The application of nursing research to clinical nursing practice has surfaced as an important issue since the 1980s. With burgeoning health care costs, many facilities are developing clinical pathways and investigating methods that will improve patient outcomes and the quality of nursing practice (Leske, Whiteman, Freichels, and Pearcy, 1994; Lindquist, Brauer, Lekander, Foster, 1990), as well as reduce costs. The use of research utilization (RU) is one method of applying knowledge obtained from research into clinical practice. Nursing interventions, policies, and procedures that are based on scientific research can improve patient care outcomes (Beyea & Nicoli, 1997; Leske et al., 1994; Lundin, Sargent, and Burke, 1998). To bring the process of RU into clinical practice, nurses must be educated on the process of RU that includes: synthesis of research literature, development of research based nursing protocols, introducing protocols into practice, and evaluating the outcomes.
DESCRIPTION OF COURSE
Graduate nursing education is beginning to explore RU, moving beyond critiquing of single research studies. A large body of practicing nurses have never been exposed to RU (Goode, Butcher, Cipperley, Ekstrom, Gosch, Hayes, Lovett, and Wellendork, 1991). Originally, the Louisiana State University Medical Center School of Nursing graduate program required two nursing research courses within the master's degree curriculum. The first course was an introduction to the research process. The second course focused on roles and issues faced by primary nurse researchers. The second course was transformed into a research utilization course with the purpose of assisting master's level nursing students (clinical nurse specialist [CNS] and nurse practitioner [NP]) to develop competency in the process of RU.
Major goals of the course were to assist CNS and NP students to demonstrate competency of RU through the development of new practice guidelines that would influence nursing practice and improve care to patients. Course objectives included:
* Identify a nursing-based innovation or nursing research-based area for change.
* Synthesize nursing literature to provide a knowledge base for the innovation.
* Develop a research utilization protocol.
* Identify a plan to introduce the protocol in a particular setting.
* Develop a plan to evaluate the outcome of a research utilization project.
Additionally, students were informed that the purpose of this course was to use previously published research in developing a protocol for change in a nursing care area.
The first assignment, due midsemester, was the submission of a paper that included identification of an area for change and reason for selection, synthesis of relevant research literature, and the RU protocol. Faculty graded the papers and included multiple suggestions on how to improve or modify the protocol. Students were expected to use the suggestions when completing the second assignment. The second assignment included the information UOm the first paper with the addition of a plan to introduce the RU protocol into a facility or neighborhood, a plan to evaluate the outcomes of the RU project, and a poster presentation of the entire project.
During the first half of the semester, students learned about the various models of RU and the processes and resources required. Research utilization models that were used to guide the students through the research utilization process included the Western Interstate Commission for Higher Education (WICHE) Model, Conduct and Utilization of Research in Nursing (CURN), Nursing Child Assessment Satellite Training (NCAST), Stetler/Marram Model, Dracup-Breu Model, Quality Assurance Model Using Research (QAMUR), Goode Model, and, Horn Model (Goode et al., 1991). These models describe the process of RU using various approaches depending on the target group. The models have many commonalities. Common steps include:
* Identifying clinical problem and relevant research.
* Critiquing studies through a research synthesis.
* Determining research base and relevancy to practice setting.
* Formulating nursing protocol/practice guidelines.
* Defining expected outcomes.
* Introducing protocol/guidelines into practice.
A total of 25 CNS and NP students were enrolled in the course. Students could choose to work on RU projects as an individual or in a group. Nursing problems were identified that would be suitable to practice the development of RU within their selected clinical area. A wide variety of problems were selected and included such topics as developing preconceptual counseling, helping mothers breastfeed their high risk NICU infants, using a parentalfocused teaching educational bulletin board to prevent childhood injuries, teaching diabetic patients daily foot care, introducing a new handwashing procedure into the surgical intensive care unit, allowing family presence during a patient's resuscitation, and encouraging/providing spiritual counseling for chronically ill individuals.
Synthesis of Relevant Research Literature
After identifying a nursing-based area for change, the students reviewed the literature for relevant researchbased studies on their topic of interest. Thie research synthesis was an important step in establishing a researchbase for the RU protocol. Students were informed that a research synthesis "involves the attempt to discover the consistencies and account for the variability in similarappearing studies0 (Cooper & Hedges, 1994, p. 4). As students read research articles, they were to analyze the applicability to the clients, institution, purpose, and the particular clinical problem. They also were to assess if the information in the article would assist them in making sound clinical judgments. A minimum of three studies was required in the synthesis. Many times replication studies were difficult to find and students were encouraged to search for articles that used meta-analysis to synthesize the results of various studies in a conceptual area.
Research Utilization Protocol
Research utilization protocols were developed and included purpose, objectives, and procedure with rationale. Additional components of a protocol could include patient inclusion criteria and equipment necessary to fulfill the protocol. Examples of equipment used in RU might be pulse oximeters, blood pressure cuas, handwashing products, or the use of oxygen therapy. For each guideline in the protocol, a corresponding referenced rationale was stated. When published, this format allows the staff nurse to understand the reason for each step in the protocol and hopefully will increase acceptance. Along with having the rationale typed within the protocol, a binder with the corresponding articles should be placed on the unit of implementation. If the nurses question the reasons for the RU protocol, the articles could be a valuable resource.
The CNS and NP students were guided to focus on writing the practice guidelines and rationale. Students were encouraged to review examples of protocols such as published by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the Agency for Health Care Policy and Research (AHCPR). The Second Stage Labor Nursing Management Protocol (AWHONN, 1994) has a purpose, goals, and a description of positioning women in second stage labor in six steps. Each step was printed with corresponding rationale and references.
One group of three CNS students developed a protocol titled, "Oxygen Therapy Protocol for Post Bypass Ambulation." They carefully defined the purpose, objectives, criteria, and equipment needed before discussing the practice guidelines. A sample of the patient criteria included:
* The patient has undergone CABG or valve surgery.
* There is a physician order for oxygen therapy.
* The clinical status of the patient includes having a stable cardiac rhythm.
* The patient is neurologically stable for ambulation.
Some of the equipment required for the Oxygen Therapy Protocol for Post Bypass Ambulation included a pulse oximeter, portable oxygen tank, and nasal cannula. The seven-step procedure described guidelines a cardiac rehabilitation nurse would follow when ambulating the patient upon transfer to a telemetry unit from the intensive care unit. Each of the seven steps in the procedure included a rationale with references.
PLAN FOR DISSEMINATION OF PROTOCOL
In assessing the feasibility of implementing the RU protocol, consideration of cost, ease of implementation, and acceptance by the nursing and medical staff was determined. Perhaps the most important aspect of the plan was the commitment and acceptance by the nursing staff within a facility. Research utilization efforts usually fail if the staff nurse is not involved, does not own the problem or see the relevance of the research findings to practice (Lindquist et al., 1990).
Students enrolled in the RU course developed elaborate plans for implementation. All students agreed that the protocol should he presented and discussed with medical and nursing directors prior to implementation. Inservice programs were suggested to allow staff nurses a chance to voice any concerns. An additional consideration was to offer alternative language forms for patients involved in RU. Several students suggested that the RU "team" be available 24 hours a day when the RU protocol is first initiated.
An evaluation tool for RU should include both process and outcome components. These components can be measured by chart audits, questionnaires, direct observation, and interviews of patients and nursing staff.
Students enrolled in the graduate RU course offered some innovative ideas for evaluating their protocols. One student who was going to implement a new handwashing procedure in the intensive care unit decided on monthly observations of nursing staff after the protocol went into effect. The evaluation tool for the Oxygen Therapy Protocol (described earlier) was a questionnaire with process and outcome questions. The questionnaire was completed by the cardiac rehabilitation nurse for each patient receiving the RU protocol. Evaluating the process of RU included questions such as: Did you feel you were adequately prepared through tile inservices? and, Are you able to carry out the procedure without any problems? An outcome question asked: Have you observed an increase in patient stamina during ambulation since the addition of oxygen therapy?
As a final assignment for the course, students presented their protocols by developing a professional poster presentation. Posters were displayed for the students and faculty in the school of nursing to view. A total of 14 nursing research problems were addressed in this course. Many students stated that they were submitting abstracts of their projects for research presentations. By the end of the semester, employers of students in several health care agencies expressed interest in using students' RU plans in their faculties.
The new research utilization course was found to be a valuable experience for both faculty and students. This course encouraged students to explore areas for change in their own clinical practice setting. Many pertinent problems were identified. Early evidence from this course suggested that students would continue their RU projects when they entered the work force as a master's prepared nurse. Increasing the interest and proficiency of master's prepared nurses in RU can enhance nursing's ability to change practice based on research and thereby improve patient outcomes and health care cost-containment.
In memory of Luida Corson Jones, PhD, RN, FAAN, whose wisdom in the RU process made this course possible.
- AWHONN. (1994). Second stage labor nursing management protocol [Brochure]. Washington, DC: Association of Women's Health, Obstetric and Neonatal Nurses.
- Beyea, S.C., & Nicoli, L.H. (1997). Research utilization models help disseminate research findings and ultimately improve patient outcomes. AORN Journal, 65(3), 640-642.
- Cooper, H., & Hedges, L.V. (1994). Research synthesis as a scientific enterprise. In H. Cooper, & L.V. Hedges (Eds.), The handbook of research synthesis (pp. 3-14). New York: Russell Sage Foundation.
- Goode, C.J., Butcher, LA, Cipperley, JA., Ekstrom, J., Gosch, BA, Hayes, J.E., Lovett, M.K., & Wellendork, SA (1991). Research utilization: A study guide [Film]. (Available from Horn Video Productions, phone  364-4676, fax  364-2564)
- Leske, J.S., Whiteman, K., Freichele, TA, & Pearcy, J.M. (1994). Using clinical innovations for research-based practice. AACN Clinical Issues in Critical Care Nursing, 5(2), 103-114.
- Lindquist, R., Brauer, D.J., Lekander, B.J., & Foster, K. (1990). Research utilization: Practical considerations for applying research to nursing practice. Focus on Critical Care, 17(4), 342-347.
- Lundin, L, Sargent, T., & Burke, LJ. (1998). Research utilization and improvement in outcomes after diagnostic cardiac catheterization. Critical Care Nurse, 18(5), 30-31, 34-39.