Nurses want to provide evidence-based care that reflects best practices. But they also have uniquely local clinical questions that can’t be readily answered through the literature alone. How can these types of questions be addressed so the answers are relevant and useful? Consider original research.
But wait, you may think, I work in a small hospital where research has never been done. I don’t have the skill set. We are not university affiliated, so we have no resources or support system within the facility. We were faced with the same limitations, but felt our clinical question was important enough to examine in detail. With no prior experience, we decided to conduct a research study that conformed to established standards. We knew it would be difficult (and might even be impossible), but we were committed to using research as a basis for change. The great news is that we completed the study and were able to make those desired changes because of it. We’d like to share the story of our journey and hopefully inspire others to take the plunge into research.
Our small rural hospital has an average daily census of 40. We employ a number of newly licensed RNs and had a long standing orientation program for them. Unfortunately, the orientation program was not meeting our goal of preparing new RNs for autonomous practice on two busy medical-surgical units. Nursing leaders asked us to examine the program and make modifications.
We wanted to get a good feel for the current state. Rather than relying exclusively on nursing administration’s viewpoint and informal feedback from nurses, we felt the best method to obtain accurate data regarding practices and gaps in the process would be to get information directly from the nurses. We also felt this would support a bottom-up approach to change.
We considered a number of assessment strategies, starting with simple ones. We talked about different ways to gain insight into current practice. We had received occasional informal feedback from orientees and preceptors, but recognized those interactions were neither inclusive nor likely to be completely accurate. Next, we thought about sending a survey to the nurses. We couldn’t come up with a survey design that would capture the richness and depth of the nurses’ perceptions. It eventually dawned on us that the only way to get the level of information we desired was to look at it from a qualitative research perspective—what was the lived experience of those who were preceptors and new nurses?
Obviously, we’d need to ask them specific questions, receive responses, and derive meaning from the responses. As we discussed how to accomplish this, we concluded there was no easy way to do it. The process would be more complex than we initially anticipated. We realized we were looking at a large-scale project and decided we wanted to treat it as if it we were conducting research. Then one of us asked the other, “If we are looking at is as if it is a research project, why don’t we do actual research?
We encountered potential barriers right away. First, as far as we knew, original nursing research had never been conducted in our hospital. Second, while we are well grounded in evidence-based approaches to care and have extensive experience as clinicians and educators, we had never been involved in actual research. Third, we weren’t really sure about the first steps of a research project. Undaunted, we started with what we knew. We spent time thinking about the type of information we desired and the best way to obtain it. We reviewed literature about qualitative research and settled on an interpretive phenomenological research approach.
Next, we developed and presented a proposal to the hospital’s administrative team who were supportive and excited about original research being conducted within the facility. Once local approval was obtained, it became evident that we needed more help to move forward. We needed mentors who could guide us through the research process.
The most obvious and eventually most effective approach was to contact nursing faculty. Serendipitously, a staff nurse enrolled in the state university’s doctor of nursing practice (DNP) program approached us to discuss a student project. It turned out she was working on the same subject we were exploring so we formed a research partnership. This gave us direct access to an experienced, university-based researcher who generously agreed to mentor all of us through the study. At this point the pieces of the puzzle began to fall together and we felt confident enough to move forward.
The university researcher’s first requirement was that we complete a national training program about using human subjects for research. Before moving forward, we knew we’d need to apply for Institutional Review Board (IRB) approval through the state university. Normally, this process would be associated with additional costs since the hospital had no affiliation with the university, but due to the DNP student’s participation, no fee was required.
At this point we followed the university’s application requirements and designed the research protocol. We identified our sample group; nurses who had been orientees and nurses who had been preceptors. We finalized the research design and submitted our proposal to the IRB, who granted approval.
Change based on evidence
In a nutshell, here’s what happened next. We began recruiting volunteers by distributing flyers and hosting informational meetings. At the end of the recruitment period, about half of the target subjects agreed to participate. They were then split into two groups—orientees and preceptors. Face-to-face interviews were scheduled and completed. The transcripts were analyzed by four reviewers. Themes were coded and cross-checked for intercoder agreement.
We presented the results to hospital stakeholders who agreed to use the data as a framework to re-envision the hospital’s nursing orientation program. At the end of our study we were able to complete a substantial revision of our nursing orientation program that was based on locally obtained evidence. It has been well received and our outcomes have improved. We also felt it was important to disseminate our findings and presented a poster at a national conference.
It’s a great feeling to complete an original research study. However, our journey was not straightforward nor without challenges and setbacks. We’re hoping the lessons we learned along the way will help other novice researchers complete their own research journey.
We greatly underestimated the time it would take to design and complete a study that complied with standard academic rigor. Even though we had a good idea of what information we wanted to gather and what we would do with it, we didn’t quite know what to do once the proposal was approved at the hospital level. It was difficult to create a structured, step-wise research process until we were able to engage our university-based researcher.
Most of our challenges arose from the very nature of a small hospital—lack of people and lack of time. Once the research protocol was approved, we encountered unexpected delays when we started our interview process. We honored the scheduling preferences of participants but needed to integrate them into the interviewer’s other work requirements. The interviews and transcription were completed a full 6 weeks later than we originally planned. We also encountered random events such as subjects dropping out or leaving the hospital. Scheduling conflicts continued when we were analyzing the data. We were aware of the possibility of knowing about the subjects even though the transcripts were anonymized. In our role as researchers, we needed to be vigilant about maintaining objectivity.
Here are our take-home points:
- Early recognition of the need to formally study a clinical question greatly facilitates the ability to complete an intended outcome.
- Don’t let the research process intimidate you, especially if you have limited or no experience.
- Don’t be afraid to make mistakes. We immediately realized we could have done a better job in many aspects of our study. It didn’t stop us, but it puts us in a better position for the next study we undertake.
- It takes a village. Seek out experts beyond your hospitals’ walls. We found that nursing faculty were receptive, even eager, to help us. If your hospital is part of a larger system, find out if any of the other hospitals have a research program
In the end, it’s worth it. Hospital-based research provides a myriad of benefits to everyone involved. Inexperienced researchers gain confidence in their ability to conduct research and increase the likelihood of future research. Participants benefit by exposure to the process, which may spark an interest in future participation. The facility benefits by being able to promote a culture of evidence-based practice, especially with locally valid evidence.
Our journey is proof that clinical research can take place in any setting. Our final advice? Believe in yourself—you can do it!
Danette Melvin is clinical nurse leader at St James Healthcare in Butte, Montana, and Maureen Brophy is an assistant professor of nursing at Montana Tech in Butte, Montana.
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