From the Ground Up

May 2013   Comments

Canadian Nurse asked Sean Clarke, one of Canada’s foremost nurse researchers, to explain what nursing research is and where he sees it heading in the future. During the wide-ranging discussion, he called for better sharing of the research done every day on the front lines to improve patient care and nursing practice. He also let us in on his current research endeavours.

“Clinicians have vital information in their heads about their practice,” says Clarke. “They’re doing important work that others beyond their immediate workplace can learn from.”
Teckles Photography Inc.

Q: Where is funding for nursing research coming from these days?
Where the funding comes from depends on the kinds of studies we’re talking about. We’re in a transitional place right now. Increasingly, I think the money is going to be earmarked for specific types of research that funders believe are important for the health-care system — and it’s going to be provided to teams rather than individuals.

I think of nursing research as a multi-layered cake, with the investments being different at various levels. There is a layer of “resource intense” research, conducted by people who are doctorally and often post-doctorally prepared and who have invested a significant period of their careers in getting research training. The studies they undertake are intended to make contributions to the literature. A significant chunk of this type of research is externally funded by groups or agencies other than the researchers, their employers or the organizations where the research takes place.

Then, there are two other layers where external funding is less common. There is a middle layer of work done by managers, educators and clinical leaders who are trying to enrich their institutions over time by drawing on the scientific literature and using systematic approaches to study and improve care or services — often, in conjunction with data collected on a regular basis to keep an eye on quality of services. These people usually have graduate education in the research process, and sometimes they will publish their experiences.

Then, there is a layer of research that involves clinicians in hands-on care or service. This research may not be large scale in terms of planning, numbers of subjects or variables, and it may be rather simple in design, but it can yield some really useful findings for shaping care in a particular setting. I think it’s important for all nurses to understand that asking questions, rather than only delivering care in the moment, is an important part of our jobs. This third type of research is arguably something everybody in the profession ought to be doing.

Q: How do you encourage everyone to get involved in hands-on research?
All nurses need to be aware of trends in their own patients and their care, and stay up to date on research that may relate to that care. Some nurses are involved in communities of practice, where people who have a common set of responsibilities for similar clientele come together to share ideas and work together to make care better. In the Internet era, communities of practice are possible even when you’re one of a handful of nurses in the country or the world who work with a particular clientele.

Beyond informal networking, we’re seeing nurses being supported in finding published evidence and guidelines that might be applied in practice and receiving help translating and adapting them to local circumstances. Some organizations are also finding ways to release nurses from their clinical responsibilities to advance this work and providing them with access to nurses with more formal research training who can facilitate framing of questions, reading the literature, and gathering and analyzing data to check out the effects of changes in practice.

Q: Would this research necessarily be submitted for publication?
Not always, but the results of applying research findings in this way should probably be available to others, even if we don’t always call them research. I definitely think the profession embraces big R research, which includes publishing papers in peer-reviewed research journals, but there are translatable lessons across settings that are lost because the practice-grounded application of findings doesn’t tend to be a great fit for many of the ways we conventionally report peer-reviewed research.

Q: So how do you share the knowledge that is gained on the ground? Is some of it being lost because we don’t have a way to collect and disseminate it?
Clinicians have vital information in their heads about their practice; they’re doing important work that others beyond their immediate workplaces can learn from. Big R research involves layers of ways of setting up studies and reporting them that can be pretty daunting to those unfamiliar with them. Conference presentations and posters can be useful for exchanging ground-level experiences, but these generally don’t reach a lot of people. We need to find other ways in the literature to do this.

A big study that cost hundreds of thousands of dollars to do and was conducted by people with extensive credentials does not necessarily make a piece of scholarship valuable to people who are trying to make real-life care decisions. On the other hand, we don’t want anyone to think that just because something was tried in one particular setting, in one city and at one point in time that it will be effective in all places at all times. However, we do want people to be reading and thinking about the lessons that can be drawn from those smaller-scale practice improvements and program evaluations.

In fact, at CJNR we are realizing that the profession is at a different point than it once was. Without negating our focus on data-based research articles, because we’re really proud of what we do in that respect, maybe there’s a way we can serve the profession by opening up some venues to exchange information that clinicians are learning over time.

Q: What are the challenges or limitations in nursing research?
Nursing research is still in its adolescence. We’ve grown a lot, but we’re still figuring out who we are and what we’re about. Certainly, in the beginning, a lot of nursing research was about nurses. When social scientists and others outside the profession looked at what we were doing, they would say, “It looks as though you guys are studying each other!” Over time, we have come to understand that nurses, out of their contacts and work with patients, tend to ask certain types of questions about how patients respond to health-related situations. Answering those questions can help us develop better care.

When I’m asked what nursing research is, I tell people that it’s about patients and the care they receive. And I think questions about the profession and our professional issues that might have a less clinical flavour can speak directly and indirectly to quality of care. Who is providing care, and what are these providers thinking about when they are on the job?

What we’re seeing is a maturation of the field in terms of research questions and approaches. I think any research area eventually has to prove its contribution. Nursing research is only as valuable as it is helpful to improving health care.

The limitations of nursing research come down to what can be studied and what can’t, in terms of ways to collect and analyze information, and to the availability of resources to gather necessary data. Frankly, the biggest resource is researcher time and the next most important are the materials and money needed to collect data: hiring people to do it, buying the equipment and supplies, and getting access to populations. Having the time to think through the process, before, during and after data collection, is absolutely critical — no matter which type of research we’re talking about, but especially when the intent of the researcher is to contribute to the wider literature.

My definition of nursing research is fairly broad in terms of health and health-related situations or factors related to the delivery of care. And even if what we study is one or two steps removed from what we might think of as nursing care, it’s still legitimate territory for nurse scholars, in my opinion. I guess that’s where we get into the professional issues.

It’s important to realize there are many questions out there that no kind of research (alone or in combination) can answer. For example, what is the best mix of nursing personnel for various care settings? It’s not only the use of an evaluative term like best that makes these questions unanswerable; it’s also all of the assumptions behind the questions and the many practical and political considerations involved in the decisions. I can’t tell you how many times I’ve been asked, What is the right nurse-to-patient ratio for a medical/surgical unit in a hospital on a day shift? That’s actually an important managerial decision with huge consequences, but handing over a formula is not something research can necessarily do.

Q: If the staff ratio question is not really answerable, is that research effort better spent somewhere else?
There’s been a lot of work on staffing. We have a critical mass of studies out there that suggest staffing is one of the factors that must be considered by managers and health-system leaders, but now we need to move on, understanding we are never going to have randomized trials of allocation of staff or staff mix. Today, we need to be evaluating and checking in on what’s happening when we change staff mix or staff coverage. We need people to think beyond traditional or common configurations of staff and draw on the literature to do it. Do we need more correlational studies that show there is a connection — sometimes weak, sometimes strong — between staffing and certain kinds of outcomes? Maybe not so much. What we really need is an understanding of important conditions in workplaces and better guidance for managers and policy-makers about the potential consequences of doing things one way versus another in organizing hospitals and other health-care organizations. As well, we need to understand how to maximize patient safety and get the best outcomes possible when we might not have the picture-perfect setup in terms of being able to afford or hire the number of nurses with the educational backgrounds that we might want.

“Any research area has to prove its contribution. Nursing research is only as valuable as it is helpful to improving health care.”
Teckles Photography Inc.

Q: So what conditions do you think we should be looking at?
The work of front-line managers is something that we have not paid enough attention to over the last years. They have a very tough job, and pretty heavy responsibilities for which they don’t often have a lot of formal training or long-term mentoring. I think what nurse managers do — managing knowledge workers in a rapidly changing environment — is an incredibly challenging prospect. Day-to-day operational and logistical challenges have to be balanced against longer- term strategy, and problems in delivery and quality of care need to be addressed. We have wonderful nurse managers in the field, but we tend to throw them out there. Some sink and some swim.

I think we need to ask some questions about the expectations we have for new nursing graduates. It’s unrealistic in health care today to believe that we can have somebody graduating from school in May or June who can walk straight into a practice setting — ready out of the box. A lot of post-graduation onboarding occurs in every other profession. There hasn’t been nearly enough dialogue between educators and practice leaders about the skill set students need to have when they graduate — the defensiveness and stress levels on both sides are so high. There are some Canadian researchers studying orientation models, matching skill sets to patients’ needs and helping nurses maintain competence over time. More of this kind of work is needed.

We also need to investigate what nurses are actually doing in their practice settings. We educate nursing students to work in a range of settings, taking on a broad range of responsibilities for different aspects of patient and community health. Some of them embrace a Cadillac version of nursing care, complete with really thorough assessments and comprehensive and holistic approaches that they see as being what every patient deserves and what nurses should always aspire to deliver, regardless of setting or budgetary constraints. I think it’s time that we look more closely at what nurses are doing and, in some instances, think about doing less of some things, especially when we don’t have much basis to believe those activities are improving the recoveries of patients or their ability to function in the community.

We need to take another look at how nurses work within groups. There is very little research on interprofessional education (IPE) and interprofessional care (IPC) as they affect patient outcomes. I’m not thinking that we’re going to find IPE has a negative impact on patient outcomes, but under what circumstances is it producing better care, and how do we know? What kind of teamwork are we actually producing as a result of IPE initiatives and programs that develop staff for IPC? Where are the impacts the greatest, and where can we get the most return for our investment of time and money?

Finally, we need to start asking questions about optimal use of resources under constrained conditions. I think there are a lot of folks in the profession that wouldn’t like to hear me say that, because it sounds defeatist, but the resources that our profession and the health-care system get will either hold steady or decline. We are not going to see a huge influx of new resources. Even though I hate the pat phrase “do more with less,” I think there is going to be more of that in health care in the decades to come.

Q: You’ve been doing some work on the concept of “failure to rescue.” Can you explain what this means?
You can’t always prevent every complication or every deviation from recovery patients have, and there are pre-existing illnesses or risks that you cannot control that come with certain procedures. The idea is that what makes some of the difference in patient outcomes — and a way we might be able to tell an excellent nursing unit from a mediocre unit or an excellent clinician from a mediocre one — could be the way that nurses and others on the health-care team respond to those deviations. The metaphor I use is that of a car going off a cliff. Usually there are early signs, so a well-informed clinician can jump in and stop the car before it goes too far. Sometimes, for a variety of reasons, maybe related to the knowledge deficits of clinicians, an inability to keep track of the patient’s condition, information overload or maybe difficulties of a team in getting a rescue effort together, a car goes over the edge — the patient succumbs to complications.

I think the idea has tons of grab, because you can talk to clinicians in any specialty and they recognize the scenario. Saving a patient from complications takes a well-informed clinician attending to the patient, knowing that this individual is at high risk, putting the pieces of the puzzle together to recognize the emerging picture, doing the right things herself/himself and then bringing the rest of the team into the picture. That whole sequence of events is really dependent on sound initial professional education, continuing education and, frankly, having a well-managed health-care organization and solid interprofessional relationships. It is contingent on so many different things.

Q: It sounds as though discussing failure to rescue would be a difficult conversation for the clinicians involved. Is there a sense that you are asking people to admit that they’ve made errors?
Safety has been a watchword in health-care research and administration for the last 15 years. Actually studying safety is a lot trickier than talking about it and trying to measure it. Evaluating our attempts to make hospitals and other health-care facilities and organizations safer is very much complicated by everyone’s sensitivities. No health-care worker goes to work with the intention of harming anybody. But frankly, the duty of professionals is always to look at their practice, see what they could be doing better and be willing to change if it is in the public’s interest. Now, in practice, in the real world, there is a lot of motivation to avoid taking a deep look at what we’re doing. People can be wedded to certain approaches to education, management and clinical practice. Maybe not all clinicians in all aspects of their practice are optimally serving the public. That’s a loaded statement, but it’s something we have to admit to and cope with because we cannot go forward otherwise. There is a big emotional component that goes with that, because of socialization within professions to save face at all times. There are many people in the safety movement who believe that being transparent about our failings is one of the first places to start as we try to make health care safer in the long run.

Q: So what role does experience play in preventing the car from rolling off the cliff?
This is a question that could start a fist fight in a room full of nurses. I think it stands to reason that experience plays a big role in effectiveness, both in readily identifying patients at risk and in the success of the rescue effort. Has this been demonstrated in research? Not directly. What the literature is clearer about — and that most would agree with, too — is that experience plus reflection on those experiences leads to better judgment and improved performance over time. In a number of studies that have tried to tie nursing experience to hard outcomes, we have not been able to see that association. But it doesn’t mean it isn’t there.

We need to start getting a handle on how experience develops and how we can facilitate the lessons that go with time in the field. In Canada and other countries around the world, the experience level of nurses in many settings is going to drop when the most seasoned nurses, now in their 50s and 60s, begin retiring in large numbers over the next five to 10 years. It’s going to happen relatively quickly. What does that mean for the profession, and what does it mean for demanding and fast-paced settings? When nurses with clinical or institutional memory leave, what will that do to quality and safety in the care of complicated clienteles? What can we do to ensure that patients aren’t put at unnecessary risk?

Sean Clarke, RN, PhD, FAAN

Sean Clarke, RN, PhD, FAAN, is a professor at the Ingram school of nursing, McGill University and editor-in-chief of the Canadian Journal of Nursing Research. He is the inaugural holder of the Susan E. French Chair in Nursing Research and Innovative Practice, and director of the McGill Nursing Collaborative for Education and Innovation in Patient- and Family-Centred Care. The collaborative recently received a $6-million commitment from the Montreal-based Newton Foundation and the development arms of McGill, the McGill University Health Centre and the Jewish General Hospital to promote linkages between research, education and practice in nursing.

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