Nurses finding a better way
Pulse editor
Sunday, November 16, 2008
The focus on best practices in all areas of health care has expanded the role of many nurses. In addition to their jobs as caregivers, educators, advanced practitioners or administrators, nurses are now adding one more role: researcher.
Health care leaders say that having nurses identify problems, ask questions and share outcomes is not only good for patients; it’s good for the profession.
Photos by BARRY WILLIAMS / Special
Rebecca Gary (left), assistant professor of nursing at the Nell Hodgson Woodruff School of Nursing at Emory University, measures Joeleitha Coppock’s performance on a test of her physical functions. Gary has studied the benefits of weight training on cardiac patients.
Nurses (from left) Richard Lamphier, Carolyn Yactayo and Christina Ryan-Ramey check Adam Foster’s chest tube at Children’s Healthcare of Atlanta at Egleston. Yactayo is working on research about pain relief for patients.
Rebecca Gary checks Joeleitha Coppock’s performance on the laundry portion of the Continuous Scale Physical Functional Performance Test. ‘I enjoy working with the patients. Their confidence is growing as they find that resistance training won’t hurt their hearts,’ Gary said.
“Nursing is still evolving as a profession, and research adds to nursing theory and knowledge. We all learn a lot from it,” said JoEllen Dattilo, Ph.D., RN, professor and associate dean of the Georgia Baptist College of Nursing of Mercer University in Atlanta.
Nurses are often involved in clinical trials led by doctors and scientists. Increasingly, they also are making their own qualitative and quantitative studies into education, medications, procedures and day-to-day practice.
“There’s more emphasis placed on research in nursing today, and evidence-based practice is driving it,” said Helen Hodges, Ph.D., RN, professor and coordinator of the RN and BSN programs at the Georgia Baptist College of Nursing. “More and more, nurses are taking research out of the ivory tower and putting it at the bedside in order to facilitate the best patient outcomes.
“Instead of a trial-and-error approach or a ‘We’ve always done it this way,’ attitude, now we’re asking, ‘Do we have evidence?’ If it’s not there, we’re doing the research.”
Nursing students are introduced to the importance of research at the baccalaureate level, Hodges said. They learn how to identify good research and to use national databases and systematic reviews to help incorporate it into their practices.
Advanced practice nurses often create their own studies with the encouragement of hospitals, such as Atlanta’s St. Joseph’s Center for Nursing Excellence, which sponsors outcome-based research.
“Because nurses are at the bedside 24/7, they are in a unique position to identify problems and improve care. It’s natural for nurses to see a problem and ask themselves, ‘How can we fix it?’ ” said Deborah Ryan, Ph.D., MSN, RN, associate professor and interim assistant dean of the BSN program at the Nell Hodgson Woodruff School of Nursing at Emory University.
Here are a few of the issues that Georgia nurses are addressing with research:
Reducing bloodstream infections
When Renee Watson, RN, CIC, became manager of infection control and occupational health at Children’s Healthcare of Atlanta in 2006, she noticed that bloodstream infection rates in some units were high. Since the hospital was already following bloodstream infection reduction initiatives, she decided to focus on prevention.
Nurses in the cardiac intensive care unit at CHOA enter patient lines about 16,000 times a month for blood sampling and medication administration. Before they enter an IV line with a needle or a catheter, nurses prep the hub of the line with an antecepsis — usually alcohol — to cut down on bacteria.
“Chlorhexidine/70 percent isopropyl (CHG) wipes worked so well on skin; we wondered how they would do on inanimate objects, like central lines,” Watson said.
The staff randomly supplied half the patient carts with the wipes — instead of alcohol — for four months.
“The results were so amazing — the BSI rate among alcohol users was almost five times that of CHG users — that hospital administrators stopped the study and immediately went to CHG wipes system-wide,” Watson added. “Even though the product is 11 times more expensive, we still saved the hospital $800,000 that year by avoiding infection costs, not to mention about five lives, which are priceless.
“We’re learning that research doesn’t have to be just about medications and procedures” Watson said. “It can be about day-to-day practices. It’s a way for nurses to use their critical-thinking skills and know-ledge to change practice and save lives.
“Research is an important part of being a stand-alone profession and being leaders, not followers.”
Safe administration of medication
“Medication errors are a huge problem in the health care system. An error can cause a longer stay in the hospital or even be life-threatening for a patient,” Ryan said. “A nurse is usually the last person who can either avoid or commit a medication error.”
Ryan wanted to find out how well educators were helping nurses understand the importance of reading prescriptions properly.
Nurses trained in the five rites of medication administration are taught to focus on the right patient, the right drug, the right dose, the right time and the right route. Ryan tested students at eight schools, asking them to read and catch medication errors in five case studies.
Of the 267 students tested, only 18 had perfect scores. Not matching the name on the physician’s order with the name on the patient’s armband was the most common error.
“We have to work harder and longer at making sure students develop proper habits,” Ryan said. “It should be automatic that they call the patient by name and check the prescription name against the armband every time.
“Nursing students need to learn a consistent and logical approach in order to decrease medication errors.”
It can make a difference, Ryan said. One study found that nurses intercepted 86 percent of medication errors.
Strength training for heart patients
“I did my dissertation study on the effects of aerobic exercise on heart failure patients, who often suffer from depression,” said Rebecca Gary, RN, Ph.D., assistant professor at Emory’s nursing school. “We found that the patients who got exercise and therapy had better outcomes. They had lower depression scores, greater mobility and a better quality of life.”
Reading the results of a study on the association of declining hand strength and mortality in cardiac patients led Gary to consider whether weight training could reduce the loss of muscle strength. Her pilot study about the effectiveness of weight training, which is being funded by the Emory Heart and Vascular Center, is showing promising results.
“I enjoy working with the patients. Their confidence is growing as they find that resistance training won’t hurt their hearts,” Gary said.
Gary hopes that weight training will become a standard recommendation for heart patients.
“Research is absolutely critical to the evolution of the nursing profession and to moving us forward,” she said. “I get the biggest satisfaction in knowing that I can make a difference in patients’ lives and hopefully change practice.”
Improving nursing student retention
“With the nursing shortage, colleges are concerned about retention of [nursing] students. Every year there are some students who aren’t successful in their studies and have to drop out,” Dattilo said.
Some of those will wait a year and come back to retake a course and continue their studies. Dattilo conducted a qualitative study to see what made students come back to school, what their experiences were like and whether professors encouraged them to try again.
“We came away with a better awareness of what we can do as educators to help students,” Dattilo said. “I get excited when we learn something we can share with others.”
Making chest tube removal less painful
A nurse for 14 years, Carolyn Yactayo, RN-BC, BSN, clinical leader of the cardiac step-down unit at Children’s Healthcare of Atlanta, had never considered doing research until nurses presented her with a problem.
“We pull one to three chest [drainage] tubes from post-cardiac surgical patients a day. The finger-sized tubes go through muscle, skin and bone and it hurts to remove them,” Yactayo said.
Nurses were concerned that young patients weren’t getting adequate pain relief and that the procedure was adding to their anxiety.
Yactayo couldn’t find clear answers in the literature or in procedures from the nation’s top pediatric hospitals. With help from Christina Ryan-Ramay in CHOA’s research department, she wrote a study to compare two drug combinations to see which gave better pain relief.
The presentation of her proposal at a nursing conference in September took first place, and now she’s working on the final details of the sixth-month study.
“Nurses are on the front line of care and they see things that others don’t,” Yactayo said. “It’s very important for them to get involved in practice and say, ‘Maybe there’s a better way of doing things.’ “
Yactayo gets satisfaction from knowing that her efforts will help young patients.
“I know that I’ll be happy that I took the time to see what works better,” she said. “It’s going to improve our care.”
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