The literature is replete with citations espousing the impact of the work environment on key performance indicators (Buhlman, 2016). Nurses’ personal and professional well-being, recruitment, knowledge evolution and retention; patient satisfaction and outcomes; and fiscal sustainability of the organization can all be influenced by the health of the workplace. Composition of the workforce, power, and opportunity has an impact on what nurses can do and how they utilize available resources to meet patients’ needs (Barnes & Lefton, 2013). Innovative, multi-faceted, and patient-centered care delivery should ideally be derived from a confluence of evidence-based data (primarily from formal research studies), experiential knowledge of professional nurses, and the incorporation of patient preferences. Creating an environment that imbues nurses with a thirst for evidence-based knowledge, and equips them with the skills, confidence and opportunities to pursue the discovery, creation and translation of data-supported exemplars is essential in building and fostering a culture of nursing excellence.
The expectation that nurses should integrate evidence into clinical and operational processes is not particularly new; this notion dates back to Nightingale’s work in the 1850s (Karimi & Masoudi Alavi, 2015). “Healthcare organizations can no longer afford for [evidence-based practice] EBP to remain an abstract concept or an idealized competency” (Black, Balneaves, Garossino, Puyat & Qian, 2015, p. 19). Nurses, particularly those working in direct patient care, are well-positioned to pose questions for clinical inquiry; however, there are often myriad competing priorities that may interfere with their availability to participate in scholarship (Scala, Price & Day, 2016). Deficient knowledge, lack of time and leadership support (inadequate provision of dedicated, protected time to participate in scholarship), or insufficient coaching in research and evidence-based practice principles have all been denoted as potential roadblocks (Dunning, 2013; Hagan & Walden, 2015; Sanjari, Baradaran, Aalaa & Mehrdad, 2015).
Purpose
A comprehensive strategic vision was created to provide the structures, processes and resources to facilitate nurse-driven clinical inquiry across a multi-site healthcare system. Involving the right people with optimal skill sets (or interest in acquiring them) was essential. Although the organization has a full-time, doctorally-prepared director of nursing research, it was evident that early involvement of both direct-care providers and nurse leaders was critical in successfully implementing the plan.
Implementation
A key strategy included the creation of pavilion INSPIRE (an acronym for Innovations in Nursing Scholarship, Performance Improvement, Research and Evidence-based practice) teams. These teams are comprised of nurse clinicians and leaders across nursing. While there had been a research committee for several years, nurses across the organization engage in many more types of scholarship than just research and it was essential to expand the scope of support to meet the wide-ranging needs related to clinical inquiry. The pavilion-based INSPIRE Teams (representing the three hospitals and healthcare clinics across a large metropolitan area) were intentional in developing goal statements that interface with the overall system-wide and nursing scholarship strategic visions, and align with the strategic direction for the Center for Nursing Scholarship (CNS).
The teams have been instrumental in: 1) identifying priorities for clinical inquiry issues requiring scholarship-driven solutions; 2) promoting the use of science to improve healthcare and patient outcomes; 3) generating and sustaining influence, excitement and support for nurse-led scholarship; 4) providing a systematic approach for integrating newly created or validated evidence into clinical practice; 5) increasing intra-disciplinary, interprofessional and multi-institutional collaboration; and 6) facilitating dissemination of generalizable results, both internally and externally.
Results
Team meetings have consistently included an educational component. Members are acutely aware of the value of self-evaluation of expertise and additional educational needs to ensure their effectiveness as peer coaches. It is important that all team members have a common knowledge and skill set. INSPIRE leaders proposed engaging members in conducting EBP projects as an ideal way to evaluate and refine their competencies. This has been accomplished by reviewing the steps of EBP (writing the PICO question, retrieving and appraising salient literature, and making informed decisions about what information to translate into practice). One of the projects is geared to exploring the impact of breastfeeding versus formula feeding on pH of stool among neonates with diaper dermatitis. Another EBP team is examining how working with nurse preceptors who migrated from countries where English is not the primary language may impact onboarding and team enculturation among recent nurse graduates.
The INSPIRE Teams have been instrumental in the comprehensive roll-out of EBP principles. This effort has already been completed by virtually all nurse leaders; the upcoming educational initiatives will be directed primarily to nurses working at the point-of-care. Since the majority of INSPIRE members are nurse clinicians, they are well-positioned to coach their peers. They have both current clinical expertise and an understanding of the steps inherent in the EBP process.
The CNS and INSPIRE Teams partner in producing an 8-page monthly newsletter to showcase scholarship in which nurses and their professional partners engage. Thirty-four issues have been produced and included over 50 evidence-based topics important to nurses, including: 1) therapeutic use of reminiscing in older patients; 2) assessing risks and failures in suicide prevention; 3) moral courage amid moral distress; 4) compassion fatigue and nurse burnout; 5) basics of designing a research study; 6) nurse leaders’ roles in peer review; and 7) impact of patients’ deaths on nurses. Many of the editorial features have been written by INSPIRE Team members. It provides them with opportunities to hone their writing skills before moving on to abstract and manuscript development for national dissemination.
The teams demonstrate excellence in clinical inquiry skills by leading or participating in several nurse-led research studies and performance improvement projects (in addition to the previously ascribed EBP projects), and publishing. Internal dissemination occurs via poster displays during Nurses Week and throughout the year to showcase nurse-led scholarship to the general public, interprofessional partners and other nurses. In the past three years alone, members have authored or co-authored 15 peer-reviewed articles, and contributed to 60 podium or poster presentations at regional, national and international conferences.
Implications for Practice
Establishing and sustaining healthy work environments is dependent upon true collaboration, effective decision making, authentic leadership, and meaningful recognition. The creation of pavilion INSPIRE Teams has strengthened the resolve to provide nurses with the tools to make evidence-based clinical decisions, evaluate and improve clinical care, and lead organizational initiatives. Our teams have clearly embraced the imperative of a healthy work environment through self-reflection and modeling the behavior to others. The INSPIRE Teams have been recognized several times in local newspaper editorials and a number of members have received prestigious awards from local and national organizations in recognition of their scholarship. Perhaps, more importantly, the mission of INSPIRE is now appreciated by nurses across the healthcare system. As recently as four years ago, nurses would have traditionally answered the question, “Where do you get information to enhance patient care?” with “…rely on traditions and experiences of nurses.” The INSPIRE Teams have partnered with the CNS to advance nurses’ perspectives and it is more common now to hear that professional nurses incorporate experiential knowledge with data-based information from top-tier journals or refereed conferences. The principles used for the INSPIRE program certainly have applicability for other institutions who are embarking upon creating or strengthening their workplace environment by equipping staff with tools for success in nurse-led scholarship.