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Beyond Terminology Confusion

Creating a Culture of Nursing Inquiry

Scala, Elizabeth MSN/MBA, RN, HNB-BC; Alderfer, Mary E. MSN, RN, CNML; Milburn, Rowena Leong DNP, RNC-LRN

Author Information
Journal for Nurses in Professional Development: May/June 2020 - Volume 36 - Issue 3 - p 156-162
doi: 10.1097/NND.0000000000000637
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Abstract

Inquiry is the foundation of nursing practice. There are three forms of inquiry, each with a different purpose, yet all interdependent in advancing nursing science to improve patient, nurse, and organizational performance and outcomes. Knowledge informed by scientific discovery supports updates in policies, guidelines, and clinical advancements (American Association of Colleges of Nursing, 2006). Although the forms of inquiry are closely related and often conducted simultaneously in practice, there are distinct and intrinsic differences in each.

Evidence-based practice (EBP) is a problem-solving approach to clinical decision-making within a healthcare organization that integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence (Dang & Dearholt, 2018). When applying EBP, nurses synthesize evidence to adopt practice changes. Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups (U.S. Department of Health and Human Services Health Resources and Services Administration, 2011). The purpose of QI is to change local structure and processes in order to improve outcomes. Research is a systematic investigation, including protocol development, testing, and evaluation, designed to develop or contribute to generalizable knowledge (Office for Human Research Protections, 2018). Nurses conduct research to generate new knowledge for broad application.

With recent policy changes in healthcare funding, organizations have placed more emphasis on leveraging inquiry work to reduce costs and improve outcomes. Using catheter-associated urinary tract infections (CAUTI) as an example, one can clearly see the interplay between EBP, QI, and research. Healthcare organizations have been charged with reducing, if not eliminating, infections caused by catheters. Nurses are expected to practice according to established evidence-based clinical practice guidelines to avoid CAUTIs within the practice setting (Centers for Disease Control and Prevention, 2016). If, despite following EBP guidelines, a particular hospital-based nursing unit continued to experience CAUTIs, the nurses could set up a QI team to intervene and improve processes. If the evidence underlying a guideline is weak or a new question or intervention had been proposed to reduce the CAUTIs, then a research study could be designed and the intervention or theory tested. As such, each of the three forms of inquiry is unique but related. Furthermore, each type of inquiry activity has its place in the healthcare setting.

The coexistence of the three forms of inquiry to address practice change that has led to confusion among clinical nurses, and worse, could hamper efforts to create rigorous nurse-led research initiatives (Carter, Mastro, Vose, Rivera, & Larson, 2017; Newhouse, 2007). Often, clinical nurses are not able to clearly differentiate research from EBP and QI, using the terms interchangeably and incorrectly. The purpose of this article is to report the responses provided by 34 clinical nurses from seven different institutions to three questions addressing their understanding of research, which had been part of a prior qualitative study. We offer reflection points for nursing professional development (NPD) practitioners to consider to build and broaden nurses’ competence and confidence in the use of inquiry in everyday practice.

A team of nurses in the Mid-Atlantic region conducted qualitative research to better understand the clinical nurse’s engagement in the research process (Scala, Patterson, Stavarski, & Mackay, 2019). The aims of the study were threefold: to gain an understanding of what motivates clinical nurses to be interested and/or engaged in research, to describe the motivators of clinical nurses who are interested and/or engaged in research, and to identify the common characteristics of clinical nurses who are interested and/or engaged in research (Scala et al., 2019).

The research team used a semistructured interview guide with open-ended questions to collect the data. Following approval from the institutional review board, 34 nurses participated across the seven study sites. Most of the participants were Caucasian, were female, were employed full time, and held a bachelor of science in nursing degree. Participants’ ages ranged from 22 to 61 years, and they worked clinically in a variety of settings (e.g., critical care, emergency, oncology, and psychiatry). Close to half of the participants (n = 14) had worked in nursing between 1 and 10 years. Data were analyzed, and results were previously reported (Scala et al., 2019). In addition to items that specifically addressed study aims, other questions were posed using the same semistructured interview guide to elicit participants’ thoughts about, and understanding of, the definition of research. The participants were asked the following: “Describe an example of a nursing research activity that you have engaged in (currently or previously)”; “What do you define as research?”; and “What does the term ‘nursing research’ mean to you?”

These questions were intended to gather information specific to research-related activities, rather than EBP or QI. However, further investigation of these data highlighted responses that were a collection of experiences and ideas that intermingled thoughts on EBP, QI, and research. From descriptive analysis of participant data, investigators propose confusion continues to exist among nurses about the three forms of inquiry, their definitions, and what activities are specific to each form of inquiry.

FINDINGS

The findings presented here are data from the original study and were not previously reported on. Table 1 contains examples of responses given for each question. The data illustrate the spectrum of thoughts and sometimes struggle for articulation within participant comments.

TABLE 1
TABLE 1:
Participant Responses From Questions Asked in “Engaging Nurses” Study

Question 1: Describe an Example of a Nursing Research Activity That You Have Been Involved in

The top shared responses included data collection effort, chart reviews, and activities involving QI projects. Most participants (n = 16) described how they acted in a supporting role, mostly conducting data collection and literature reviews. A few participants (n = 5) reported completing EBP internships. Some participants tried to conduct an actual research study but had stopped due to what they perceived as arduous tasks involved or remained stuck in developmental stages.

Question 2: What Do You Define as Research?

Answers to this question were wide ranging as having a question and then doing further “research” to find the answer to more defined, academically accepted responses. Most participants responded that “research” is a way “to look for a solution and solve a problem,” “generate or find a gap in knowledge,” and “finding new information.” However, some participants (n = 3) defined research as “EBP.” Many responses were a version of the definition of EBP.

Participants’ responses all had an element of describing a personal or organizational gap in knowledge that needed to be resolved. Participants went further to articulate how understanding that gap might be addressed: measuring outcomes, data collection, literature review, or using an EBP approach. Some participants mentioned learning “new” things, but only a few (n = 2) addressed a “process” or “study.” None of the respondents fully articulated a scientific process with protocol-driven steps that lead toward the generation of new knowledge.

Question 3: What Does Nursing Research Mean to You?

The responses to this question can be summarized as a learning or information-seeking activity that involves nurses and applies to patient care or clinical practice. Participants described said activities as those that are led by nurses and support or enhance nursing practice. Based on responses received, “nursing research” for participants meant research that is applicable to nursing practice and improves patient care.

In addition, few participants (n = 5) described nursing research as an opportunity for professional growth and collaboration. The basis of the research activity can be curiosity, problem-solving, or practice improvement, and it may occur in different time frames. “Research” was used to validate past and current practices, in the present sense to address a problem or situation, or for future needs such as promoting nursing or improving patient care. Nursing research was also considered to be an activity that was solely nursing related or multidisciplinary when nurses were involved in project teams.

RECOMMENDATIONS

Overall, the responses illustrate that clinical nurses who are engaged in research-related activities may be unable to define and articulate examples of the three forms of inquiry with ease. Although participants received the semistructured interview guide prior to the interview, answers pertaining to the definition of nursing research were varied and inaccurate. The confusion around the three types of inquiry illustrated that clinical nurses lacked an understanding about the application and/or performance of research versus QI or EBP. On the basis of these findings, NPDs have an important role to play in ensuring that clinical nurses understand these differences in order that their patient care be based on a knowledgeable application of existing or newly generated and tested best evidence. The proposed solutions are offered to assist NPD practitioners in this challenging yet vital aspect of professional nursing practice.

Create a Foundational EBP Culture to Support Robust Inquiry

It is widely understood that a steady conduct of EBP “leads to high-quality safe care, improved patient outcomes, and reduced costs” (Melnyk et al., 2018, p. 16). Despite the availability of EBP competencies since 2014, the state of EBP competency in U.S. nurses remains unknown (Melnyk et al., 2018). At the organization level, an EBP environment demonstrates immense variability and is not standard practice across healthcare systems nationally and globally. Given this information, institutions should consider creating an infrastructure rooted in the EBP competencies for consistent implementation (Melnyk et al., 2018).

It is crucial for hospitals and healthcare systems to have an EBP infrastructure as the foundational culture of inquiry. NPD practitioners are central to planning, building, and sustaining EBP and other forms of inquiry within organizations. The NPD practitioner must reach out to nurse leaders with a detailed plan and promote the value of inquiry. This inquiry plan should include hardwiring EBP as a stepping stone for all forms of inquiry as it requires clinical nurses to begin with a search, review, and evaluation of evidence. The NPD practitioner is in a prime position to champion EBP as being the initial step before pursuing QI projects and research studies (Harper & Maloney, 2017). Nurses who are competent and confident in EBP can further progress to QI and research efforts as they evolve in the clinical scholarship continuum (Carter et al., 2017).

Sustain Inquiry Interest Post-Nurse Residency Program

Many organizations incorporate EBP project work into Nurse Residency Programs (NRPs). This teaches new nurses about the EBP process and also helps them apply concepts in practice. Because NRPs currently provide building blocks for certain aspects of inquiry work, NPD practitioners may consider offering an additional feature post-NRP graduation in the form of a scholars’ cohort. The scholars’ cohort would consist of a select group of clinical nurses who are brought together in order to develop, design, and conduct a research study (Latimer & Kimbell, 2010).

In a structured experience, NPD practitioners could support new nurses in practicing EBP skills obtained during NRP. This format would deliberately allow NRP graduates to go beyond the theoretical application of EBP. The NRP graduates, as to not lose momentum, may turn completed EBP projects into future QI and/or research work. Project progression may allow the newly formed cohort to reinforce knowledge learned during NRP. In addition, this type of program could broaden research capacity among nursing staff as mentorship opportunities for subsequent cohorts would provide continued structure for practical application (Latimer & Kimbell, 2010).

Provide Access to Education, Training, Mentoring, and Project Opportunities

Each form of inquiry requires continuing education for clinical nurses to ensure knowledge and skills gained in academic settings are not lost while keeping up with competencies and standards. This continuing education must include the definitions of each inquiry type and an articulation of the various inquiry activities involved using concrete examples. Learning activities that NPD practitioners might consider include developing educational offerings, such as workshops, ongoing mentoring support for an individual and/or group, and conducting inquiry projects (Ingersoll, Witzel, Berry, & Qualls, 2010). Experiential learning may keep nurses engaged, as these opportunities can further develop the clinical nurse into a future mentor with a strong foundation in the three forms of inquiry (Scala, Price, & Day, 2016).

The focus on mentoring clinical nurses to first become key participants in and then lead QI projects or research studies must be a priority for institutions. In general, all nursing research projects should involve at least one clinical nurse on its proposed team, as this is undeniably the most opportune time to develop knowledge and skills based on the nurse’s interest areas and provides an opportunity for nurses to contribute to the project bringing the frontline perspective. For example, when a research study has a nurse acting in the principal investigator (PI) role, the PI should specifically recruit and add a clinical nurse to the study team as co-investigator. The PI would serve as the mentor for the clinical nurse in the co-investigator role and can provide real-time education about the research process by working together on protocol design and implementation. NPD practitioners are pivotal in assisting clinical nurses to find and secure roles on project teams.

Mentoring for research studies could also include the addition of a local expert in the administration and conduct of research. A research study requires knowledge of protocol policies, human subject protection, legal contracting, protected health information, statistics, and several other regulations. A novice researcher can quickly become frustrated and overwhelmed by the required tasks of research. Even experienced researchers benefit from the knowledge and guidance of an administrative navigator and mentor for research studies. As leaders within nursing teams, NPD practitioners are in prime position to network and solicit expertise from experienced researchers.

Establish Collaborative Partnerships

Clinical nurses often feel inadequate in the realm of inquiry due to varied academic preparations for entry into the nursing profession. The presence of this self-doubt is not unfounded (Ravert & Merrill, 2008). There should be a seamless transition from the didactic setting to clinical practice when implementing inquiry work. The service–academia partnership is symbiotic and has been found to be effective in helping build nursing research initiatives. With partnership, “annual research conferences, presentations by nurse authors, roundtables, and rapid dissemination of research into practice” are used to promote nursing research activities in both academic and clinical settings (Ravert & Merrill, 2008). Service–academia partnerships can bridge the gap between clinical expertise and research experience while building collaborative relationships. Partnerships would ultimately benefit both academic and service settings if a solid nursing research curriculum is established that delivers clear and consistent knowledge and skills regarding the three forms of inquiry (Carter et al., 2017; Newhouse, 2007).

In order for inquiry projects to occur at the bedside consistently and systematically, additional types of partnerships must be forged among health systems. Inter- and intraprofessional partnerships may be beneficial in distributing valuable resources and research opportunities. NPD practitioners can learn from professional colleagues who have research experience. Partnering with interprofessional colleagues may be an effective way to gain the necessary research knowledge and skills (Harper & Maloney, 2017). NPD practitioners should be aware that networking strengthens research quality, allows for vast dissemination of research findings, and increases access to inquiry resources across health systems that otherwise may not have been available. Collaborative partnerships demonstrate that NPD practitioners have expanded learning and practice environments that necessitate interaction within complex systems (Harper, Warren, Bradley, Bindon, & Maloney, 2019).

Promote the Appropriate Use of Inquiry Terminology

Within nursing, incorporating standardized language is a means of improving communication and decreasing confusion among teams. For example, lack of common and shared language has shown to be a barrier in carrying out nursing care plans (De Melo et al., 2017). Similarly, in order to avoid confusion among the three forms of inquiry, it is imperative that NPD practitioners are intentional with language used in practice, as it pertains to the specific type of inquiry project being pursued. More often, nursing teams engaging in research-related activities loosely use the term “research,” but they may or may not actually be conducting research by definition.

When a clinical nurse is conducting a literature search, it is usually mistaken as “performing research.” However, searching for literature is merely locating and appraising evidence. When referring to QI, the term “project” should be used, and conversely, the term “study” accompanies research. The term “research study” should only be used when a person is referring to an actual research protocol and conduction of an institutional review board-approved research study.

Nurse leaders, NPD practitioners, and mentors must be cognizant of the language used both in verbal and written platforms that describe inquiry work. Strategies to encourage common use terminology throughout the nursing department include providing education for staff during nursing orientation and as part of annual competencies, utilizing a standardized language in nursing councils/committees that implement practice changes, and developing learning outcome metrics to ensure knowledge retention of intentional language (Harper et al., 2019). Clearly, it is easy to incorrectly use the terminology. However, every effort must be made by nurse leaders and NPD practitioners to ensure correct inquiry terms are used, in clinical and academic settings, to curtail the confusion that continues to exist.

DISCUSSION

Participant responses demonstrate there is confusion in the understanding of when a nurse is conducting research and when he or she is engaged in EBP activities or QI projects. It is likely that these intersecting responses could be echoed at most organizations. A recent study of 1,015 U.S. nurses found that barriers to implementing EBP “are the same ones that have been cited by nurses for over two decades, including lack of time, knowledge, mentors, and organizational support” (Yoder et al., 2014). Although the study targeted EBP, it is evident that research support has also been a long-term problem in the practice setting. Therefore, it is incumbent upon NPD practitioners to eliminate this ongoing terminology confusion. Consistent language and communication are necessary in defining and articulating the three forms of inquiry.

The reasons to articulate this distinction in each organization are many and varied, not the least of which are limited resources and complex responsibilities that take nurses’ attention and time. If nurses, NPD professionals, and administrators misunderstand inquiry-related definitions and components, it may short-circuit the efforts for all to participate in inquiry projects. Nurses may sincerely believe they are conducting research when they are actually engaged in components of EBP or QI. Knowing and consistently referring to the correct aspects of inquiry activities may provide much-needed clarification of expectations. It is vital that administration define and articulate the culture and provide resources for inquiry work not only for clinical nurses but also for themselves and the institution.

CONCLUSION

Nursing research and inquiry work are integral mainstays in health care. Developing an organizational culture where nurses are able to define and articulate the significance of EBP, QI, and research cannot be understated. NPD practitioners have a significant role in supporting the clinical nurse to know and understand the differences between inquiry terminologies. It is evident that it is not easy to pursue and sustain a robust inquiry culture. However, the long-term benefits for nursing, healthcare organizations, and, most especially, patient populations cannot be undermined. Nursing leaders owe it to the nursing profession to create a strategically planned and well-defined foundation for a promising future in nursing science that the three forms of inquiry provide.

ACKNOWLEDGMENT

The research team would like to thank the study sites, lead site investigators, and participants who shared their time, experience, and expertise for the purposes of this project.

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