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Exploring Learning Experiences and Selected Nurse, Patient Safety and Organizational Outcomes Associated with a Research Capacity Building Strategy

Lianne Jeffs St. Michael’s Hospital (Toronto, ON)

October 2009

Exploring Learning Experiences

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This work was funded by a contribution from the Canadian Council on Learning

All documents produced by the Canadian Council on Learning (CCL) will be available in both French and English. However, documents produced by external organizations for CCL will be posted on the website only in the language of origin. When a full translation is not available, CCL will ensure that an executive summary is available in the other official language.

The opinions expressed herein are solely those of the authors. The Canadian Council on Learning bears no responsibility for its content.


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Exploring Learning Experiences and Selected Nurse, Patient Safety and Organizational Outcomes Associated with a Research Capacity Building Strategy

Executive Summary A large proportion of annual preventable deaths from adverse events in healthcare is posited to be related to the lack of research use in clinical practice.1, 2 Given that the conduct and use of high-quality, clinically significant research has long-reaching benefits for both patients and the nursing profession, it is imperative that nurses take a lead role in generating knowledge in safer health care practices and translating this knowledge to the point of care. Specifically, nursing leadership in scholarly investigations is essential to the design and delivery of safe and effective health care.3-6 Moreover, nurses on the frontlines of patient care are ideally situated to identify phenomena that are clinically relevant and pose questions for research.7,8 Nurses’ ability to contribute to the evolving patient safety knowledge base through research is contingent upon several critical factors, including, but not limited to, possession of competencies required to conduct research and translate empirical findings,4, 9, 10 organizational commitment to nurse participation in research,3,11 and the availability of funding for patient safety research projects. Research capacity building approaches, defined as activities designed to enhance the ability within a discipline or professional group to undertake high-quality research,12 must strategically address these in order to be successful. The literature on research capacity in nursing reveals a need for more empirical studies to examine the learning processes, experiences, and outcomes of nursing research capacity building in organizational settings.13 To date, the literature base describing the effectiveness of nursing research capacity strategies has been limited to academic departments; 13 students in internships/fellowships in patient safety; 14, 15 and research utilization and/or evidence based practice amongst nurses in health care settings; 2,16 with less of a focus on research capacity building as a continuous professional development opportunity for nurses employed in health care organizations.17 Moreover, there were no descriptions of safetyoriented research capacity building strategies for point of care nurses practicing in a hospital setting in the literature to date. It is thus posited that targeting research capacity building opportunities to front line nurses will allow for the identification of patient-centered phenomena and the formulation of research questions with clinical relevance.4 In this context, a descriptive, mixed methods study was conducted that examined selected outcomes (nursing, patient, and organizational) and learning experiences (knowledge translation) associated with the implementation of a research capacity intervention with nurses. Given methodological challenges (small sample size and missing data elements) analysis was limited to a description of the selected nursing (satisfaction, research utilization and barriers to research utilization); patient safety (patient satisfaction, falls, pressure ulcers, hospital acquired pneumonia and medication errors); and organizational (turnover, absenteeism, overtime and agency use) outcomes. However, the qualitative aspect of the study revealed a rich narrative whereby four key themes emerged. From the thematic analysis of interview data involving 9 registered nurses from a teaching hospital, the following four overlapping themes emerged: 1) raising the bar for nursing and safer care through research; 2) having someone always behind you while taking steps; 3) riding the ups and downs of the RAP wave; and 4) paving the way for others to engage in research. Collectively, study findings add to both the evolving patient safety science knowledge base and the understanding of the methodological challenges associated with


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measuring outcomes of targeted research capacity building strategies for individual nurses and the nursing profession.


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1.0. Overview The report provides a detailed description of the Exploring Learning Experiences and Selected Nurse, Patient Safety and Organizational Outcomes Associated With a Research Capacity Building Strategy study funded by the Canadian Council on Learning (Health and Learning Research Competition). This report is organized under the following sections: background and rationale for study; research methodology (research questions, the intervention, methods, measures and analytical approach); results (research questions # 1 & 2) with embedded data tables and figures; and implications/conclusions. 2.0. Background and Rationale for Study A large proportion of annual preventable deaths from adverse events in healthcare is posited to be related to the lack of research use in clinical practice.1, 2 Given that the conduct and use of high-quality, clinically significant research has long-reaching benefits for both patients and the nursing profession, it is imperative that nurses take a lead role in generating knowledge in safer health care practices and translating this knowledge to the point of care. Specifically, nursing leadership in scholarly investigations is essential to the design and delivery of safe and effective health care.3-6 Moreover, nurses on the frontlines of patient care are ideally situated to identify phenomena that are clinically relevant and pose questions for research.7,8 Nurses’ ability to contribute to the evolving patient safety knowledge base through research is contingent upon several critical factors, including, but not limited to, possession of competencies required to conduct research and translate empirical findings,4, 9, 10 organizational commitment to nurse participation in research,3,11 and the availability of funding for patient safety research projects. Research capacity building approaches, defined as activities designed to enhance the ability within a discipline or professional group to undertake high-quality research,12 must strategically address these in order to be successful. The literature on research capacity in nursing reveals a need for more empirical studies to examine the learning processes, experiences, and outcomes of nursing research capacity building in organizational settings.13 To date, the literature describing the effectiveness of nursing research capacity strategies has been limited to academic departments; 13 students in internships/ fellowships in patient safety; 14, 15 and research utilization and/or evidence based practice amongst nurses in health care settings; 2,16 with less of a focus on research capacity building as a continuous professional development opportunity for nurses employed in health care organizations.17 Moreover, there are no descriptions of safety-oriented research capacity building strategies for point of care nurses practicing in a hospital setting in the literature to date. It is thus posited that targeting research capacity building opportunities to front line nurses will allow for the identification of patient-centered phenomena and the formulation of research questions with clinical relevance.4


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3.0. Research Methodology A description of the research methodology that was employed in this study is organized under the following sub-headings: research questions, the intervention, and the methods and measures. 3.1. Research Questions Derived from the aforementioned gap in literature described in section 2.0, the following two research questions with aligned hypotheses for research question # 1 guided the inquiry. Research Question 1) Is there a difference on selected nursing, patient safety and organizational outcomes after the introduction of a research capacity building strategy? Within this research question, the following hypotheses were posited: Hypothesis # 1) Study participants will report greater satisfaction, less barriers to research utilization, and more research productivity/involvement in research one year after the introduction of the research capacity building strategy. Hypothesis # 2) In the clinical/program/departmental areas that are involved in the study intervention, a lower rate of medication errors, falls, hospital-acquired pneumonia, and pressure ulcers and higher rate of patient satisfaction will be reported compared to the overall aggregate corporate hospital rates. Hypothesis # 3) In the clinical/program/departmental areas that are involved in the study intervention, a lower rate of turnover, absenteeism, overtime and agency use will be reported compared to the overall aggregate corporate hospital rates. Research Question # 2 What are the learning experiences associated with the research capacity building strategy of participating nurses and other health care professionals? The exploratory nature of this question precluded hypothesis formulation for testing. 3.2. The Intervention The premise of the overall intervention (research capacity building strategy) was to create both a cultural shift and structural investment in creating learning opportunities targeted for nurses at the point of care to participate in the research process. The initiative’s key aim was to establish a corporate value in nurses’ contribution to research within an organized structure (integrated curriculum) and aligned resources (both internal and external academic and professional association partners). Given the target were nurses at the point of care (clinical nurses and/or staff nurses), there was an open call for Letters of Intents (LOIs) hospital wide. There were a series of 4 general information sessions; invited sessions on clinical units; and both hard copy information packages and electronic submission packages that included a LOI submission template was sent out corporate wide to the Clinical Directors and Managers at the hospital. The submitted LOIs were reviewed using the selection criteria described below by a Scientific Review and Advisory Committee and rated using a criteria worksheet. This committee had


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broad inter-professional representation from the hospital and community partners (University of Toronto, Ryerson University, York University and College of Nurses of Ontario). Selection Criteria for Clinically-Relevant Research Projects: 1) Demonstration of one or more of nursing core competencies articulated in the SMH Professional Nursing Care Delivery Model: a) provide patient-centred care; b) employ evidence-based practice; c) work in interdisciplinary teams; d) apply quality improvement; and e) utilize informatics derived from the Institute of Medicine’s Health Care Professional Core Competencies. 2) Takes place in a clinical or community affiliated setting, where SMH nurses provide care; led by a nurse as Principal and/or Co-Principal, involves at least one staff/clinical nurse and can involve interdisciplinary members. 3) A maximum of 1 project per clinical program and department will be awarded. 4) A minimum of 5 out of the 10 funded projects will be linked to the priority clinical safety areas (falls, pressure ulcers, hospital-acquired pneumonia and medication errors). 5) Research study is conducted and completed (or close to completion) by end of 2007. 6) Endorsement from management (Clinical Leader Manager/Manager, Program Director) to participate in related activities associated with the research capacity building strategy. Out of 22 LOI submissions, twelve were selected for inclusion in the inaugural Nursing RAP program. Box 1 provides an overview of the successful research topic areas that were selected to be explored as part of the intervention. Box 1 Original Nursing RAP Program Research Projects Topic Areas • Fall Risk in Patients Post-Cardiovascular Surgery: Does Delirium Play a Role? • An Observational Study of the Medical Surgical Intensive Care Unit (MSICU): Examining Staff Implementation of Interventions to Prevent/Treat Pressure Breakdown of the Sacrum and/or Heels, and the Impact on Pressure Ulcer Incidence • A Study to Evaluate the Incidence & Prevalence of Physical Restraint Use in the Critical Care Environment • Nurses’ Perceptions of Pain Behavior in the Assessment of the Nonverbal End-of-Life Patient • Quality of Life for Patients Living in the Community with Enterocutaneous Fistulas • Strategies to Reduce Medication Error and Increase Patient Safety in the Emergency Department • Effectiveness of an Educational Intervention to Enhance Nursing Competencies in the Care of Patient with Late Vasospasm Post Subarrachnoid Hemorrhage • Physical Restraint as a Nursing-Sensitive Adverse Outcome In Acute Care Psychiatric Treatment Settings: An Exploratory Study of the Perceptions of Registered Nurses in an Inner City Mental Health Service • Examining the Relationship Between the Use of Sugarless Candy and Thirst in Hemodialysis Out-Patients: The Sugarless Candy Study • Diabetes Prevention Study • Evaluating the Effectiveness of an Education Program Provided to Nurses on the Use of the Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) Scale and Pre-printed Order Form on a General Internal Medicine Unit • Evaluating the Impact of a Falls Prevention Partnership on Emergency Department (ED) Nursing Practice (withdrawn)


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The successful applicants were guided through the integrated curriculum to develop a full research proposal for submission to the St. Michael’s Hospital Research Ethics Board for approval. Specifically, the research capacity building strategy consisted of an 18 month program [Nursing Research Advancing Practice (RAP) Program] that used a mentorship framework to equip participants with the competencies required to develop, implement and evaluate a research project based on a clinical idea and/or improvement. In this context, the mentorship framework for the research capacity building strategy involved creating communities of practice where research teams participated in an integrated curriculum that was a partnership between existing internal expertise (SMH researchers and research administration), external academic partners (University of Toronto, Ryerson University and York University), and nursing’s professional regulatory body (College of Nurses of Ontario). Communities of practice are created when individual members in an organization learn by participating in a shared activity that is situated in social contexts with workplaces and in occupational communities.18-19 Table 1 provides an overview of the integrated curriculum.

Table 1 Integrated Research Capacity Building in Nursing Practice Curriculum Module Module Module Module Module Module Module Module Module Module Module

1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11:

Research Capacity Module Defining the Research Question Transforming a Clinically Relevant Question to A Research/Search Question Research with Human Subjects: Ethical Considerations Getting Started: The Literature Review Moving On: Answering Your Research Question Moving On To When Where and What? Data Collection: From Theory to Practice Creating an Effective Dissemination Strategy Deliverables, Benefits and Budget Conducting the Research: Data Analysis Knowledge Translation Strategies: Publications and Presentations

3.3. The Methods and Measures This exploratory descriptive study used a mixed methods approach involving quantitative and qualitative methods to address research question # 1 and 2 respectively, described below. 3.3.1. Research Question # 1 Is there a difference on selected nursing, patient safety and organizational outcomes one year after the introduction of a research capacity building strategy? A longitudinal, descriptive design was initially proposed to analyze trends and look for differences in selected nursing (satisfaction, research utilization and barriers to research utilization); patient safety (patient satisfaction, falls, pressure ulcers, hospital acquired pneumonia and medication errors); and organizational (turnover, absenteeism, overtime and agency use) outcomes. Given that the sample of study participants involved in the intervention (Nursing Research Advancing Practice Program) were from across the hospital, representing several clinical areas, the stratified analysis with a matched control group could not be conducted. Specifically, the majority of Nursing RAP participants came from specialty areas where there were no similar units (patient population, number of beds) and both general internal medicine units had Nursing RAP participants. There were other challenges encountered in conducting statistical analysis including missing data and selection bias as the study sample was already motivated towards or involved in research already. Alternatively, we conducted a simple pre-post design instead. This alternative approach renders the lack of transferability and generalizability of the study findings to


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other health care settings. However, methodological lessons learned from this pilot study have informed (e.g. a larger sample size of 40 study participants and accessible clinical and human resource databases) the next study exploring and examining selected outcomes and experiences associated with the Nursing Research Advancing Practice Program. 3.3.1.1. Nurse Outcomes. To gather data on the nurse outcomes associated with the introduction of the research capacity building strategy a questionnaire was developed. The Research Utilization and Productivity Nursing Questionnaire (RUPNQ) is a combination of three existing tools to measure different aspects of nursing’s perceptions of research. The RUPNQ is included in the Appendices of this report. The McCloskey/Meuller Satisfaction Scale (1990) is a 31 item survey that focuses on nursing satisfaction with aspects of their job.20 Items 27 and 28 are specifically related to the research domain of nursing. This scale has been used in several studies including the international Understanding the Costs and Outcomes of Nurses' Turnover In Canadian Hospitals.21 A question is included from the Alberta Registered Nurses Association that asks participants to rate on a scale of 1 – 7 (never to nearly every shift) the frequency of research use in nursing practice. The third instrument in the questionnaire is the 29 item BARRIERS to Research Utilization Scale22 which involves rating items on a scale of 1 – 5 (1 - 4 no barrier to great extent a barrier and 5 no opinion). This scale has been used to evaluate research utilization strategies in past studies.23,24 A successful research enterprise depends not only on a carefully designed agenda that responds to clinical and societal needs but also on the research capacity necessary to perform the work. Concerted efforts to enlarge the research capacity must be complemented by an ability to assess (short and long term) that capacity over time to gauge research productivity.25 The fourth component of this analysis includes questions around research productivity amongst the RAP participants (publications, presentations, research grants/funding, and graduate student supervision). The questionnaire was pilottested for clarity and comprehension by members of the Scientific Review and Advisory Committee. Following the pilot-testing of the RUPNQ, the survey tool was administered pre (December 2006) and post-strategy implementation (June/July 2008) to study participants. 3.3.1.2. Patient Safety Outcomes: The following patient safety outcomes most consistently appear in the nursing literature as being theoretically and empirically linked to nursing practice. These include hospital-acquired pneumonia;26-28 pressure ulcers;26,29 medication errors and falls.26-29 In addition, given the key role that nurses play in the provision of care, patient satisfaction was also included as an outcome. The patient safety outcomes for pressure ulcers; patient satisfaction and medication errors and falls were reported from October 2006 to September 2008. The hospital acquired pneumonia results were reported for the period of January 2008 to September 2008 as the hospital started tracking these outcomes in Fall 2007. 3.3.1.3. Organizational Outcomes: The organizational outcomes included in the study were turnover, absenteeism, overtime and agency use. These outcomes have been previously associated with nurse recruitment and retention.30, 31 Table 2 provides a description of the domain category specific measures, sources and data collection period for each of the measures.


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Table 2 Description, Sources and Data Collection Period Category Nurse

Tool/Source

Data Collection Period

Satisfaction

Measure

McCloskey/Meuller Satisfaction Scale (1989)

Research Utilization

Alberta Registered Nurses Association Survey (Wallins, Estabrooks, Midodzi & Cummings, 2006) “Overall in the past year, how often have you used research in some aspect of your nursing practice? (7 point likert scale, ranging from never to nearly every shift) BARRIERS scale (Funk et al., 1991)

BASELINE (PRE-STRATEGY): December 2006 POST-STRATEGY: June/July 2008 BASELINE (PRE-STRATEGY): December 2006 POST-STRATEGY: June/July 2008

Barriers to Research Utilization

Patient Safety

BASELINE (PRE-STRATEGY): December 2006 POST-STRATEGY: June/July 2008

Research Productivity

Number of Publications Number of Presentations (poster and oral) Funding (Frontera et al., 2006)

BASELINE (PRE-STRATEGY): December 2006 POST-STRATEGY: June/July 2008

Patient Satisfaction

Patient Satisfaction Score (Picker Satisfaction Tool)

BASELINE

Falls

# of Falls (Event Tracking)

Medication Errors

# of Medication Errors (Event Tracking)

INTERVENTION

Ventilator Acquired Pneumonia

Ventilator acquired Pneumonia per 1000 patient days (Decision Support)

POST INTERVENTION

Pressure Ulcers

# of Pressure Ulcers per unit on patient’s discharge from hospital (Decision Support)

BASELINE

Quarterly October – December 2006 January 2007 – June 2008 July – September 2008

Quarterly August – December 2006 INTERVENTION January 2007 – June 2008 POST INTERVENTION July – September 2008

Organizational

Turnover

Absenteeism

# of RNs who have left the hospital (Administrative/Human Resources Data Base)

BASELINE

Measured in number of days absent per RN per month (Human Resources Data Base)

INTERVENTION

Overtime

Hours per month per RN (Human Resources Data Base)

Agency Use

RN hours per month (Human Resources Data Base)

Quarterly April – December 2006 January 2007 – June 2008 POST INTERVENTION July – September 2008

Research Question # 2 What are the learning experiences associated with the research capacity building strategy of participating nurses and other health care professionals? The research question was addressed through the conduct of two focus groups. Focus groups are a qualitative method typically used to explore experiences that tap into beliefs, values and perceptions that groups of individuals ascribe to a designated topic.32, 33 The study interview guide asked the Nursing RAP Program participants to reflect and comment


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on their overall experience with the research capacity strategy and their key learnings throughout the process. They were also asked to consider the impact of program participation on their subsequent clinical practice. Table 3 provides an overview of the interview guide questions and prompts. Informed consent was obtained before each focus group, which took 45 and 90 minutes to complete respectively. Focus groups occurred 3 months after completion of the Nursing RAP Program and were audio taped and transcribed verbatim for analysis. Focus group transcripts were analyzed using the content analysis approach outlined by Ryan & Bernard.34 In the initial phase, the investigative team, including the focus group moderators, independently reviewed the transcripts line-by-line to identify sections of text to serve as potential codes. The researchers then met face-to-face and determination of codes and categories was made through consensus. To be included as a code or category, supporting data had to be included in both focus group discussions. As a second step, the first author followed the theme development approach outlined by Ryan & Bernard.35 Thematic consensus amongst investigators was achieved as the final step in the analytical process.36 Table 3 Interview Guide Interview Questions What are your key learnings from participating in the Research Capacity Building in Nursing Practice strategy

Tell us your experience providing nursing care since your participation in the research capacity building in nursing practice strategy? How would you describe your overall experience with the Research Capacity Building in Nursing Practice strategy?

Prompts • Do you have a greater understanding of the research process and how to conduct research? • What research competencies have you acquired through your participation? • What were the key enablers for you to learn and acquire research competencies and participate in the research process? • What were the key barriers for you to learn and acquired research competencies and participate in the research process? • Describe one of your key learnings. • Has your practice changed as a result of your participation in the research capacity building in nursing practice strategy? • Do you feel you are providing a safer care as a result of your participation in the research capacity building in nursing practice strategy? • Provide an exemplar of how your practice has changed. No prompts

Two focus groups were conducted in June 2008. 9 (one with 5 and one with 4 )nurses from the RAP program participated in the focus groups with one focus group . This represented 42.8% (9/21) of the total sample. The two groups were 49 and 70 minutes respectively. Four main themes emerged from the data and they are outlined below:


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Themes Raising the bar for nursing and safer care through research

Having someone always behind you while taking steps

Sample Passage from Focus Group “It makes you look at the bigger picture of the patient and what’s going on. And it makes you question and challenge things that you may have not been comfortable with before because you were afraid to. And in turn you provide safer care and I think that you’re more respected.” “I didn’t feel alone during the whole RAP program. Doing the research itself. Like I’m not alone, I’ve got mentors. Like anytime you need to clarify something, they’re there and then at the same time…you have other people who are going through the same process as you is a huge help. You feel like: OK so it’s not only me.”

Riding the ups and downs of the RAP wave

“You know when we did our little interim presentation there was a reason why I called mine Riding the RAP Wave. It’s because that is what it was. It was an up and a down all the time.”

Paving the way for others to engage in research

“I found that other people have come up to me: Oh that’s so neat that you’re doing this. Can I do it too? Basically you pave the way for others.”

4.0. Results Research Question 1) Is there a difference on selected nursing, patient safety and organizational outcomes one year after the introduction of a research capacity building strategy? 4.1. Sample Demographics Table 4 Sample Demographics The overall total sample size was 21 (out of the original 25). One team withdrew (n=3) and another nurse left the hospital as her husband was relocated to out of the province. Of the 21, only 17 provided demographic data. Age N= 17 42.4 (11.8) Post Data represents mean (SD).

# of Years in Nursing 15.8 (11.1)

# of Years on Unit 7.4 (5.24)

Other demographic characteristics of the sample included an increased enrollment in post RN studies (from 2 to 4) and in Masters programs (from 0 to 7) in the pre to post study period.


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4.2.Nursing Outcomes Analysis for the nursing outcomes involved the following tools: McCloskey/Meuller Satisfaction Scale for Nurse Satisfaction Outcome (see Table 4); Alberta Registered Nurses Association Question for Research Utilization (see Table 5); and Barriers to Research Scale for Barriers to Research Utilization (see Table 6). For each scale, the individual items were scored and compared from pre to post using a paired t-test. For each scale, the collective scores on each factor were also averaged and compared from pre to post using a paired ttest. Level of significance was set at p