Advancing a Nursing Culture of Inquiry: Strategies for the Community

A culture of inquiry in health care reflects the shared expectations, goals, practices, and structures woven through exemplary practice and professionalism that support and advance clinical inquiry. A culture of inquiry also reflects individual and organizational curiosity about the best evidence and the autonomy to question and advance practice.1 Underpinning the advancement of a culture of clinical inquiry are beliefs and competencies. A growing body of evidence supports strategies to advance a culture of clinical inquiry. However, research demonstrates that although nurses at all organizational levels believe in the importance of evidence-based practice (EBP), they rate their EBP competency as low,2,3 and EBP implementation across organizations is also relatively low. This article, which draws on studies related to EBP competencies, describes several activities (along with their scientific foundation) that have been undertaken at the local and community levels to advance a culture of inquiry.Although there is a large body of literature related to developing individual and organizational capacity for research and EBP in health care, to our knowledge no studies of developing a community-wide culture of inquiry have been published. This concept expands the advancement of exemplary practice to multiple organizations, in contrast to a singular culture within 1 organization.In 2005 the Seattle Nursing Research Consortium (SNRC) was established among 8 local health care organizations (https://seattlenursingresearch.nursingnetwork.com). The current consortium includes a partnership with the Psi at Large Chapter of Sigma Theta Tau International. The mission of SNRC, which is a non-profit organization, is to develop and advance a community-wide culture of inquiry by providing a venue where nurses can share and learn about research and EBP. The core team for SNRC consists of direct-care nurses, nurse educators, nurse practitioners, clinical nurse specialists, and nurse scientists (many in dual academic-service roles). Annually, 200 to 350 nurses from all practice and administrative roles participate in the SNRC workshop and conference. Community-wide enhancement of a culture of inquiry in health care is important, as demonstrated by research showing that EBP improves outcomes4 and as captured by the aphorism “a rising tide lifts all boats.”According to leaders of large research and EBP conferences, outcome measures of these conferences are generally related to the educational offering but are not long-term or broader outcomes associated with actions tied to content provided to participants. Exploration of the impact of these programs at the community level is missing. An area for exploration that can be undertaken using implementation science5–7 is to examine research conducted at the organizational level8 to determine the factors that promote the adoption and integration of research and EBP into practice at the community level. A second area of exploration is to determine how to measure the development and advancement of a culture of inquiry across a community. An example metric is the number of Magnet facilities in a community because this designation reflects the 5 Magnet components (transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and empirical outcomes).9 When SNRC began in 2005, the Seattle region had 1 Magnet-designated facility; now it has 3. Another possible metric is the number of units that have received the American Association of Critical-Care Nurses Beacon Award for Excellence within an organization or community.10 This award recognizes units that provide high-quality patient care in a healthy work environment. Other possible strategies are measuring nurses’ EBP competencies and beliefs over time and using validated instruments to characterize the capacity and capabilities of nurse leaders and organizations to advance EBP.11–18 A third area of exploration is to investigate the association between a community-level culture of inquiry and metrics of quality care and patient/family satisfaction. Research is needed to measure the impact of research and EBP conferences, especially those held by consortium community groups such as SNRC, to understand the collective influence and meaningful translation of conference content into practice advancement.Melnyk et al2 conducted a cross-sectional study of 2344 direct-care nurses and advanced practice registered nurses to assess nurses’ perceptions of their EBP competencies. In general, the nurses did not rate themselves as competent in any area. Among the lowest-rated competencies for both direct-care nurses and advanced practice registered nurses were critically appraising preappraised evidence or studies, systematically searching for external evidence, and integrating a body of external evidence. In a study of 1709 medical-surgical nurses3 that also used the Melnyk EBP beliefs and competencies instruments,2,19 respondents rated themselves as competent in only 2 of 24 competencies (questioning clinical practice to improve the quality of care and describing clinical problems using internal evidence). Among the lowest-scored competencies were participating in critical appraisal of published research studies, critically appraising relevant preappraised evidence and primary studies, and formulating evidence-based policies and procedures.3 In addition, only 68% of the respondents believed they could search for evidence in a time-efficient way.An activity that directly addresses these competencies is an exercise humorously known as “speed dating” for research. This exercise identifies 5 critical questions to consider when reviewing any research article and a strategy to rapidly find this content in an article (Table 1). For example, the purpose of the study, in addition to being stated in the abstract, is typically stated in the last sentence of the introduction section, immediately before the methods. During the exercise, the facilitator uses an example article to demonstrate to the participants where to find the critical content. To further narrow the focus to the critical content, the facilitator asks the participants to spend no more than 2 minutes finding the content for the targeted question. The key information is recorded on an evidence grid with columns for each question.To focus on the process of finding and evaluating critical content rather than an article’s specific topic, one strategy is to select articles that are short and straightforward and reflect several types of research. Another strategy is to select satirical research articles that were written to make a point about research and EBP.20,21 Examples of satirical articles include randomized controlled studies on the effectiveness of parachutes in preventing gravitational injuries22,23 and the effect of maternal kisses on minor injuries (boo-boos).24 Studies using within-subjects design include an evaluation of swearing as a response to pain25 and a study of fast versus slow adhesive bandage removal.26 An example of a study evaluating the sensitivity and specificity of a test is an evaluation of the diagnostic accuracy of maternal tactile fever assessment.27 The exercise in speed dating for research (Table 2) can be done with a small group (eg, local practice council) or hundreds of nurses at a conference. This exercise demystifies how to find essential information within a study. The satirical nature of the studies chosen for review also makes the activity fun.In a workshop this exercise can be preceded by a session on interpreting the statistics used in the selected studies, which allows for direct knowledge application during the review process. This exercise, which is designed to build confidence and competence in the analysis and integration of evidence, also demonstrates how this work can be conducted within the constraints of a busy work schedule. The mentoring of those facilitating this work also addresses another low-rated competency: mentoring others. Overall, this team-based activity is undertaken with concentration and a great deal of laughter, making the learning process enjoyable and nonthreatening.Other low-rated EBP competencies reflect the process of undertaking an EBP initiative, including collecting data, evaluating outcomes, and generating external evidence.2 A strategy to address these competencies is to conduct a demonstration project referred to as a study in a day. One of our goals for the SNRC conference was to expose the attendees to all components of a project, including identifying the purpose, conducting the study, presenting the results, and making recommendations for practice. The exercise draws on the general principles of flash mob research33,34 or point-prevalence studies. Flash mob research is designed to rapidly (within a day or a short period) conduct a study on a relevant research topic using multiple study sites. Examples of flash mob research include interobserver agreement on capillary refill time35 and the accuracy of recorded versus actual respiratory rates.36The first study in a day was designed to demonstrate the research process by addressing the following clinical question: Does blood pressure measurement differ according to the direction of the tubing (tube up or tube down) on an automated blood pressure cuff in individuals with normal blood pressure? The research team was led by a senior nursing student from the University of Washington School of Nursing, Seattle, as a part of their senior honors program. Two University of Washington Medical Center nurse educators and a clinical nurse specialist supported the nursing student, the principal investigator. A nurse scientist was the faculty member of record and project mentor. The research team completed the literature review in collaboration with a research librarian. The methods of speed dating for research were used to provide the initial evidence summary, which informed the protocol development. The protocol was classified as “Exempt” by the institutional review board. Study preparation took approximately 1 month. The actual study was completed in 8 hours (Table 3). According to international blood pressure measurement standards, blood pressure measurements did not significantly differ on the basis of tube direction in individuals with normal blood pressure. This study could be redesigned as a flash mob research study to explore this question in hospitalized or clinic patients, including those with hypotension or hypertension, across the community. Demystifying the research process into a flash mob or study-in-a-day design provides active engagement and ideally builds participants’ confidence in research knowledge and skills. Since completion of this project, teams from hospitals across the region, with nurse scientists as mentors, have led the annual SNRC study-in-a-day exercise. Topics are selected to demonstrate the conduct of different types of research. Examples include how to conduct survey research (eg, with the Climate, Health, and Nursing Tool), how to include survey design and web-based survey methods into an intervention (eg, with the Three Good Things– Burnout), physiological measurements (eg, measuring skin interface pressure with patient microturns), and introduction to qualitative methods (eg, evaluating perceptions of lavender therapy).In the study by Melnyck et al,2 the factors most strongly associated with EBP competency were mentorship and EBP beliefs (eg, “I am sure evidence-based guidelines can improve care” and “I am sure that I can implement EBP”). Similar to the speed dating exercise, the study-in-a-day project developed advanced practice registered nurses’ competencies in leading and mentoring EBP initiatives and enhanced participants’ beliefs about the importance of EBP and their ability to implement an inquiry project. For several of these teams, this activity was their entry into participation in EBP. The study in a day served as a springboard for the team to initiate other EBP or research initiatives at their home institution.Although the activities described in this article support the technical aspects of using evidence to advance practice, they are also designed to build confidence through the more subtle aspect of using evidence to answer clinical inquiries. The use of evidence exists on a continuum extending from conceptual use (indirect use of evidence resulting in changes in perception and understanding) to the more obvious instrumental or persuasive use (use of evidence to inform practice and policy decisions).37 Although greater emphasis is placed on instrumental use and overt outcomes (eg, reducing hospital-acquired infections), conceptual use is of equal importance in a culture of inquiry. For example, an article by Wilkinson38 described the impact of providing access to evidence-based resources. The impact extended along the continuum of use; however, nurses indicated that conceptual use was the most important for them. This conceptual use was manifested as increased confidence in their ability to access and understand evidence as related to practice. Other conceptual aspects included increased morale and sense of team, personal and professional development, and desire to continue to explore improvements in care. The nurses indicated that they rapidly moved from these conceptual uses to the instrumental use of evidence to change practice. The importance of highlighting both conceptual and instrumental uses of evidence in a culture of inquiry is exemplified by a quote from a nurse who described how engaging in research had affected them: “I used to hate research—now it’s the coolest thing. Who would have thought I could do a study and present it at a national conference? Now I’m looking for my next study!”The advancement of individual EBP is critical, but creating a milieu that advances a culture of inquiry and diffuses practice innovations at the organizational and community levels is equally important. During the COVID-19 pandemic shutdown, SNRC was able to maintain this sense of community centered around clinical inquiry by pivoting to a virtual platform. The community desire to engage in this culture of inquiry was evidenced by participants from across the entire western United States. At the community level, participation in SNRC (or other national conferences, such as the EBP conference at the University of Iowa) and the activities presented in this article support both conceptual and instrumental uses of research and a culture of inquiry, and this participation creates the opportunity to move evidence translation forward. Our challenge is to engage in and study this opportunity.We offer special thanks to Mary Beth Flynn Makic, PhD, RN, for reviewing the manuscript. This article is in memory of Dr Marie Driever, longtime member of the SNRC Board of Directors.