Nancy Theresa Blake, PhD, RN, CCRN, NEA-BC, FAAN, is Nursing Director for Critical Care Services at Children’s Hospital Los Angeles and Associate Editor of the Journal of Pediatric Nursing.
A new generation of nurse researchers is helping to improve patient care. A leader of this movement is Dr. Nancy Blake, Nursing Director for Critical Care Services at Children’s Hospital Los Angeles, Associate Editor of the Journal of Pediatric Nursing, and a member of the Patient Centered Outcomes Research Institute (PCORI) Communication and Dissemination Advisory Panel, which is working to get patients involved in research to improve outcomes.
Dr. Blake is encouraging and supporting nurses to get involved in research to build a solid base of evidence on which to build stronger practices. Ultimately, this will benefit not only patients and their families but the inter-professional teams in hospitals. It will also add a vital new perspective to the peer-reviewed research that acts as a foundation for developing knowledge in healthcare.
Here, Dr. Blake writes about how nurse researchers use the knowledge they uncover to improve care.
A baby lies in a hospital bed hooked up to medical devices that buzz and ring as a respirator pumps air rhythmically into her small body. Her parents sit close by, watching and waiting for a change. A nurse comes to explain what the care plan is for the day – changes in medication, tests to run and continued monitoring. She has spent the night caring for the baby and noted a few improvements in his vital signs. The parents are comforted, though still concerned.
When an alarm sounds, the nurse explains to the parents that it’s nothing to worry about – the oxygen in the child’s blood has just dipped below the average adult range but is nowhere near the danger zone. Having recently completed a research project on alarms in neonatal and pediatric units, the nurse knows they can cause undue stress for the parents. She makes a note to adjust the settings on the alarm so they’re appropriate for the child’s age range and standard vital signs.
Nurses play a vital role in the education of patients and their families, helping them adjust to life after the hospital. A new generation of nurse researchers is conducting research that informs evidence-based practices to improve patient care.
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Generating new knowledge
Yes, nurses do research. In order to have evidence-based practice, we need evidence. And with their knowledge and hands-on experience, nurses can theorize, hypothesize, structure studies, and collect evidence that leads to better care. The goal of nursing research is to achieve better care standards and applications for patients and families.
Take the oxygen saturation alarm. When children have cardiac arrests, the cause is usually respiratory problems, except for children with primary cardiac disease including congenital heart disease. In a child with a congenital heart defect, the oxygen saturation in their blood may never be higher than 90 percent because their blood doesn’t flow through the lungs way it would in a child with a normal heart. However, the default alarms on most monitors are set above 90 percent, which is the limit for adults. Knowing this and researching the effect of constant alarms give nurses insights that can lead to better care.
Hospitals should be healing environments, so you don’t want alarms going off all the time. If I’m a parent and the alarm is going off and people aren’t coming right away, I’ll be concerned. I won’t know if it’s a false alarm. Healthcare workers need to understand which alarms they have and how to monitor them appropriately to reduce false alarms.
In fact, often equipment for pediatrics is different than equipment for adults.
One of the challenges facing pediatric nurses is that the machines and equipment they use in hospitals are based on the average population, which is made up mostly of adults. For the most part, children are healthy, whereas geriatric patients spend more time in the hospital. When manufacturers develop equipment, sometimes there isn’t the rigor of looking at the wide spectrum of patients, partly because clinical staff are not working with the research and development staff. By getting involved in research projects, nurses can help make sure the equipment used for children is more suitable.
I’ve done a lot of work with biomedical engineers to give them feedback. For example, if they’re developing equipment for us, we need to make sure it works with the nurse’s workflow. An engineer who develops medical devices explained to me that we need to make sure the nurse’s mental model matches the bioengineer’s mental model. It’s important to have pediatric nurses doing research with manufacturers and patients to understand their unique needs. This assures that the equipment can be used as the developers intended it to be used.
Nurses in research and higher education
A growing number of nurses are getting PhDs and doing research, according to a 2014 survey by American Association of Colleges of Nursing AACN):
- The survey found a significant growth in research-focused doctoral programs (i.e., PhD, DNS), which climbed to 134 programs in 2014.
- Enrollment in PhD nursing programs increased by 3.2 percent over the previous year with 5,290 students enrolled in 2014.
- Since 2004 when the DNP movement began to take shape, enrollment in research-focused doctoral programs has increased by 53.8 percent.
Research to support evidence-based practice – for all ages
I started working in pediatrics as a student nurse and was immediately drawn to working with children. People tend to think it’s more difficult working with sick children, especially in end-of-life care, but that has not been my experience.
When I worked with adults 25 years ago, it was really sad for me to see an 80-year-old man who died after he and his wife had been married for 55 years; that was equally as sad to me as what we see here in pediatrics. But kids are resilient and they are very positive and upbeat until the very last minute. There are also more positive stories working with children. Supporting them and their families at the end of life, you feel valued and can walk away knowing you made the end of life for somebody the best it could be.
Of course, the aim is to reduce mortality and get patients healthy again. This is where research comes in: as researchers, nurses can find and share new knowledge to support evidence-based practice. It’s not the same as running clinical trials; nurses can really work closely with patients and families to find out how to treat them better.
Sometimes that means changing a practice that’s been standard for decades. For example, for years it was best practice to sleep babies on their bellies rather than their backs, in case they vomited and choked. But today, following extensive research into sudden infant death syndrome (SIDS), the advice is to sleep babies on their backs.
When it comes to policy, it’s important not to waste time reinventing the wheel. If nurses are developing a policy or procedure, they can go to a database and search for the latest relevant research. At all hospitals, policies and procedures are revisited every three years, and when this happens, nurses need to find three to five relevant studies on the topic to see if there has been a change. SIDS is an example of why policies need to keep up with research.
I’ve been a nurse since 1980, and things have changed. We’ve done things before the evidence and found out we need to do them differently. When I was a new nurse, we put babies on their stomachs, and now with research they’re saying no, you don’t do that. As nurses, when we discharge newborn babies from hospitals, we make sure the parents understand that the best place you can put the babies to sleep is on their backs.
Some people are still practicing the old way because they haven’t heard about the research and how important it is. Because of this, it’s vital not only for nurses to carry out the research, but also to disseminate it – at conferences, in academic papers and even by sharing the results with their families, neighbors and colleagues. As more and more nurses get involved in research, the balance is shifting – where previously there were one or two “experts” who spoke at conferences, many more nurses are now presenting their research.
Changing opinions of nurses – and new opportunities
Public opinion is slower to shift, though, and this partly because the media sometimes projects nurses not in the best light. And nurses are trying to get the word out that they have to be better educated, that most nurses are educated to a bachelor’s level at a minimum. The general public trusts nurses and things are changing, but people don’t understand the rigor of the education nurses have to go through.
Despite the lack of public knowledge about what it means to become educated as a nurse, people trust nurses, and this can have a positive impact on patients’ understanding and acceptance of research-based information. Since working on my PhD, which I completed in 2012, I look at things completely differently. When I read articles, for example, I don’t take the findings for granted but look at how they did the research, their methodology. Is it sound? Are there flaws in the way they collected samples or set up the study, or did they use an unreliable tool?
That kind of critical thinking means filtering information before passing it on to patients. In fact, doing research changes the way I interact with patients. When I’ve done research, I can share that knowledge with them. We’re trying to train more and more nurses right out of school to look at the literature in this way to make sure we’re basing our knowledge and advice on sound research.
There’s already a lot we know about patient care from evidence generated by nurses, and this is likely to increase in the future. At Children’s Hospital, there is an endowment to provide grants for nurses to do research, and to give them protected time to work on it; when time is allocated for nursing staff, it is usually based on having them at the bedside, not taking research into account.
New graduates go through a 22-week residency program, which includes an evidence-based project. They do a performance improvement project that has been identified as something the nurses want to improve in their units, and they focus on an area the staff have questions about or that is problematic. At the end, they present a poster. Many of those nurses want to immediately go on and do a research project on this problem.
It’s very exciting to see them wanting to get more information and do research at this facility. They own it, and they’re excited about it, and they like to share it.
One key factor in ensuring more nurses get involved in research is building strong inter-professional teams. On a neonatal intensive care unit, for example, babies on respirators don’t have early experiences of sucking because they have a breathing tube, so an occupational therapist works with them to help them develop that reflex. If research is being done on sucking, it’s not done by the nurse in isolation but in collaboration with the occupational therapist.
Traditionally, research coming out of hospitals has been led by physicians, but this is changing.
A lot of large funding is still for physicians, but more and more nurse researchers are doing research with physicians as a strong inter-professional team. It’s important that we strive for this – nurses look at things with a slightly different lens, and it brings a different scope to the research. I would also like to see more physicians invite nurses to participate in their research, as it would enrich the results and strengthen the team.
Dr. Nancy Blake has been Nursing Director of Critical Care Services at the Children’s Hospital Los Angeles since 1995, where she is responsible for the administrative, clinical, quality and fiscal activities in the critical care services and nursing areas of several departments. She is also Associate Editor of the Journal of Pediatric Nursing, the official Journal of the Society of Pediatric Nurses and the Pediatric Endocrinology Nursing Society (PENS), published by Elsevier.
Nancy is also inspiring the next generation of nurses as an Associate Adjunct Professor in the UCLA School of Nursing, where she received her PhD in 2012. Her dissertation was on the relationship between the nurse’s work environment and patient and nurse outcomes.
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