed as a resource for staff nurses and an educator for the research process. The role of site coordinator for this project initially involved obtaining approval from the hospital and the appropriate department leaders and educating staff nurses, parents, and physicians about the project. After the project was under way, the CNS was responsible for ensuring that there was a basic understanding of the protocol in the unit, troubleshooting problems, and checking data collection. The CNS spent 1-2 hours each day working with staff in the unit, and 1 hour per infant was spent in reviewing data collection. Practical Matters of the Project Before subject enrollment and data collection could begin at Site A, ethical approval and access to patients were required. To obtain these, consent forms and explanatory letters for parents were developed by the CNS and approved by the hospital ethics committee and the director of nursing research. The consent forms stressed that participation in this project was voluntary, that withdrawal from participation could occur at any time with no negative effect on patient care, and that confidentiality would be maintained. Approval of the research protocol and the consent forms were received from the director of nursing research and vice president of nursing. Not all hospitals require ethical approval for utilization projects because changes in nursing practice generally are not under the aegis of these review boards. At Site B, the next step was to present the protocol to the clinical investigations committee. This group oversees any clinical research project implemented at the institution. The committee chairperson concluded that the protocol was based on current research findings and would not change accepted standards of care. Thus, the protocol did not have to be approved by this committee. This represents one of the differences in the process at Site A and B; one site required formal consents from parents, and the other did not. Obtaining consents in some ways formalized other aspects of the project because implementation could not proceed until the project had been discussed with parents. Three families at Site A declined to participate in the project. Research involves change, and change is never easy. At both sites, the protocol for this research study represented a marked departure from normal practice in the nurseries and also involved some extra work on the part of the staff nurses. An assumption was made that the more informed those involved were, the more likely they would be to identify infants who were appropriate for enrollment, talk to parents, and be willing participants in the process. To engage the staff and facilitate the implementation of the project, the following actions were undertaken at Site A: formal staff orientation to the project occurred primarily in small group sessions with some one-on-one discussions; letters of information were sent to all attending pediatricians and family physicians with admitting privileges to the nurseries informing them of the project, its purpose, and protocol; and meetings were held with head nurses and educators in the areas involved to solicit their support. At Site A, infants eligible to participate in the crib project were located in three different nurseries with three different staffs and head nurses. This made consistency and sharing of information challenging. A decision tree poster was developed that outlined the study protocol, and a fact sheet for nurses also was developed that listed and answered common questions, such as: 338 JOG Volume 23. Number 4

The Clinical Nurse Specialist and the Research Process How will this project benefit nurses? How will I know that my patient is enrolled? How will I know what to do when my patient is enrolled? As a staff nurse, what will my role in this project be? The poster and fact sheet were made available in each nursery. In addition, bedside cards were used to assist the staff to track the infant s progress in the project. Responsibilities for staff nurses at this site included initiating transfer of infants to cribs when study criteria were met and recording weight, skin temperature, and environmental temperatures on unit flow sheets. At site B, staff orientation to the project occurred on a one-to-one basis and in small group sessions until all 30 staff members had been oriented. At this time, the protocol and data collection sheets were reviewed and questions answered. Staff responsibilities were established and included identifying infants for participation in the study, transferring of infants to cribs, and data collection. Parental orientation began at the time an infant was being prepared for transition to an open crib. Advantages and Problems At Site A, there was a great deal of support for this project from the staff nurses. Although they were not expected to obtain consent from parents, many did. Sometimes there was such enthusiasm for the new protocol that infants were weaned from their isolettes before they met the criteria of 5 days of weight gain. Some nurses did not enroll infants in the study unless the charge nurse or CNS identified the infant as meeting the study criteria. For others, disagreement with the premise of the study resulted in some reluctance in moving infants into cribs, even when the infants met all of the criteria. Other problems intrinsic to the project occurred as a result of the protocol design. Many infants were in incubators with temperatures of less than 28 C for several days before they met the other criteria of weight gain and full oral feeds. Equipment problems in the form of thermistor probes that were unreliable and often read low also led to a great deal of frustration. Finally, some difficulty was experienced in following the study protocol because the nurses definition of what constituted a layer of blankets varied, as did their diligence in recording the needed information. At Site B, the initial stumbling block came when the first infant was ready for inclusion into the study and the equipment had not arrived. Other problems were directly related to patterns of behavior and attitudes of the nurses and the neonatologists. The project confronted many hurdles that are discussed. Data revealed that the YSI thermistor recorded skin temperatures that were 0.2 C less than axillary measures. The range of this discrepancyalso depended on the position of the infant and whether the infant was lying on the probe. To keep infants from being placed back into heated isolettes or not making the transition to open crib, the decision was made at Site B to focus more on the axillary, rather than the YSI, thermistor reading. Although this made more work for the staff, they were willing to follow through because it meant that project data would be more accurate. Site A experienced similar problems with the thermistor and found it necessary to double-check low temperatures with axillary readings. Change is not easy. In fact, it tends to be more difficult when one is trying to modify an individual s beliefs about how things should be done. The attitude I ve always done it this way and never had a problem is even more difficult to moderate. Although research is an expected part of nursing practice at Site B, many individuals had never been involved in any type of clinical study. Educating staff members about the research process, research utilization, and why research is critical to the science of nursing proved to be another challenge. As data collection proceeded at Site B, it became obvious which staff nurses had problems collecting data. Reasons for this varied. Individuals did not always refamiliarize themselves with the steps of a protocol before they began collecting data. In fact, there were many staff members who admitted that they had never read the protocol or reviewed the data collection sheets. To combat this problem, note cards were taped to each infant s isolette or crib indexing key points along with a tentative time line for the transition to occur. This reminder served another purpose. It alerted the parents about what was occurring with their child s transition and how they could affect the progress. In retrospect, things could have been done differently. Flow charts that would facilitate decision making may have helped. Orienting the entire NICU staff at the same time may have made a difference. The acceptable temperature range per the protocol (36.0-37.0 C) posed another barrier. The acceptable range for Site B s NICU was 36.5-37.0 C. This range was set by the neonatologists and never challenged because many of the staff had never worked in other neonatal units. Much encouragement and reinforcement was needed to convince staff that temperatures of 36.0 C and greater were safe. As in many neonatal units, some areas of the unit are warmer than others. This project quickly identified where the drafty sections were. The unit at Site B is located against an outside wall of the building, which faces a lake. Although the windows are double-pane glass, there tended to be drafty spots. As a result, there were individuals placing extra blankets on infants because the person was cold. When asked about that intervention, the reply was That s what we tell our mothers to do at home. Similar problems with environmental temperature fluctuations were noted at Site A. What We Have Learned from the Process The process of collaborative research utilization holds many advantages for the beginning researcher or a CNS May 1994 JOG 339

C L I N I C A L I S S U E S with multiple roles to fulfill. The initial time required to develop a research-based protocol from idea to finished product can be daunting. The benefits of others expertise in research can greatly enhance the process and the outcome of the research-utilization project. Other benefits include pooling the collective minds of 10 diverse teams in protocol development and troubleshooting and each center needing only a fraction of the infants required for a statistically significant study. Collaborative research also can lead to additional studies, allowing various sites to capitalize on their areas of interest and expertise. The disadvantages of collaborative research utilization are greatly outweighed by the positives but should not be overlooked. Each site will need to compromise on a protocol adopted by the larger group. There is limited flexibility in adapting or modifying the research-based protocol to protect the integrity of the project, and individual sites may not have control over dissemination of the final results or publications from the study, depending on how that process is established. This project has created tremendous interest among nursing staff because it resulted in immediate and tangible changes in the care of low-birth-weight infants. This excitement has generated suggestions for other researchutilization projects from staff members in the units. Questions about the types of nursing research being done in other centers has increased, as have requests for research articles and discussion of those articles at journal club. All of these benefits enhance the ability of the CNS to bring research into current practice and to participate more actively in the research process. Conclusion The job functions of the CNS do not fit neatly within the 8-hour work day. Making time for one more activity is not easily accomplished. However, the benefits of becoming actively involved in clinical research and research utilization are worth the time and effort. The CNS will always have to contend with the challenge of individual standards. Moving beyond our own values and beliefs and participating in the testing of nursing theory enhances the practice of the CNS and that of the larger staff. As the body of knowledge accumulates, the goal of researchbased practice will be attained, which will greatly benefit clients and the profession of nursing. References American Nurses Association (ANA). (1980). Nursing: A social policy statement. Kansas City: Author. Briones, T., & Bruya, M. (1990). The professional imperative: Research utilization in the search for scientifically based nursing practice. Focus on Critical Cure, 17( l), 78-81. Canadian Nurses Association. (1988). Position statement: The role and Function of the Clinical Nurse Specialist. Ottawa, Ontario; Author. Hamric, A,, & Spross, J. (Eds.). (1989). The clinical nurse specialist in theory andpractice (2nd ed). Toronto: WB Saunders. Hodgman, E. C. (1983). The CNS as researcher. In A. Hamric & J. Spross (Eds.), The clinical nurse specialist in theoy and practice (1st ed., pp. 73-82). New York: Grune & Stratton. Keefe, M. (1993). Incorporating research findings into practice. MCN, 18,65-70. Lindquist, R., Brauer, D., Lekander, B., & Foster, K. (1990). Research utilization: Practical considerations for applying research to nursing practice. Focus on Critical Care, 17(4), 342-347. McGuire, D., & Harwood, K. (1989). The CNS as researcher. In A. Hamric & J. Spross (Eds.), The clinical nurse specialist in theory andpractice (pp. 169-198). Toronto: WB Saunders. Address for correspondence: Debbie Fraser Askin, RNC, MN, 9 Rosewarne Avenue, Winnipeg, Manitoba, Canada R2M OV8. Debbie Fraser Askin is a clinical nurse specialist at St. Boniface General Hospital in Winnipeg, Manitoba, Canada. Kim Bennett is a clinical nurse specialist at St. Vincent Health Center in Erie, PA. Carla Shapiro b a clinical nurse specialist at St. Boniface General Hospital in Winnipeg, Manitoba, Canada. 340 J O G N N Voolume 23, Number 4