The Quest for Change 

A Member of the Research Committee Writes about Her Journey of Discovery
By Judith Lauerman, BSN, RN, Tower 9AB

Judith Lauerman, BSN, RN, and Tracy Cragin, BSN, RN, of Tower 9AB, review the new IV protocol.

"It is a bad plan that admits of no modification."- Publilius Syrus, First Century BC

The situation had become all too familiar: I was working with Heather, a young, healthy woman who was participating in a research study on our unit. She was motivated to earn money toward her tuition and would be living in a dimly lit room on 9B while we monitored the effect different light levels could have on wakefulness and sleep in healthy volunteers. This required a variety of data collection methods, including computer tests, EEGs, temperature recordings and saliva and blood samples. Obtaining those blood samples by inserting an IV is where this story begins. 

I walk into the dim room; it is lit at 5 lux, equivalent to a few candles. I chat with Heather to put her at ease, assess that she is tolerating all aspects of the study. We talk about the IV. Being young and healthy, Heather had never had an IV, but she wasn't particularly worried about it. She knew it was part of the study. I assessed her forearms (the preferred area for placement) and knew this wasn't going to be easy. After applying warm packs to both arms, I began to have a little hope, but between the dim lighting, the lengthy IV prep (the standard operating procedure for our unit) and two unsuccessful attempts, I knew something needed to change. We could do better for our study participants and for ourselves.

The staff nurses on our unit knew it was time for a change. We collectively grumbled about the lengthy IV prep, questioned it, proposed alternatives, shook our heads and kept right on doing it the same old way. Change is a hard thing, and it was especially challenging on our clinical research unit where standard operating procedures are crucial for eliminating variation in measurement outcomes. We felt little recourse except to follow a procedure that, while harmless to patients, was time-consuming and antiquated. 

I decided to learn what I could about current practice and use evidence to talk with the leadership on my unit about making a change. Since 9AB exists to perform clinical research studies, I knew data and information would be especially valued. I also knew there was consensus among the staff nurses. Everyone was confident that we needed an update that could improve our population's care. The staff nurses were in agreement, motivated and ready to change this procedure.

I am fortunate to be surrounded by inquisitive people; it didn't take long to realize that we had some valuable resources in our quest for change. I found guidance and support in my nurse coworkers, nurse director, technical staff and co-ops on 9B, physicians and post docs, and the IV team. I collaborated with Patti Underwood, PhD, NP, who was involved with clinical research studies on our unit, and with Rita O'Donnell, MSN, RN, 9AB's nurse educator.

The first step was a literature review. This was incredibly informative and confirmed the need for a change. It also provided me with a great review of study designs and research language. I realized that, even after working on a research unit for 20 years, there was a lot that I did not know.

Once our lit review was done, I was disappointed to find that the answer I was looking for was not there. How could I make a change without adequate relevant findings? I was discouraged in the face of this setback, but Patti was really excited. "There is a gap in the literature; this is great!" she said, smiling. She went on to explain that we could do a study to fill that gap.

We began to think about how to compare our unit's IV prep with a more current, evidence-guided prep using a crossover design (one in which each subject receives each IV prep in succession). We knew we would need help with the details, but felt this design was solid. We were building momentum and were ready to present our proposal to the directors of the unit. Although the presentation was met with mixed reviews, we found enough support to move forward.

We were encouraged to apply for the Department of Nursing's Lily Kravitz award. Looking back, this process was an invaluable opportunity. I needed to learn several skills just to complete the application, but found support and encouragement at the Center for Nursing Excellence. We refined our study design as a result of this consultation. I found myself routinely stepping outside of my comfort zone at the bedside. We were overjoyed when we received the Kravitz Award in 2010, which provided us with even more resources to help us reach our goal.

With almost every challenge, I was surprised and relieved to find a structure designed to help us navigate through the tough parts. Patti helped us design spreadsheets to keep track of our lit review. When I became routinely overwhelmed and was lagging, she encouraged us to create a timeline with attainable goals to keep the project moving forward. With the help of templates from the IRB, I was able to write a protocol summary, a detailed protocol and a consent. I managed to navigate the electronic submission to the IRB. I learned about research posters and created one that was accepted by the International Association of Clinical Research Nurses for their conference in Bethesda, Md. We reached out to the Center for Nursing Excellence for help with our data analysis.

Finally, in 2012, we reached our goal of updating the IV prep for our research participants. This took much longer and was more frustrating than any of us had anticipated, but I would do it all over again. I gained such an appreciation for the process: something needed improvement and there were resources available for support and guidance. This change also empowered the 9AB staff nurses and opened our minds: we can examine our standard operating procedures and look for evidence that could provide better care for our research participants. 

My path that started in a dark room on 9B has also led me to membership on BWH's Nursing Research and Evidence-Based Practice Committee. Our purpose is "to build on the scientific, evidence-based foundation of nursing practice through the evaluation and generation of new knowledge, as well as to support and advance the dissemination of nursing science through nursing research."

The committee's focus is to:

• Promote awareness of research and research findings relevant to professional nursing practice.
• Promote the need for nurse-driven research and promote the image of nursing research at BWH.
• Promote the application of new knowledge.
• Foster inquiry and evidence-based practice that advances the mission of the Department of Nursing.
• Act as a support for nurses to participate in nursing research at BWH.
• Serve as an advisory board for nursing-led research at BWH.
• Promote and foster communication and awareness of nursing research activities throughout the Department of Nursing.

If, in your everyday efforts to provide the best care, you find yourself wondering about a situation, imagining alternatives or seeing the change you want to make, you have already stepped onto a path of opportunity. Look to our committee, the Center for Nursing Excellence and the Haley Immersion Program for support, ideas and collaboration. 

Our committee is excited to be conducting a nursing research study: "Barriers and Facilitators To Nursing Research Utilization at BWH." We would like to understand nurses' perceptions of research and use the results to provide support and guidance to promote nursing research throughout our institution. Please watch for and participate in our email survey in the coming months.

For more information on the research committee, contact co-chairs Yvonne Sheldon, RN, and Lisa Preston, RN.