FEBRUARY 1992, VOL 5 5 , NO 2
AORN JOURNAL
Practice-Based Perioperative Research MEETING THE CHALLENGES Jane Stover Leske, RN
T
he aim of perioperative nursing research is to produce a body of knowledge from which events or situations related to surgical intervention, human responses to these events, and the relationships between these events and responses can be described, explored, understood, predicted, andlor possibly controlled. The goal is to improve the care to surgical patients. Most nurses recognize the importance of designing and executing studies, implementing innovations and findings, and documenting and evaluating the many ways that perioperative nursing makes a difference in patient outcomes. The benefits of clinical research are well acclaimed, yet there are challenges to overcome in conducting and using perioperative nursing research.
standing of how research affects perioperative nursing practice, support for clinical studies may be limited. Any research project entails a prolonged commitment and requires support from others. Nursing service, at all levels, needs to be supportive of agency- and unit-based research projects. Department and unit administrators must recognize and reward the efforts of perioperative nurses who are striving for research competence. Time may be needed for the researcher to study a particular clinical problem. Other supportive activities may include funding travel so a nurse
Pe rioperative Nursing Research Challenges
R
esearch has been the force for change in clinical nursing practice, and most perioperative nurses are aware of important studies and results. Recognizing the need for research is not enough, however. Perioperative nurses also need to develop strategies to overcome these challenges and use research findings to advance the art and science of perioperative nursing practice. Lack of perceived value and commitment. Some authors report a lack of commitment to the use or generation of new knowledge in the practice setting.' Because of this lack of under-
Jane Stover Leske, RN, PhD, is an assistant professor at the University of Wisconsin at Milwaukee and holds a post-doctoral fellowship at the University of Utah, College of Nursing, Salt Lake City. She earned her bachelor of science and muster of science degrees in nursing at Marguette University, Milwaukee, and her doctoral degree in nursing a t the University of Wisconsin,Milwaukee. sni
AOBN JOI‘RNAL
FEBRUARY 1992, VOL 5 5 , NO 2
Clinical studies that document the effectiveness and cost of perioperative nursing interventions are needed desperately.
can attend a research conference or recognizing the value of nursing research through a clinical ladder program. Individual nursing administrators can sell the idea to others. sanction the research process, and foster changes in clinical roles and responsibilities with a supportive environment. Even when research activities are factored into budgets and staffing arrangements. practitioners may perceive the responsibilities associated with sporadic studies as ”extra work.” Also. s o m e c l i n i c i a n s may believe that researchers have not been interested in clinical problems. This is changing, however. because nurses are beginning to see that the purpose of nursing research is to benefit pa!ient care. Ways to reward staff members for research activities are needed to tip the balance of rewards and costa i n the favor of enthusiastic participation.’ If clinically relevant study results are made available to nurses. the value of and need for more nursing studies will become apparent when persistent problems arise i n the delivery of care, when nursing standards are being developed. or when changes in procedures are being considered. Clinical studies that document the effectiveness and cost of perioperative nursing interventions are needed desperately. Limited access to resources. Perioperative nurses conducting and using research may find access to resources challenging. This challenge may include limited access to subjects. equipment. settings. other researchers, and money. Getting the right resources can be very time consuming and frustrating. Developing a research proposal lor an approval-granting body (eg, hospital research committee. formal institutional review board) can be the most lengthy and stressful of all. An approval committee may be composed of physicians and may require the nurse to seek the support o r sponsorship of a physician 582
colleague to conduct the study. Some studies require special equipment, which d e p e n d s on collaboration between departments. Conducting a study without someone to h e l p c o n c e p t u a l i z e a n d f o r m u l a t e methodological issues can make research more difficult. A viable alternative is having a researcher and clinician conduct collaborative projects. Another challenge may be to find the funds needed to conduct the study, Research money is in short supply, and the competition for it is strong; however, it can be obtained.
Lack of research experience and education. Not all perioperative nurses have the academic preparation and experience to pursue answers to clinical questions or use research results. Nursing students at all educational levels can participate in conducting research, but course content on research usually is not begun until the baccalaureate level. Baccalaureate research courses generally provide some experience in the conduct and critique of research; however, information a b o u t w h e n a n d how to u s e research may be omitted.’ More advanced nursing research education usually does not occur until the master’s degree level, and research exposure and experience may not be consistent at all levels of nursing education. In addition, not all nurses are interested in. exposed to, prepared for, or experienced in the research process. In order to facilitate practice-based research, perioperative nurses need to foster, develop, and support professionals who are interested in research and who expose others to the research process. Unavailability of f i n d i n g s . T h e b e s t intended plans for facilitating practice-based perioperative research can be hindered by a lack of understandable research findings. Much has been said about the need to publish nursing research, particularly in the practice journals. As these journals begin to publish
FEBRUARY 1992, VOL 55, NO 2
more nursing research, clinicians will have access to research data. Designing and conducting a research project in the clinical setting means dealing with objectivity and applicability. Ideally, scientific inquiry requires that knowledge be produced under unbiased conditions. In practice-based research, the desire for a specific outcome can affect the accuracy of the information obtained. Knowledge obtained through research is meant to be useful in practice ultimately, but scientific inquiry does not demand that the information produced be applicable immediately. Clinical practice, however, requires immediate information for use in improving patient care. A study's findings should be appropriate to the clinical area. Research findings must be reviewed critically to be applied appropriately. Publishing research results and presenting and discussing study findings at conferences are not sufficient for translating research results into practice." Nurses who wish to use research findings often find it difficult to evaluate the quality of the research report and often fail to see the applicability of the findings in their own area of practice. Often, the practicing nurse does not use research study findings because he or she does not understand research language. If findings and implications for clinical practice are presented succinctly and in a readable form, practitioners will be more apt to use the research results.
Overcoming Research Challenges
C
hallenges to perioperative nursing research may be perceived as obstacles or roadblocks to conducting and using perioperative nursing research. Some of the major contributing factors that limit the use of research findings are as follows. 0 Findings may not be interpreted or presented in understandable terms that are useful in practice. 0 Access to results may be limited by publication in research journals and presentation of findings only at research conferences.
AORN JOURNAL
Reliability, validity, and generalizability of findings may be questionalbe because few, if any, replications have been done. Nursing research may be viewed as irrelevant to clinical practice, and care provided to patients is according to approaches learned in basic nursing education or what is encountered in the workplace. Lack of systematic research review by nurses to extract knowledge that has validity and relevance for clinical practice. Lack of nursing professionals with expertise in research and clinical practice.s Despite these challenges, the following strategies foster the perioperative nursing research process. Collaboration. Collaboration means merging the talents of health care workers with a diversity of backgrounds and motivations for the research process. Nurse-to-nurse collaboration is a significant strategy that maximizes the conducting and use of research. Collaboration may occur between nursing service and education personnel, within and between institutions, and between researchers and practitioners. Several conditions that are necessary for a practice-based research environment are facilitated by the collaboration between nursing service and education. This collaboration can be a group of people with preparation, experience, and interest in research who can devise and understand mechanisms for funding. The availability of essential facilities and resources (eg, computers, statistical consultants) also can be enhanced with this type of collaboration. The presence of support systems is better when nursing service and education personnel work together. Practice-based research actually may serve to bridge the gap between service and education and foster an increased valuing of clinical practice among academicians. Some agencies employ an educator who uses 10% to 20% of his or her time as a research facilitator. This research facilitator can have various responsibilities depending on the needs of the agency. Most likely, the 583
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AORN JOURNAI.
Table 1
Selected Perioperative Nursing Preoperative care The following studies pertain to preoperative patient anxiety. characteristics. knowledge, education. assessment. and outcomes. Durst. L M. ”Preoperative teaching videotape: The effect o n children‘s behavior.“ AORN 5oiirnd 52 (September 1990)576-584. Dziurbejko. M M: Larkin. J C. “including the family in preoperative teaching.” Americnr~ JoiiriioI of Nursing 78 (November 1978 I
tion on state anxiety.” Journal of Neurosurgical Nursing I3 (December 1981) 318-322. Takahashi, J J; Bever, S C. “Preoperative nursing assessment: A research study.” A O R N Journril 50 ( N o v e m b e r 1989) 1022-1035. Vogelsang, J: Ragiel, C. “Anxiety levels in female surgical patients.” Journal of Post Anesthesia Nursing 2 (November 1987) 230-236.
Intraoperative care
1893-1x91.
Klos, D. et al. ”A comparison of two methods of de 1 i ver i n g pi-es u rg ic al instructions . Pcirient Coiinsdiiig & Hroltl7 E&c~ition 2 (First Quarter 1980) 6-13. LeuLe. M: McKenzie. J . “Preoperative assess-ment: Using the Roy adaptation model.” AORN Joiirritil 16 (December 1987) 1 122113.1. Levesque. L. et al. ”E\.aluation of a presurgical group program given at two differenr times.” Rrwrrrch in Nirrsirrg & Hr~crlrh 7 (September 1981)2 7 - 3 6 , Parfitt. J M. ”Humorous preoperative teachingEffect on recall of postoperative exercise routines.“ AORN Joirrrial 5 2 (July 1990) 1 14- 120. Quinn. J C. ”Another dimension in post-anesthesia nursing“ JOi1,77(il of Posr Anesthrsio Nursing 1 (February 1986) 26-30. Shiniko. C. “The effect of preoperative instruc”
researcher consults with the hospital research committee. reviews proposals. and offers guidance and critiques. Helping other researchers ,ubmit proposals may be an additional function. An agcnc) benefits in a number of ways when i t e m p l o y s a nurse researcher. T h e researcher who c o n d u c t s his or h e r o w n research within the agency and cxposes clinicians to this process is of particular value. The
These studies reflect intraoperative concerns about anesthetic waste gas, types of anesthesia and their effects, reducing patient anxiety, ensuring patient safety, evaluating patient awareness during anesthesia, infection control, the responsibility of the perioperative nurse, and actual versus forcasted time for surgical procedures. Abbott. C A: Rodriguez, W P. “Delegating intraoperative activities: A pilot study.” AORN Journal 50 (August 1989) 338-35 1. Chung. F, et al. “General or spinal anesthesia: Which is better for the elderly?’ Anesthesiologs 67 (September 1987) 422-427. Copp. G. et al. “Footwear practices and operating room contamination.” Nursing Research 36 (Novemberrnecember 1987) 366-369. Copp. G, et al. “Covergowns and the control of operating room contamination.” Nursing
a c t i v e presence a n d visibility of n u r s e researchers serve to facilitate the practice of scientific inquiry as a part of the profession.6 Most agencies, however, currently expect the clinical nurse specialist (CNS) to fulfill this role. The CNS who must be educator, practitioner. and researcher may have difficulty balancing and prioritizing these roles. Nurse collaboration between and within departments or institutions also can improve
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AORN JOURNAL
Studies in Need of Replication Research 35 (September/October 1986) 263-268. Hartstein, A L, et al. “Nosocomial urinary tract infection: A preoperative evaluation of 108 catheterized patients.” Infection Control 2 (1981) 380-386. Kemp, M G, et al. “Factors that contribute to pressure sores in surgical patients.” Research in Nursing & Health 13 (October 1990)293-301. Kneedler, J A; Darling, M H. “Using an enzymatic detergent to prerinse instrument: A research study.” AORN Journal 51 (May 1990) 1326-1332. Okell, R W. “Awareness in pediatric anesthesia.” Anesthesia 41 (June 1986) 658-660. Plummer, J L, et al. “Attitudes of anaesthetists and nurses to anaesthetic pollution.” Anaesthesia and Intensive Care 15 (November 1987) 41 1-420. Pimke, L L. “OR scheduling: A study of actual versus projected time.” AORN Journal 49 (April 1989) 1083-1086.
Postoperative Care These studies address postoperative patient care, temperature, intracranial pressure, psychological responses, arterial line maintenence, pulmonary status, and nursing interventions for the family of patients. Campbell, K J. “The role of continuous passive
sharing of resources, increase communication, and prevent research duplication. Research can benefit all areas of practice and is not a competitive issue between departments or institutions. It is a general issue for all. Collaboration between peers is a satisfying personal and professional experience. Any relationship between researcher and practitioner is vital because research and use of its findings do not occur in isolation. It has been suggested that nursing
motion in the recovery and rehabilitation of the total knee prosthesis recipient.” Journal of Post Anesthesia Nursing 1 (August 1986) 161-169. Clifton, G D, et al. “Comparison of normal saline and heparin solutions for maintenance of arterial catheter patency.” Heart & Lung 20 (March 1991) 115-118. Erickson, R S; Yount, S T. “Comparison of tympanic and oral temperatures in surgical patients.” Nursing Research 40 (March/ April 1991) 90-93. Ingersoll, G L; Grippi, M A. “Preoperative pulmonary status and postoperative extubation outcome of patients undergoing elective cardiac surgery.” Heart & Lung 20 (March 1991) 137-143. Junge, C. “Development and evaluation of parental visitation in the PACU.” Journal of Post Anesthesia Nursing 2 (August 1987) 166-170. Knable, J. “Handholding: One means of transcending barriers of communication.” Heart & Lung 10 (NovembedDecember 1981) 1106-1110. Lim-Levy, F. “The effect of oxygen inhalation on oral temperature.” Nursing Research 3 1 (May/June 1982) 150-152. Mitchell, P H; Ozuna, J; Lipe, H P. “Moving the patient in bed: Effects on intracranial pressure.” Nursing Research 30 (July/ August 1981) 212-2188.
staff members’ attitudes and behaviors regarding the conducting and use of research reflect the attitudes and behaviors of their nursing service administrator^.^ Administrators and staff members must demonstrate a commitment to nursing research. Some strategies for doing this are to establish a research interest group where the stimulation for research activities is the focus. Journal clubs, in which an article pertinent to periopera585
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tive nursing care is discussed at each meeting. and strategies are identified to apply these ideas to practice, can be used in this way. Another strategy may be to initiate a small newsletter that deals with a particular topic, such as working with families of pediatric surgical patients. It is not important what is done. but how the s t a g e is set f o r r e s e a r c h . a n d h o w a healthy exchange among colleagues is develo p e d so that, ultimately. n u r s i n g c a r e is improved. Replication. Another method to facilitate practice-based research in perioperative nursing is to replicate previously conducted studies. Replication adds to the existing body of nursing knowledge by supporting or refuting research findings. Replication allows people to generalize validated research findings to other patient populations and settings. Also. it is easier to replicate a research study than to design an original proposal. Replication can help the nurse to learn the research process. The nurse who is considering conducting a study needs to ask: what has been done and what needs to be studied further? Some selected perioperative nursing studies in need of replication are listed i n Table 1 . These studies are examples of research that has generated conflicting findings or findings that cannot be generalized to any population other than that of the study. Literature reviews. Periodic, published literature reviews of timely topics also can facilitate the conducting and use of perioperative nursing research. These comprehensive reviews may make a significant contribution to nursing by clarifying the need for additional studies. Critique. critical review, and synthesis of studies by nurses educated in research design and methodology can help the practitioner understand the research questions, methods, limitations, and implications. This can help other nurses make educated decisions about whether to replicate the study with similar or different populations, design a new study, or apply the findings from completed studies. AORN recently published a 10-year review of selected topics of perioperative nursing 586
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research.8 These integrative literature reviews provide direction for future perioperative nursing research topics. As the body of perioperative knowledge generated by clinical research continues to grow, the question of whether results are valid and reliable will be asked by more practicing nurses. These comprehensive literature reviews help clinicians know what the next step should be in conducting and using perioperative research. New research. In considering a topic of research, investigators usually look to their own areas of practice and the research questions a n d c l i n i c a l p r o b l e m s i n that a r e a . Research questions are numerous in perioperative nursing. In an effort to prioritize these questions, AORN issued a statement that i d e n t i f i e s a r e a s of p e r i o p e r a t i v e nursing research that need to be explored (Table 2). Delineating research priorities is an effective way of shaping the direction of research so that limited funds are used wisely. In addition, research priorities clearly reflect the dominant concerns of the professional group. AORN supports a broad range of nursing research to advance the science of perioperative nursing, and i t pays particular attention to d e ve 1oping sc i e n t i fi c ration ii 1e s for re commended practices. Preferences for funding are given to studies that address the preparation of competent perioperative nurses, their influence on patient outcomes, and the frameworks required to provide quality nursing care. Perioperative nurse researchers might consider this list of research priorities in organizing their own areas of study. Publication. The lack of published, completed research studies hampers the translation of research findings into clinical practice applications. If perioperative nurse researchers want to improve patient care, they need to publish in journals that reach the practicing clinician as well as publishing in research journals. Researchers and clinicians have a responsibility to use research findings. Strategies to do this include publishing research in practice journals so clinicians can learn about new or current findings. Articles published in research
Table 2
Priorities for Perioperative Nursing Research 0
Development of scientific rationale for AORN recommended practices
0
Identification and classification of nursing practice phenomena specifically related to perioperative care
0
Development of instruments to measure perioperative nursing outcomes
0
Identification of nursing practices that ensure quality care while maintaining cost-effectiveness
0
Identification of nursing practices that ensure quality care for the surgical patient experiencing complex multi-system health problems
0
Description of nursing practices that provide effective care in alternative health care delivery systems
0
Development of educational programs to prepare perioperative nurses in evolving delivery systems
0
Identification of perioperative ethical issues and development of models to promote resolution
1 . “AORN policy, plan, and priority statement on nursing research,” AORN Journal 48 (September 1988) 436-439.
journals need to focus more strongly on the implications for clinical practice. In addition, clinicians need to read library copies of research journals and request that editors of practice journals regularly publish articles about research. The need for nurses to acquire skills in reading research is growing as the science of perioperative nursing develops. Although it is not essential for all nurses to conduct research, individual and collective professional growth mandates that all nurses read research. The challenges to conducting and using research can be met by strategies that facilitate practice-based perioperative nursing knowledge (Fig 1). These strategies include collaboration, replication, timely literature reviews, conducting new studies, and pub-
lishing. Despite all these strategies, research findings must be used on a widespread basis to benefit patient care.
Applying Research Findings
T
here is substantial evidence that there is a gap between knowledge production and knowledge use.9 It is clear that knowledge use, in general, and research use, in particular, are complex processes. Perioperative nursing science that specifically focuses on the generation and use of knowledge is evolving. At best, research always will be only a guide for perioperative practice. The practitioner will combine practical wisdom, derived from clinical experience, with an understanding of the patient’s situation and with knowledge derived from research to make a clinical 587
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Literature reviews Publication
\I/
Collaboration Perioperative
1
New studies
Replication
Clinical trials Fig 1. Activities that lead to increased perioperative research.
judgment to benefit the patient. A perioperative nurse has the potential to contribute substantially to the quality of patient care by following a few important suggestions. Stay current. Using research is as important as conducting it. Implementing the results requires that clinicians know about research findings. Practicing nurses must make ambitious attempts to remain current through reading research and practice journals. Critique studies. To use the findings in perioperative settings, nurses have to carefully consider the results. Before a study can be used in practice, it must be reviewed and evaluated carefully to determine the scientific merit of the study; nurses should keep in mind that one study is rarely a sound basis for changing practice. This review process involves critiquing the study design, sample size, selection criteria, research methods, and the validity and reliability of the research tools. Findings should be reported, including the data collection methods and data analysis techniques, the significance of the findings, the conclusions, the ability to generalize, and the limitations.'O Critiquing reports is helpful for staff members and can be used as a research learning tool. Clinical trials. Some studies with consistent findings suggest that a change in practice should be considered, but they require a large scale clini-
cal evaluation by perioperative nurses. Consistent or clinically significant findings should signal application of practice-based research activities. The following are selected research findings suggested for use in clinical trials: the effect of group instruction strategies on preoperative psychoeducation, preoperative relaxation techniques and their effect on postoperative pain, the effect of new procedures on biological hazards to personnel, the effects of compliance with recommended standards, the effect of clipping body hair on postoperative wound infection rates, the effect of one-minute alcohol skin preps on bacterial counts and cost effectiveness, 0 the effect of hyperventilation on patients with the administration of 100% oxygen in the postanesthesia care unit, 0 the effect of music on postoperative pain, and 0 the effect of prn suctioning of patients based on gas exchange and clinical symptoms. Carefully controlled clinical trials should follow exploratory and experimental efforts to answer problems encountered in perioperative nursing practice. 589
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Conclusion
T
h e need for research in perioperative nursing is evident in the number of questions being asked and the number of studies being generated by researchers and clinicians. There are challenges to conducting and using research, but there are strategies for meeting these challenges. T h e task is not always simple, and the way is not always clear. One thing is clear: the potential benefit to surgical patients demands that nurses do all that they can to advance the art and science of perioperative nursing through conducting and using research. Clinical c h a n g e s f r o m practice-based research already include modifications of specific nursing procedures. Some of these examples include decubiti care, intravenous and hyperalimentation line management, and tracheal suctioning. Nurses have researched more accurate documentation of services to patients, such as care planning protocols, special flow sheets, charting formats, and chart audits. Facilitating perioperative research requires that nurses continue to learn about the research process, change theory, and the application of research findings to practice. Helping staff m e m b e r s d e v e l o p s o m e familiarity with research methods and appreciation of researchbased practice is a worthwhile beginning. Clinicians often are the ones who begin the research process by identifying problem areas, and they are the ultimate users of the researchbased knowledge. If findings generated from nursing research are to have meaning for practicing nurses, research must begin where nursing is practiced. Administrators can encourage staff-member interest in research and secure the necessary support and resources. Researchers should include implications for nursing practice in their reports and make concrete and practical suggestions for formatting their findings for use in practice. Educators should assist nurses through the systematic review of research to help extract research-based knowledge that has validity and relevance for practice and to trans-
late the criteria for evaluating research findings into terms that clinicians can use. Through these efforts, the scientific base of perioperative nursing will continue to expand. The greater the extent to which nursing practice is based on research, the higher the quality of that practice. This benefits both perioperative nurses and patients. I I Notes
1. M L McClure, “Promoting practice-based research: A critical need,” Journal of Nursing Administration 1 1 (NovemberDecember 1981) 6670; E A Hefferin, J A Horsley, M R Ventura, “Promoting research-based nursing: The nurse ad mi n i s t r a t or ’s r o 1e , Jo u m a 1 of Nu rs in g Administration 12 (May 1982) 34-41. 2. L R Cronenwett, “Research and the staff nurse: Troublesome issues,” Journal of Nursing Administration 16 (November 1986) 7-8. 3. K T Kirchhoff, “Using research in practice: Should staff nurses be expected to use research?’ Western Journal of Nursing Research 5 (Summer 1983) 245-47. 4. Hefferin, Horsley, Ventura, “Promoting research-based nursing: The nurse administrator’s role,’’ 34-4 1. 5. Ibid, 36. 6. McClure, “Promoting practice-based research: A critical need,” 66-70. 7. Hefferin, Horsley, Ventura, “Promoting research-based nursing: The nurse administrator’s role,” 34-4 1. 8. Perioperative nursing research: A ten year review (Denver: Association of Operating Room Nurses, Inc, 1989). 9. C A Tanner, “Evaluating research for use in practice: Guidelines for the clinician,” Hearr & Lung 16 (July 1987) 424-43I . 10. M C Alderman, “Using research in clinical practice: A staff nurse’s guide,” Perioperative Nursing Quarterly 1 (December 1985) 10-16; K L Soeken, “Critiquing research: Steps for complete evaluation of an article,” AORN Journal 41 (May 1985) 882-93. ”
AORN JOURNAL
Practice-Based Perioperative Research MEETING THE CHALLENGES Jane Stover Leske, RN
T
he aim of perioperative nursing research is to produce a body of knowledge from which events or situations related to surgical intervention, human responses to these events, and the relationships between these events and responses can be described, explored, understood, predicted, andlor possibly controlled. The goal is to improve the care to surgical patients. Most nurses recognize the importance of designing and executing studies, implementing innovations and findings, and documenting and evaluating the many ways that perioperative nursing makes a difference in patient outcomes. The benefits of clinical research are well acclaimed, yet there are challenges to overcome in conducting and using perioperative nursing research.
standing of how research affects perioperative nursing practice, support for clinical studies may be limited. Any research project entails a prolonged commitment and requires support from others. Nursing service, at all levels, needs to be supportive of agency- and unit-based research projects. Department and unit administrators must recognize and reward the efforts of perioperative nurses who are striving for research competence. Time may be needed for the researcher to study a particular clinical problem. Other supportive activities may include funding travel so a nurse
Pe rioperative Nursing Research Challenges
R
esearch has been the force for change in clinical nursing practice, and most perioperative nurses are aware of important studies and results. Recognizing the need for research is not enough, however. Perioperative nurses also need to develop strategies to overcome these challenges and use research findings to advance the art and science of perioperative nursing practice. Lack of perceived value and commitment. Some authors report a lack of commitment to the use or generation of new knowledge in the practice setting.' Because of this lack of under-
Jane Stover Leske, RN, PhD, is an assistant professor at the University of Wisconsin at Milwaukee and holds a post-doctoral fellowship at the University of Utah, College of Nursing, Salt Lake City. She earned her bachelor of science and muster of science degrees in nursing at Marguette University, Milwaukee, and her doctoral degree in nursing a t the University of Wisconsin,Milwaukee. sni
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FEBRUARY 1992, VOL 5 5 , NO 2
Clinical studies that document the effectiveness and cost of perioperative nursing interventions are needed desperately.
can attend a research conference or recognizing the value of nursing research through a clinical ladder program. Individual nursing administrators can sell the idea to others. sanction the research process, and foster changes in clinical roles and responsibilities with a supportive environment. Even when research activities are factored into budgets and staffing arrangements. practitioners may perceive the responsibilities associated with sporadic studies as ”extra work.” Also. s o m e c l i n i c i a n s may believe that researchers have not been interested in clinical problems. This is changing, however. because nurses are beginning to see that the purpose of nursing research is to benefit pa!ient care. Ways to reward staff members for research activities are needed to tip the balance of rewards and costa i n the favor of enthusiastic participation.’ If clinically relevant study results are made available to nurses. the value of and need for more nursing studies will become apparent when persistent problems arise i n the delivery of care, when nursing standards are being developed. or when changes in procedures are being considered. Clinical studies that document the effectiveness and cost of perioperative nursing interventions are needed desperately. Limited access to resources. Perioperative nurses conducting and using research may find access to resources challenging. This challenge may include limited access to subjects. equipment. settings. other researchers, and money. Getting the right resources can be very time consuming and frustrating. Developing a research proposal lor an approval-granting body (eg, hospital research committee. formal institutional review board) can be the most lengthy and stressful of all. An approval committee may be composed of physicians and may require the nurse to seek the support o r sponsorship of a physician 582
colleague to conduct the study. Some studies require special equipment, which d e p e n d s on collaboration between departments. Conducting a study without someone to h e l p c o n c e p t u a l i z e a n d f o r m u l a t e methodological issues can make research more difficult. A viable alternative is having a researcher and clinician conduct collaborative projects. Another challenge may be to find the funds needed to conduct the study, Research money is in short supply, and the competition for it is strong; however, it can be obtained.
Lack of research experience and education. Not all perioperative nurses have the academic preparation and experience to pursue answers to clinical questions or use research results. Nursing students at all educational levels can participate in conducting research, but course content on research usually is not begun until the baccalaureate level. Baccalaureate research courses generally provide some experience in the conduct and critique of research; however, information a b o u t w h e n a n d how to u s e research may be omitted.’ More advanced nursing research education usually does not occur until the master’s degree level, and research exposure and experience may not be consistent at all levels of nursing education. In addition, not all nurses are interested in. exposed to, prepared for, or experienced in the research process. In order to facilitate practice-based research, perioperative nurses need to foster, develop, and support professionals who are interested in research and who expose others to the research process. Unavailability of f i n d i n g s . T h e b e s t intended plans for facilitating practice-based perioperative research can be hindered by a lack of understandable research findings. Much has been said about the need to publish nursing research, particularly in the practice journals. As these journals begin to publish
FEBRUARY 1992, VOL 55, NO 2
more nursing research, clinicians will have access to research data. Designing and conducting a research project in the clinical setting means dealing with objectivity and applicability. Ideally, scientific inquiry requires that knowledge be produced under unbiased conditions. In practice-based research, the desire for a specific outcome can affect the accuracy of the information obtained. Knowledge obtained through research is meant to be useful in practice ultimately, but scientific inquiry does not demand that the information produced be applicable immediately. Clinical practice, however, requires immediate information for use in improving patient care. A study's findings should be appropriate to the clinical area. Research findings must be reviewed critically to be applied appropriately. Publishing research results and presenting and discussing study findings at conferences are not sufficient for translating research results into practice." Nurses who wish to use research findings often find it difficult to evaluate the quality of the research report and often fail to see the applicability of the findings in their own area of practice. Often, the practicing nurse does not use research study findings because he or she does not understand research language. If findings and implications for clinical practice are presented succinctly and in a readable form, practitioners will be more apt to use the research results.
Overcoming Research Challenges
C
hallenges to perioperative nursing research may be perceived as obstacles or roadblocks to conducting and using perioperative nursing research. Some of the major contributing factors that limit the use of research findings are as follows. 0 Findings may not be interpreted or presented in understandable terms that are useful in practice. 0 Access to results may be limited by publication in research journals and presentation of findings only at research conferences.
AORN JOURNAL
Reliability, validity, and generalizability of findings may be questionalbe because few, if any, replications have been done. Nursing research may be viewed as irrelevant to clinical practice, and care provided to patients is according to approaches learned in basic nursing education or what is encountered in the workplace. Lack of systematic research review by nurses to extract knowledge that has validity and relevance for clinical practice. Lack of nursing professionals with expertise in research and clinical practice.s Despite these challenges, the following strategies foster the perioperative nursing research process. Collaboration. Collaboration means merging the talents of health care workers with a diversity of backgrounds and motivations for the research process. Nurse-to-nurse collaboration is a significant strategy that maximizes the conducting and use of research. Collaboration may occur between nursing service and education personnel, within and between institutions, and between researchers and practitioners. Several conditions that are necessary for a practice-based research environment are facilitated by the collaboration between nursing service and education. This collaboration can be a group of people with preparation, experience, and interest in research who can devise and understand mechanisms for funding. The availability of essential facilities and resources (eg, computers, statistical consultants) also can be enhanced with this type of collaboration. The presence of support systems is better when nursing service and education personnel work together. Practice-based research actually may serve to bridge the gap between service and education and foster an increased valuing of clinical practice among academicians. Some agencies employ an educator who uses 10% to 20% of his or her time as a research facilitator. This research facilitator can have various responsibilities depending on the needs of the agency. Most likely, the 583
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Table 1
Selected Perioperative Nursing Preoperative care The following studies pertain to preoperative patient anxiety. characteristics. knowledge, education. assessment. and outcomes. Durst. L M. ”Preoperative teaching videotape: The effect o n children‘s behavior.“ AORN 5oiirnd 52 (September 1990)576-584. Dziurbejko. M M: Larkin. J C. “including the family in preoperative teaching.” Americnr~ JoiiriioI of Nursing 78 (November 1978 I
tion on state anxiety.” Journal of Neurosurgical Nursing I3 (December 1981) 318-322. Takahashi, J J; Bever, S C. “Preoperative nursing assessment: A research study.” A O R N Journril 50 ( N o v e m b e r 1989) 1022-1035. Vogelsang, J: Ragiel, C. “Anxiety levels in female surgical patients.” Journal of Post Anesthesia Nursing 2 (November 1987) 230-236.
Intraoperative care
1893-1x91.
Klos, D. et al. ”A comparison of two methods of de 1 i ver i n g pi-es u rg ic al instructions . Pcirient Coiinsdiiig & Hroltl7 E&c~ition 2 (First Quarter 1980) 6-13. LeuLe. M: McKenzie. J . “Preoperative assess-ment: Using the Roy adaptation model.” AORN Joiirritil 16 (December 1987) 1 122113.1. Levesque. L. et al. ”E\.aluation of a presurgical group program given at two differenr times.” Rrwrrrch in Nirrsirrg & Hr~crlrh 7 (September 1981)2 7 - 3 6 , Parfitt. J M. ”Humorous preoperative teachingEffect on recall of postoperative exercise routines.“ AORN Joirrrial 5 2 (July 1990) 1 14- 120. Quinn. J C. ”Another dimension in post-anesthesia nursing“ JOi1,77(il of Posr Anesthrsio Nursing 1 (February 1986) 26-30. Shiniko. C. “The effect of preoperative instruc”
researcher consults with the hospital research committee. reviews proposals. and offers guidance and critiques. Helping other researchers ,ubmit proposals may be an additional function. An agcnc) benefits in a number of ways when i t e m p l o y s a nurse researcher. T h e researcher who c o n d u c t s his or h e r o w n research within the agency and cxposes clinicians to this process is of particular value. The
These studies reflect intraoperative concerns about anesthetic waste gas, types of anesthesia and their effects, reducing patient anxiety, ensuring patient safety, evaluating patient awareness during anesthesia, infection control, the responsibility of the perioperative nurse, and actual versus forcasted time for surgical procedures. Abbott. C A: Rodriguez, W P. “Delegating intraoperative activities: A pilot study.” AORN Journal 50 (August 1989) 338-35 1. Chung. F, et al. “General or spinal anesthesia: Which is better for the elderly?’ Anesthesiologs 67 (September 1987) 422-427. Copp. G. et al. “Footwear practices and operating room contamination.” Nursing Research 36 (Novemberrnecember 1987) 366-369. Copp. G, et al. “Covergowns and the control of operating room contamination.” Nursing
a c t i v e presence a n d visibility of n u r s e researchers serve to facilitate the practice of scientific inquiry as a part of the profession.6 Most agencies, however, currently expect the clinical nurse specialist (CNS) to fulfill this role. The CNS who must be educator, practitioner. and researcher may have difficulty balancing and prioritizing these roles. Nurse collaboration between and within departments or institutions also can improve
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Studies in Need of Replication Research 35 (September/October 1986) 263-268. Hartstein, A L, et al. “Nosocomial urinary tract infection: A preoperative evaluation of 108 catheterized patients.” Infection Control 2 (1981) 380-386. Kemp, M G, et al. “Factors that contribute to pressure sores in surgical patients.” Research in Nursing & Health 13 (October 1990)293-301. Kneedler, J A; Darling, M H. “Using an enzymatic detergent to prerinse instrument: A research study.” AORN Journal 51 (May 1990) 1326-1332. Okell, R W. “Awareness in pediatric anesthesia.” Anesthesia 41 (June 1986) 658-660. Plummer, J L, et al. “Attitudes of anaesthetists and nurses to anaesthetic pollution.” Anaesthesia and Intensive Care 15 (November 1987) 41 1-420. Pimke, L L. “OR scheduling: A study of actual versus projected time.” AORN Journal 49 (April 1989) 1083-1086.
Postoperative Care These studies address postoperative patient care, temperature, intracranial pressure, psychological responses, arterial line maintenence, pulmonary status, and nursing interventions for the family of patients. Campbell, K J. “The role of continuous passive
sharing of resources, increase communication, and prevent research duplication. Research can benefit all areas of practice and is not a competitive issue between departments or institutions. It is a general issue for all. Collaboration between peers is a satisfying personal and professional experience. Any relationship between researcher and practitioner is vital because research and use of its findings do not occur in isolation. It has been suggested that nursing
motion in the recovery and rehabilitation of the total knee prosthesis recipient.” Journal of Post Anesthesia Nursing 1 (August 1986) 161-169. Clifton, G D, et al. “Comparison of normal saline and heparin solutions for maintenance of arterial catheter patency.” Heart & Lung 20 (March 1991) 115-118. Erickson, R S; Yount, S T. “Comparison of tympanic and oral temperatures in surgical patients.” Nursing Research 40 (March/ April 1991) 90-93. Ingersoll, G L; Grippi, M A. “Preoperative pulmonary status and postoperative extubation outcome of patients undergoing elective cardiac surgery.” Heart & Lung 20 (March 1991) 137-143. Junge, C. “Development and evaluation of parental visitation in the PACU.” Journal of Post Anesthesia Nursing 2 (August 1987) 166-170. Knable, J. “Handholding: One means of transcending barriers of communication.” Heart & Lung 10 (NovembedDecember 1981) 1106-1110. Lim-Levy, F. “The effect of oxygen inhalation on oral temperature.” Nursing Research 3 1 (May/June 1982) 150-152. Mitchell, P H; Ozuna, J; Lipe, H P. “Moving the patient in bed: Effects on intracranial pressure.” Nursing Research 30 (July/ August 1981) 212-2188.
staff members’ attitudes and behaviors regarding the conducting and use of research reflect the attitudes and behaviors of their nursing service administrator^.^ Administrators and staff members must demonstrate a commitment to nursing research. Some strategies for doing this are to establish a research interest group where the stimulation for research activities is the focus. Journal clubs, in which an article pertinent to periopera585
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tive nursing care is discussed at each meeting. and strategies are identified to apply these ideas to practice, can be used in this way. Another strategy may be to initiate a small newsletter that deals with a particular topic, such as working with families of pediatric surgical patients. It is not important what is done. but how the s t a g e is set f o r r e s e a r c h . a n d h o w a healthy exchange among colleagues is develo p e d so that, ultimately. n u r s i n g c a r e is improved. Replication. Another method to facilitate practice-based research in perioperative nursing is to replicate previously conducted studies. Replication adds to the existing body of nursing knowledge by supporting or refuting research findings. Replication allows people to generalize validated research findings to other patient populations and settings. Also. it is easier to replicate a research study than to design an original proposal. Replication can help the nurse to learn the research process. The nurse who is considering conducting a study needs to ask: what has been done and what needs to be studied further? Some selected perioperative nursing studies in need of replication are listed i n Table 1 . These studies are examples of research that has generated conflicting findings or findings that cannot be generalized to any population other than that of the study. Literature reviews. Periodic, published literature reviews of timely topics also can facilitate the conducting and use of perioperative nursing research. These comprehensive reviews may make a significant contribution to nursing by clarifying the need for additional studies. Critique. critical review, and synthesis of studies by nurses educated in research design and methodology can help the practitioner understand the research questions, methods, limitations, and implications. This can help other nurses make educated decisions about whether to replicate the study with similar or different populations, design a new study, or apply the findings from completed studies. AORN recently published a 10-year review of selected topics of perioperative nursing 586
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research.8 These integrative literature reviews provide direction for future perioperative nursing research topics. As the body of perioperative knowledge generated by clinical research continues to grow, the question of whether results are valid and reliable will be asked by more practicing nurses. These comprehensive literature reviews help clinicians know what the next step should be in conducting and using perioperative research. New research. In considering a topic of research, investigators usually look to their own areas of practice and the research questions a n d c l i n i c a l p r o b l e m s i n that a r e a . Research questions are numerous in perioperative nursing. In an effort to prioritize these questions, AORN issued a statement that i d e n t i f i e s a r e a s of p e r i o p e r a t i v e nursing research that need to be explored (Table 2). Delineating research priorities is an effective way of shaping the direction of research so that limited funds are used wisely. In addition, research priorities clearly reflect the dominant concerns of the professional group. AORN supports a broad range of nursing research to advance the science of perioperative nursing, and i t pays particular attention to d e ve 1oping sc i e n t i fi c ration ii 1e s for re commended practices. Preferences for funding are given to studies that address the preparation of competent perioperative nurses, their influence on patient outcomes, and the frameworks required to provide quality nursing care. Perioperative nurse researchers might consider this list of research priorities in organizing their own areas of study. Publication. The lack of published, completed research studies hampers the translation of research findings into clinical practice applications. If perioperative nurse researchers want to improve patient care, they need to publish in journals that reach the practicing clinician as well as publishing in research journals. Researchers and clinicians have a responsibility to use research findings. Strategies to do this include publishing research in practice journals so clinicians can learn about new or current findings. Articles published in research
Table 2
Priorities for Perioperative Nursing Research 0
Development of scientific rationale for AORN recommended practices
0
Identification and classification of nursing practice phenomena specifically related to perioperative care
0
Development of instruments to measure perioperative nursing outcomes
0
Identification of nursing practices that ensure quality care while maintaining cost-effectiveness
0
Identification of nursing practices that ensure quality care for the surgical patient experiencing complex multi-system health problems
0
Description of nursing practices that provide effective care in alternative health care delivery systems
0
Development of educational programs to prepare perioperative nurses in evolving delivery systems
0
Identification of perioperative ethical issues and development of models to promote resolution
1 . “AORN policy, plan, and priority statement on nursing research,” AORN Journal 48 (September 1988) 436-439.
journals need to focus more strongly on the implications for clinical practice. In addition, clinicians need to read library copies of research journals and request that editors of practice journals regularly publish articles about research. The need for nurses to acquire skills in reading research is growing as the science of perioperative nursing develops. Although it is not essential for all nurses to conduct research, individual and collective professional growth mandates that all nurses read research. The challenges to conducting and using research can be met by strategies that facilitate practice-based perioperative nursing knowledge (Fig 1). These strategies include collaboration, replication, timely literature reviews, conducting new studies, and pub-
lishing. Despite all these strategies, research findings must be used on a widespread basis to benefit patient care.
Applying Research Findings
T
here is substantial evidence that there is a gap between knowledge production and knowledge use.9 It is clear that knowledge use, in general, and research use, in particular, are complex processes. Perioperative nursing science that specifically focuses on the generation and use of knowledge is evolving. At best, research always will be only a guide for perioperative practice. The practitioner will combine practical wisdom, derived from clinical experience, with an understanding of the patient’s situation and with knowledge derived from research to make a clinical 587
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Literature reviews Publication
\I/
Collaboration Perioperative
1
New studies
Replication
Clinical trials Fig 1. Activities that lead to increased perioperative research.
judgment to benefit the patient. A perioperative nurse has the potential to contribute substantially to the quality of patient care by following a few important suggestions. Stay current. Using research is as important as conducting it. Implementing the results requires that clinicians know about research findings. Practicing nurses must make ambitious attempts to remain current through reading research and practice journals. Critique studies. To use the findings in perioperative settings, nurses have to carefully consider the results. Before a study can be used in practice, it must be reviewed and evaluated carefully to determine the scientific merit of the study; nurses should keep in mind that one study is rarely a sound basis for changing practice. This review process involves critiquing the study design, sample size, selection criteria, research methods, and the validity and reliability of the research tools. Findings should be reported, including the data collection methods and data analysis techniques, the significance of the findings, the conclusions, the ability to generalize, and the limitations.'O Critiquing reports is helpful for staff members and can be used as a research learning tool. Clinical trials. Some studies with consistent findings suggest that a change in practice should be considered, but they require a large scale clini-
cal evaluation by perioperative nurses. Consistent or clinically significant findings should signal application of practice-based research activities. The following are selected research findings suggested for use in clinical trials: the effect of group instruction strategies on preoperative psychoeducation, preoperative relaxation techniques and their effect on postoperative pain, the effect of new procedures on biological hazards to personnel, the effects of compliance with recommended standards, the effect of clipping body hair on postoperative wound infection rates, the effect of one-minute alcohol skin preps on bacterial counts and cost effectiveness, 0 the effect of hyperventilation on patients with the administration of 100% oxygen in the postanesthesia care unit, 0 the effect of music on postoperative pain, and 0 the effect of prn suctioning of patients based on gas exchange and clinical symptoms. Carefully controlled clinical trials should follow exploratory and experimental efforts to answer problems encountered in perioperative nursing practice. 589
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Conclusion
T
h e need for research in perioperative nursing is evident in the number of questions being asked and the number of studies being generated by researchers and clinicians. There are challenges to conducting and using research, but there are strategies for meeting these challenges. T h e task is not always simple, and the way is not always clear. One thing is clear: the potential benefit to surgical patients demands that nurses do all that they can to advance the art and science of perioperative nursing through conducting and using research. Clinical c h a n g e s f r o m practice-based research already include modifications of specific nursing procedures. Some of these examples include decubiti care, intravenous and hyperalimentation line management, and tracheal suctioning. Nurses have researched more accurate documentation of services to patients, such as care planning protocols, special flow sheets, charting formats, and chart audits. Facilitating perioperative research requires that nurses continue to learn about the research process, change theory, and the application of research findings to practice. Helping staff m e m b e r s d e v e l o p s o m e familiarity with research methods and appreciation of researchbased practice is a worthwhile beginning. Clinicians often are the ones who begin the research process by identifying problem areas, and they are the ultimate users of the researchbased knowledge. If findings generated from nursing research are to have meaning for practicing nurses, research must begin where nursing is practiced. Administrators can encourage staff-member interest in research and secure the necessary support and resources. Researchers should include implications for nursing practice in their reports and make concrete and practical suggestions for formatting their findings for use in practice. Educators should assist nurses through the systematic review of research to help extract research-based knowledge that has validity and relevance for practice and to trans-
late the criteria for evaluating research findings into terms that clinicians can use. Through these efforts, the scientific base of perioperative nursing will continue to expand. The greater the extent to which nursing practice is based on research, the higher the quality of that practice. This benefits both perioperative nurses and patients. I I Notes
1. M L McClure, “Promoting practice-based research: A critical need,” Journal of Nursing Administration 1 1 (NovemberDecember 1981) 6670; E A Hefferin, J A Horsley, M R Ventura, “Promoting research-based nursing: The nurse ad mi n i s t r a t or ’s r o 1e , Jo u m a 1 of Nu rs in g Administration 12 (May 1982) 34-41. 2. L R Cronenwett, “Research and the staff nurse: Troublesome issues,” Journal of Nursing Administration 16 (November 1986) 7-8. 3. K T Kirchhoff, “Using research in practice: Should staff nurses be expected to use research?’ Western Journal of Nursing Research 5 (Summer 1983) 245-47. 4. Hefferin, Horsley, Ventura, “Promoting research-based nursing: The nurse administrator’s role,’’ 34-4 1. 5. Ibid, 36. 6. McClure, “Promoting practice-based research: A critical need,” 66-70. 7. Hefferin, Horsley, Ventura, “Promoting research-based nursing: The nurse administrator’s role,” 34-4 1. 8. Perioperative nursing research: A ten year review (Denver: Association of Operating Room Nurses, Inc, 1989). 9. C A Tanner, “Evaluating research for use in practice: Guidelines for the clinician,” Hearr & Lung 16 (July 1987) 424-43I . 10. M C Alderman, “Using research in clinical practice: A staff nurse’s guide,” Perioperative Nursing Quarterly 1 (December 1985) 10-16; K L Soeken, “Critiquing research: Steps for complete evaluation of an article,” AORN Journal 41 (May 1985) 882-93. ”
