VOL: 97, ISSUE: 37, PAGE NO: 38
Mary FitzGerald, PhD, MN, CertEd, RN, DN, FRCNA, is head of the department of clinical nursing, Adelaide University;
Helen McCutcheon, PhD, MPH, BA, RN, RM, is a lecturer at Adelaide University;Anthea Court is a communications officer at the Joanna Briggs Institute for Evidence Based Nursing and Midwifery; andKiriaki Athanasiadis, MNSc, GradDipNSc, BN, RN, is a research officer at Adelaide University, Adelaide, south AustraliaClinical governance and evidence-based practice depend on the production of quality clinical research. However, the logistics of carrying out a study, from arranging access to gaining the cooperation of clinicians and patients, can be daunting and nurse researchers may long to retreat to the relative safety of a university office or laboratory.
Clinical governance and evidence-based practice depend on the production of quality clinical research. However, the logistics of carrying out a study, from arranging access to gaining the cooperation of clinicians and patients, can be daunting and nurse researchers may long to retreat to the relative safety of a university office or laboratory.
But it does not have to be that way. This article describes the steps taken by a team of Australian researchers to enable clinical research to take place in an atmosphere conducive to inquiry.
The researchers were from three institutions in Adelaide, south Australia: the department of clinical nursing at Adelaide University, the Royal Adelaide Hospital and the Joanna Briggs Institute for Evidence Based Nursing and Midwifery. This consortium has worked together for five years and has built up a partnership based on mutual recognition of individual skills and respect for the contribution of each organisation (Pearson and FitzGerald, 1997).
A dynamic philosophy underpins the department of clinical nursing's research: it values clinical expertise and aims to contribute to nursing practice.
The Joanna Briggs institute's aim is to bring together clinical and research expertise to review evidence for specific nursing practices, prepare evidence-based guidelines for clinical practice and evaluate the effect of these guidelines according to cost and patient outcomes.
The Royal Adelaide Hospital is a large tertiary acute care facility that recognises the mutually beneficial relationship with the university in terms of applied research and teaching. There has been a long tradition of collaboration between the hospital and Adelaide University.
Initiation of the research
In September 1996 the department of clinical nursing established the Blood Transfusion and Intravenous Cannulation Service (BTICS) in response to requests from the transfusion committee and hospital management. The service's remit was to examine the appropriateness of transfusions and the methods of administering and monitoring them.
To date the BTICS has produced several reports, all of which highlighted a need to review the way patients are observed during transfusion (Pearson et al, 1997; FitzGerald et al, 1999). These reports supported the recommendations made by the Joanna Briggs institute in its systematic review of vital signs (Evans et al, 1999), and the natural progression was for the department of clinical nursing to institute primary research on the practice of monitoring vital signs during blood transfusion.
The research team offered a mix of current clinical skills and research expertise which, coupled with funding and the positive research culture described, increased the likelihood that the work would succeed (Kitson et al, 1998).
The study was designed to determine whether there was a significant difference in patient outcomes when using a protocol of routine vital signs monitoring compared with clinically indicated vital signs monitoring during a blood transfusion. In the context of this study, clinically indicated meant using knowledge, experience and expertise to judge the need to monitor vital signs.
Clinician involvement in the study was gradual. During the initial phase clinicians were asked to direct the research assistant to patients' casenotes. Before the second phase there was a month's lead in period during which clinicians were trained so that they could move confidently from routine monitoring to the clinically indicated measurement of vital signs.
These training sessions informed clinicians about the study, described their role and included a discussion of clinical decision-making, accountability and responsibility. They were also given important information on blood transfusions and the possible side-effects.
Monthly follow-up training sessions ensured optimal and consistent nursing care of patients throughout phase two of the study, during which the clinicians were asked to:
- Identify patients who met the inclusion criteria;
- Ascertain the patients' willingness to participate;
- Obtain written consent;
- Document their clinical judgement in the patients' casenotes and the observations to be taken during the transfusion;
- Inform the research assistant.
During the planning stage of the project the research team met with the transfusion committee and wrote to all relevant physicians to inform them about the study and recruit their support. Ethics approval was obtained from the hospital research and ethics committee.
Engaging the clinicians
The research team thought that it might be able to foster a commitment from staff on the participating wards by getting them to see the project as one way for clinicians to question traditional observations.
Many of the nurses were or had been postgraduate students at the department of clinical nursing. Meetings were held with nursing directors and clinicians in all participating areas to inform them about the study and ask for their support and advice on the practicalities of data collection.
The research team responded to feedback by reducing the impact of data collection on nursing practice. A research assistant with relevant experience was appointed and a range of promotional literature was designed at the Joanna Briggs institute to market the study.
Phase one of the study was completed and data from 476 blood transfusions was collected. Early in phase two it was noted that nurses were reluctant to ask patients for written consent because it was time-consuming and some were concerned about the legal implication of basing observations on their clinical judgement. The research team responded by taking over the responsibility of gaining patients' consent.
The research team also met concerned senior nurses who supported the study but had difficulties fielding the objections of some of their staff. After the meeting the senior clinicians said they felt better prepared to explain the implications of the change in practice to their staff. The director of nursing issued a written statement informing staff in participating wards that the hospital protocol for blood transfusion observations was to be suspended for the duration of the study and observations based on clinical judgement were to be recorded in patients' notes.
The research assistant attended the senior clinicians' meetings once a week to provide feedback on progress. She visited the participating wards twice a day to encourage staff and remind them of her role once they had identified potential patients. The senior clinicians' group suggested that an element of fun be introduced and that participating wards should be rewarded for including patients, so chocolates were awarded to the 'ward of the week' - the one that recruited the most subjects to the study during that week.
The research team has been sensitive to the fact that there is a fine line between encouraging staff to participate and badgering them. The slower rate of inclusion of patients into phase two was accepted and all involved took care not to convey a desperate or defensive attitude to participants.
A collection of colourful and professionally presented posters circulated during the second phase of the study became part of the motivating strategy used by the research team. The posters and promotional material were designed in keeping with Adelaide University's guidelines on colour, type font and logo placement. A blood bag was chosen as the identifying icon on all publicity. Keeping this icon constant throughout the series of posters helped the clinicians to identify the study.
The posters were produced in the following order as research progressed:
- Phase one poster: introduced the study and the research assistant;
- Lead in to phase two poster: informed clinicians of the times of information sessions;
- Phase two poster (poster 3): asked clinicians to telephone the research assistant if people suitable for inclusion were about to have a transfusion;
- The washroom poster (poster 4): reminded staff about the study;
- Incremental poster (posters 5a, b, c): depicted a blood bag gradually filling up with the current number of subjects in red against the target sample size in grey. This poster was displayed on the 'ward of the week'.
Fig 1 shows the introduction of posters during phase two and the corresponding numbers recruited to the study.
The slow but consistent increase in numbers recruited to the study and the ongoing commitment of staff is a measure of the success of these strategies. The sensitivity of the research team to the feelings of the clinicians and the team's willingness to respond in a range of ways to the problems that occurred was also vital.
The relationships that have been developed between the three institutions involved over the past five years created the foundation for successful clinical research. All involved have enjoyed the process of collecting the research data and look forward to disseminating the study's findings in a way which will attract nurses' attention.