By Kenneth Miller
This article originally appeared in the Spring 2018 issue of Columbia Nursing magazine.
As a charge nurse in the pediatric diagnostic and imaging center at NewYork-Presbyterian Morgan Stanley Children’s Hospital, Dan Hogan, MSN, knew that kids often feel anxious about undergoing magnetic resonance imaging (MRI). Having to lie motionless for a prolonged period inside a machine that makes loud clanking and buzzing noises can be unnerving, even for adults. Children may grow so distressed that they can’t keep still. To ensure a clear image, many are given general anesthesia.
One day a colleague of Hogan mentioned that her niece was facing an MRI; the colleague said she’d gone online in search of an educational video to help prepare the girl, but the few she found were of surprisingly low quality. Hogan volunteered to try to make something better, drawing on the expertise of Morgan Stanley’s nurses, MRI technologists, and child-life specialists. A few months later, he premiered a seven-minute production— starring his young daughter and her mom, and featuring several animated sequences—which received rave reviews from patients and their parents.
Hogan’s patient-care director suggested he go further: Why not conduct a clinical study to see whether the movie had a measurable effect on anxiety levels before and during the procedure? If so, perhaps such videos could lessen the use of anesthesia (which poses health risks, cost burdens, and scheduling challenges) as well as the incidence of emotional trauma (which may discourage families from seeking future medical care) for kids who need MRIs.
There was just one problem: The study would be the first to address this topic, and Hogan had no idea how to go about it. “I was always intimidated by the notion of research,” he recalled. “I’d been exposed to the basic methods as an undergrad, but I’d never led a project of my own.”
Hogan was hardly the first RN to come up with an insight into how care might be improved, only to hesitate at the challenges of testing the concept scientifically. “Staff nurses are on the front lines, and they often have great ideas about how to make things better,” noted Elaine Larson, PhD, the Anna C. Maxwell Professor of Nursing Research and associate dean for scholarship and research at Columbia University School of Nursing. “But they seldom know how to put those ideas into a researchable framework.”
Over the past few years, the school has launched a series of initiatives aimed at closing that gap, in partnership with major medical centers in the New York City area. “In health care systems nationwide, there’s an expectation that nursing practice be evidence-based rather than just doing things the way they’ve always been done,” explained Dean Bobbie Berkowitz, PhD. “By working with hospitals to foster nurseled research, we’re helping to advance that goal. We’re also helping nurses fulfill their deepest motivation—to achieve the best possible outcomes for their patients.”
Columbia Nursing’s research-practice partnerships benefit from a deep form of collaboration: Faculty members serving in joint appointments with medical centers or other health care providers commit to spending half their time cultivating staff research efforts, and the other half pursuing their own research. “This collaboration is essential as we continue to build a culture of inquiry and advance nursing science,” noted Wilhelmina Manzano, MA, senior vice president, chief nursing executive, and chief quality officer at NewYork-Presbyterian.
The first such arrangement began in 2013, in collaboration with the Visiting Nurse Service of New York’s (VNSNY) Center for Home Care Policy & Research. Dawn Dowding, PhD, then a professor of nursing at Columbia Nursing, collaborated with the research team at VNSNY to develop and carry out projects related to nurse decision making and how technology affects that process.
The second research-practice partnership was different. It started in November 2014, when Eileen Carter, PhD—a nurse-scientist who’d recently earned her doctorate at Columbia Nursing—was named an associate research scientist at the school and a nurse researcher at NewYork-Presbyterian. (She’s now an assistant professor.) In the hospital setting, Carter’s duties ranged from conducting grand rounds on literature-search techniques to helping nurses design and implement research studies.
Not long after she began the clinical aspect of her joint appointment, Carter was approached by Hogan, who was struggling to get started on his research project. “Dan played me his video, which I thought was very professional, and told me he wanted to do things in a rigorous way,” Carter recalled. She suggested a randomized controlled trial, in which one group of participants would watch the video before their MRIs, while the rest received standard care—a brief talk about what to expect during the procedure and instructions to hold still. Over the following months, Carter helped Hogan shape the parameters of the study and prepare a proposal for Columbia’s institutional review board (IRB), reassuring him when the board sent it back for more work. “I was quite disappointed, but she laughed and told me proposals are rarely accepted the first time,” Hogan said. After the IRB approved the revised plan, Carter guided him in selecting a research assistant and recruiting 50 subjects for the study. And once the data had been collected, she introduced Hogan to biostatistician Jianfang Liu, PhD, a senior data analyst at Columbia Nursing, who helped him interpret the results.
The study showed significant improvements in relaxation and understanding of the procedure in patients 13 to 17 years old who watched the video, suggesting that this type of intervention was worthy of further investigation. With Carter’s guidance, they selected a prestigious journal as his target publication, and began writing up a manuscript. “Dr. Carter is an incredible educator,” said Hogan. “She opened my mind and broke down barriers. And she had so much confidence in me that I worked twice as hard to avoid disappointing her.”
Over time, the research-practice partnership expanded. In January 2016, Assistant Professor Kenrick Cato, PhD, a clinical informatics specialist who’d served as an Army captain in Iraq, became a joint appointee of the school and the medical center. Associate Research Scientist Carolyn Sun, PhD, who’d conducted nursing research in Africa and the Middle East—and who, like Cato, had earned her doctorate at Columbia Nursing—soon joined him. More NewYork-Presbyterian nurses launched research projects under their mentorship, and (according to a study the team published in the Journal of Nursing Administration) a culture of inquiry began to flourish among the staff as a whole. Nurses’ monthly use of the hospital library nearly tripled.
That March, the American Association of Colleges of Nursing (AACN) released a report titled “Advancing Healthcare Transformation: A New Era for Academic Nursing,” which confirmed that collaborations like those Columbia Nursing was pioneering were just what academic health centers should be pursuing. Urging a closer relationship between academic research and clinical nursing, the document called for strengthening research-training programs for health-system nurses, and “creating mechanisms to coordinate research projects and activities” between nursescientists and their clinical counterparts.
The AACN report confirmed for Dean Berkowitz and her colleagues at the school and NewYork-Presbyterian that their collaboration could become a national model. The group developed a more formal structure for the partnership, calling it Linking to Improve Nursing Care and Knowledge: The LINK Project. LINK was designed to ensure that any nurse with a viable idea for a clinical study could receive at least as much help as Hogan had. After filling out an online application, the clinician aspiring to develop a research project would be assigned a project manager (one of the joint appointees or Larson), who would provide conceptual and logistical support, including assistance in seeking funding. The clinician would also work with data expert Liu at every stage of the endeavor. “The idea was to give nurses the resources they needed without them having to come search for us,” Cato explained. Larson became LINK’s co-director, along with Reynaldo Rivera, DNP, director of nursing research and innovation at NewYork-Presbyterian.
“This initiative has been a great value to both organizations and has certainly contributed to advancing the nursing profession and improving patient care,” Rivera said.
The school was also pursuing such partnerships with other institutions. Around the time LINK launched, Amanda Hessels, PhD—a nurse scientist at Hackensack Meridian Health, New Jersey’s largest health care system—completed her postdoctoral studies under Larson. Columbia Nursing then hired her as an associate research scientist, in a joint appointment with Hackensack Meridian. At the medical center, Hessels’ responsibilities include mentoring dozens of staff nurses who wish to pursue research projects. As a faculty member at a leading academic institution, with a growing list of published papers and a grant from the National Institute of Occupational Safety and Health, Hessels has been able to pass along skills and perspectives that these clinicians otherwise might have missed out on. She also serves as a role model. “Most of them know me as one of their own,” she said. “They think, if Amanda can do this, maybe I can, too.”
Today, Columbia Nursing’s research collaborations continue to grow. A joint appointment with Memorial Sloan Kettering Cancer Center was recently filled by Bevin Cohen, PhD, a recent graduate of the school who also holds a doctorate in epidemiology. At NewYork-Presbyterian, more than 30 nurses have consulted with LINK’s mentors since the project’s founding; several are now conducting studies on topics such as avoiding catheter-associated urinary tract infections and reducing emergency-department wait times. Cato is writing up a study evaluating the project’s first year, which he’ll submit for publication soon.
The school recently launched the Academic-Practice Research Fellowship with NewYork-Presbyterian, which aims to further reduce the barriers between academic and clinical nursing. Spearheaded by Carter, the two-year fellowship is a competitive program. Proposals are evaluated by nurse members of the medical center’s Evidence-Based Practice Research Committee; those that score highest are reviewed by a faculty committee at Columbia Nursing, which selects the winning entries based on how important they are to the nursing profession and patient care, and whether they can be completed within the allotted time frame. Out of the 15 candidates who applied for the first round, five were chosen. In addition to mentoring by faculty members, statistical consultation, and a writing-for-publication workshop to assist in the dissemination of study results, the nurses get protected time off from their nursing duties for the duration of the fellowship. Upon completion of the fellowship, they’ll also receive a certificate of advanced training. “This is the only nursing fellowship of its kind that I know of,” said Courtney Vose, DNP, vice president and chief nursing officer at NewYork-Presbyterian/Columbia University Irving Medical Center and Allen Hospitals, who helped shape the initiative. “It’s something nurses have dreamed of for years, and it’s amazing to see it come to fruition.”
The fellows’ research projects—including studies of extubation protocols for extracorporeal membrane oxygenation (ECMO), identifying delirium in ICU patients, techniques for improving medication communications, and the use of meditation to reduce burnout among surgical ICU nurses—are just getting started. But if all goes well, these clinical nurses will experience the same sort of satisfaction that Hogan’s MRI-video research ultimately brought him.
The LINK team was thrilled when that study appeared in the January 2018 issue of the Journal of Pediatric Nursing, with Carter, Liu, and Larson among the co-authors. By then, the video had become part of standard care at NewYork-Presbyterian, and had scored nearly 40,000 views on YouTube. Hogan, meanwhile, had become a clinical nurse manager at the pediatric ICU of Seattle Children’s Hospital, overseeing a staff of more than 120. “I often wonder if I would have gotten this position if it hadn’t been for my research project,” he mused. “When I told them at the interview that I’d submitted a manuscript for publication, they were like, ‘wow!’ But what makes me most excited is the study’s potential for improving patient outcomes and family experience.”
Or as Carter put it: “The point is not just to get published—it’s to make a difference.”
That’s the central goal of all Columbia Nursing’s research-practice partnerships.
“Every nurse is driven by a passion to get it right,” said Dean Berkowitz. “Helping them find out how is what these collaborations are all about.” Manzano added, “Close ties between service and academia are critical to our ability to improve patient care through nursing science.”