Times are A-changin'
Nurse researchers turn ritualized hospital routine on its head, replacing myths with scientific sense

By Heather World
February 11, 2003

Not many people want to study preoperative fasting or decipher doctors' handwriting samples, but Elizabeth Winslow, Ph.D., RN, FAAN, has made a life's work of questioning the efficacy of such elements of hospital rituals.

Take bedpans, for example. Winslow, a research consultant at Presbyterian Hospital of Dallas, first challenged the status quo when she examined the hospital's rule ordering postoperative heart attack patients to use a bedpan.

"They hate the bedpan," she said of patients. "It's very awkward to use."

Winslow measured oxygen consumption to compare the effort a patient exerted while using a bedpan, a bedside commode and a regular toilet. She found no difference.

"There is no reason why these patients couldn't get up and use the commode," she said. Patients not only preferred getting out of bed, but the movement also helped them to maintain their compensatory mechanisms for changing position.

Winslow published her findings in the American Journal of Nursing. Now, that particular bedpan tradition has gone the way of leeching blood not only in her hospital, but also in others around the country.

"There are so many rituals and traditions in nursing practice," Winslow said. "This is such fertile ground for research. We want our practice to be based on evidence."

The rituals of hospital routine have come under increased scrutiny as nurses like Winslow question why things are done a certain way and whether accepted methods make scientific sense.

The questioning has intensified in the last 20 years, coinciding with a tripling of the number of RNs whose highest level of preparation is either a master's degree or a doctorate. Furthermore, funding agencies and professional associations have turned away from theoretical research and toward outcomes-based research, which backs up or debunks practice with science.

Ann Jacobson, Ph.D., RN, who collaborated with Winslow on studies about intravenous needle insertion, has seen the gap between practicing nurses and nursing research close since the 1980s, when she attended Texas Woman's University to earn her Ph.D. Back then, nursing students favored developing theories about nursing and patients.

"The focus of study was to test a theory," she said. "It's not at a level of practice that's useful."

Now an associate professor at Kent State University's College of Nursing, Jacobson recalls battling professors and colleagues who resisted her pursuit of outcomes-based research. "They were not accustomed to students doing a dissertation on such clinical phenomena," she said.

These days, it is theoretical research that is outside the norm. The government and other sources of funds have moved toward favoring outcomes-based research in nursing schools, Jacobson said.

The change in emphasis stems partly from a realization that quality of care could be measured, said Patricia Rowell, Ph.D., RN, a senior policy fellow in the department of Nursing Practice and Policy at the American Nurses Association.

It started in the late '80s and early '90s, when the Agency for Health Care Policy and Research-at that time a center within the Department of Health and Human Services-started looking at the effects of managed care and capped reimbursement costs.

Researchers realized the primary product delivered in hospitals, nursing homes and home health services is nursing care, Rowell said, and soon they set their sights on studying health services. The center grew into an agency, which issued clinical practice guidelines about 10 years ago.

Still, more research is needed, Rowell said. "Some people estimate that just 20 percent of nursing practice has been proven to do less harm than good," she said.

National groups and associations have placed greater emphasis on following such national guidelines based on outcomes-based research, said Marianne Chulay, DNSc, RN, FAAN.

The American Association of Critical-Care Nurses, for example, decided to publish the "Protocols for Practice" series, easy-to-read articles that summarize the latest research and best practices in critical care nursing.

"One to two are published every year in a format that is easy for a clinician to see the critical recommendations and incorporate the research," Chulay said.

Still, getting the growing amount of practical research into the hands of clinicians is a problem, she said.

Incorporating research

Until the late '90s, Winslow and Jacobson addressed this problem by writing a column in the American Journal of Nursing called "Working Smart." The column was inspired by a complaint among nurses that research is often too dry and highbrow to read.

Many of Winslow's studies, including some topics for the column, come out of comments made by nurses on the nursing research committee that Winslow chairs at Presbyterian Hospital. Petroleum jelly, which for years had been used to moisturize the dry lips and noses of patients, had been banned, and the nurses found other moisturizers ineffective. They wanted to know why they couldn't use the product.

Winslow tries to demystify rituals and traditions by looking at research, but she is not deterred if none is available.

"The first thing I usually do is go to the literature," she said. She found that petroleum-based Vaseline was deemed potentially flammable and therefore banned, but she could not find any reports of actual harm from the product.

Winslow then consulted colleagues and, in this case, found that some hospitals still used Vaseline.
She consulted the national group responsible for writing fire protection manuals for hospitals. She learned the original standard that called for the ban didn't apply to use on lips and noses.

Finally, Winslow wrote a paper on the subject that was evaluated by an independent researcher. A year later, the hospital switched back to Vaseline. Winslow publishes her findings in a variety of nursing and medical journals, but she no longer publishes the column with Jacobson.

That's in part because nursing has come a long way, Jacobson said.

"We no longer edit that column, I'm happy to say," she said. "AJN felt its readership no longer needed to be handheld in applying research findings."

Some, like Chulay, wish the column were still around. "They wrote in a conversational style," she said. "I believe that's really missing in our nursing literature."

Hard habit to break

But getting the research into the hands of practicing nurses is not the end of the story either, Chulay said. Although she has worked in more than a dozen hospitals as a director of nursing research and practice, Chulay has spent the last two years as a consultant in critical care nursing and nursing research from her base in Chapel Hill, N.C.

She sometimes runs into difficulties persuading nurses to change their practices, even when presented with evidence-based research.

"The hardest things to change are some of the rituals we have in nursing that we've done probably since Florence Nightingale," she said. "Just having knowledge doesn't mean we change behavior."

Much of her work is spent helping nursing staff understand the basis for their practice.

Chulay does not blame nursing schools for perpetuating out-of-date practices.

"When you come out of nursing school, you're such a neophyte you get taught how to do your job, and that's how the problem starts," she said.

Often, Chulay helps hospitals set up nursing research programs that involve staff nurses. "I believe it's a powerful way to open their eyes to basing their practice on research," she said.

Experience is no measure of resistance to change. Nurses who are naturally inquisitive-regardless of whether they have spent their careers following one routine-will be open to new ideas, Chulay said.

Nursing leadership sets the tone for each hospital, she said, and she sees more and more nurse leaders with either the intuition or education to go beyond ritual-based practice.

"We absolutely have stronger leadership in hospitals than 30 years ago," she said of nursing. "We have a lot more doctorally prepared nurses who have gone in-depth into research and continue to stay employed full-time in the service setting."

Contact Heather World at H_world@yahoo.com