Change Agent
Columbia Nursing’s LINK program celebrates 10 years of helping nurses transform ideas into practice.
In 2020, at the dawn of the COVID-19 pandemic, a group of nurses at NewYork-Presbyterian Queens Hospital (NYP Queens) noticed a pattern in COVID patients’ clinical presentations that resembled respiratory distress. With no vaccines or evidence-based treatments for the virus at that time, the nurses—whose hospital had one of New York City’s highest mortality rates—felt an urgency to treat their patients with the only proven interventions they had: remedies for respiratory distress, including ambulation, upright positioning for sleep, incentive spirometer usage 10 times a day, and close monitoring of their fluid and nutrition intake. But the nurses didn’t have solid evidence that these interventions would improve COVID patients’ respiratory function. Acquiring such evidence would necessitate conducting a study. The problem was, they lacked research experience.
“I had a group of clinical nurses who called me within the first week of the shutdown, asking for guidance in creating a research study for an evidence-based checklist to treat COVID patients in respiratory distress,” recalls Allison Norful, PhD, an assistant professor at Columbia Nursing. A highly experienced nurse-scientist, Norful conducts research across NewYork-Presbyterian’s (NYP) 11-hospital system. She agreed to teach the nurses how to create and measure a checklist, collect data, and secure approval from their hospital’s Institutional Review Board (IRB) to fast-track their study. As a member of a program called Linking to Improve Nursing Care and Knowledge (LINK), an academic-practice partnership between Columbia Nursing and NYP, Norful had instant access to the data and the academic resources the nurses would need to advance their study. “We went from not knowing how to treat COVID patients to putting our heads together to create a research trial. Within a month, the checklist was being adopted across the hospital and we were seeing improvements,” Norful recalls, noting that the study appeared in the Journal of Clinical Nursing and was presented as a poster at the International Congress of Nurses. It also received commendation from the American Nursing Association-New York (ANA-NY), garnering first place at an ANA-NY conference. Says Norful, “The partnership between Columbia and NYP produced a therapeutic, all-hands-on-deck reaction to the pandemic that made a difference and saved lives.”
This year, LINK celebrates 10 years of helping clinical nurses throughout NYP transform their research ideas into studies by connecting them to Columbia Nursing’s academic nurse-scientists. It is a momentous benchmark, one that the American Academy of Nursing (AAN) has honored by selecting the LINK program as the recipient of its 2024 Edge Runner Award.
The AAN’s Edge Runner initiative recognizes nurse-designed models of care that reduce cost, improve health care quality, advance health equity, and enhance consumer satisfaction. Indeed, LINK not only has accelerated the application of evidence-based interventions to clinical care but also has advanced nursing satisfaction and the field of nursing itself—two factors that are critical as nurses, the backbone of the health care workforce, are increasingly considering leaving the profession.
Creating a culture of inquiry
Christine DeForge, PhD, a postdoctoral research fellow at Columbia Nursing who, since her earliest days in nursing, wanted to know how research informed clinical practice, found the answer she was seeking through LINK. “The LINK program meaningfully influenced my career trajectory and helped shape my future in becoming a nurse-scientist,” says DeForge, who participated in the inaugural cohort of LINK’s two-year, competitive Academic Practice Research Fellowship. The fellowship pairs an NYP nurse who has a research idea based on their clinical experience with a Columbia Nursing faculty member who provides one-on-one mentoring in how to design and conduct a research study. The faculty mentor guides the clinical nurse through securing IRB approval, collecting and analyzing data, writing up the study results, and submitting their manuscript to a peer-review journal. “I knew there was potential for clinical nurses to contribute to improving patient care through research, but there was nothing to fuel that flame until I came to NYP,” DeForge says.
The “fuel” that inspired DeForge is the culture of inquiry that LINK has created across the NYP enterprise, according to its co-founder, Elaine Larson, PhD, Columbia Nursing’s Anna C. Maxwell Professor Emerita. “Nurses commonly encounter clinical questions that evolve from contact with patients or problems with procedures that have been done a certain way forever,” says Larson, who for over 20 years was also a professor of epidemiology at Columbia University’s Mailman School of Public Health. “Often, you just do your work and get through the day, but LINK helps staff nurses question things that they know are not working well. It helps them question whether what they’re doing has good outcomes: whether patients feel better, can manage their illness better, and have an improved quality of life,” she explains.
Generating verified knowledge from insights informed by practice is crucial to improving health care, which is fundamental to LINK, explains Kasey Jackman, PhD, who directs the Academic Practice Research Fellowship. “So much research in the hospital setting is physician-driven and yet nurses are the largest segment of the health care workforce and have the most contact with patients,” says Jackman, an assistant professor of nursing and the school’s director of academic-practice partnerships.
Adds Larson, “Because nursing is a practice discipline, the research we do should be directly related to the clinical care we provide.”
But research takes time, a commodity that most hospital nurses lack. Moreover, the road from an initial concept to its practical application is long. One of LINK’s big achievements has been significantly shortening that road, Norful says. “For a clinical nurse to think of an idea, tease it out, talk to me, and get it approved can take eight months,” she says.
Furthermore, “it can take as long as 17 years for research to be integrated into practice or for practice to adopt research findings.” By joining the resources of NYP and Columbia Nursing, LINK has eliminated that lag. “While Columbia Nursing halted most research during the pandemic, it partnered with the NYP enterprise to give us instant access to its data and workforce, providing its nurses with the most current evidence for improving COVID outcomes,” she says. “From idea to implementation took only two weeks.”
Increasing opportunities
In addition to shortening the road between an idea and its implementation, the LINK program paves the way for new career opportunities in the field of nursing and, in turn, for elevation of nurses’ professional status. “To date, the program has trained 3,000 nurses across the clinical enterprise, from brand new nursing graduates to veteran nurses who have 40 years of clinical experience but never conducted their own nursing research study,” Norful says. “We’ve also created a pipeline for more nurses to seek a doctoral degree. By increasing a nurse’s exposure to research and securing needed resources and training, more nurses are likely to go on to obtain a PhD, which has led some to leadership positions in industry, policymaking, or academics,” she adds.
Revitalizing nurses’ interest in their work is especially important today, with the overburdened health care system fueling nurse burnout, DeForge notes. “Now more than ever, we want to maintain a strong nursing workforce, and it is therefore important to engage nurses in ways that they want to be engaged,” she says. “Nurses by nature are inquisitive and problem-solvers, so it’s important to be able to link them with resources to help them address the questions they have and the improvement opportunities they see to ultimately advance care for patients.”
For example, becoming an Academic Practice Research Fellow allowed DeForge to pursue her interest in improving the assessment and treatment of patients with delirium in a medical intensive care unit (ICU). “There was a misconception among nurses that many patients with delirium couldn’t be assessed,” DeForge says. What nurses didn’t realize was that delirium itself, in addition to common ICU treatments like sedation and mechanical ventilation, was preventing patients from engaging in and completing parts of the assessment protocol. As a result, opportunities to identify delirium were being missed. “We were under-detecting the problem,” she says.
With support from the Academic Practice Research Fellowship, DeForge conducted a retrospective study of electronic health record data to evaluate the efficacy of an educational intervention she delivered in the medical ICU to improve nurses’ documented delirium assessments, pre- and postintervention. The study showed improved assessments in those ICU patients most difficult to assess for delirium, demonstrating a potential to improve nurses’ ability to detect delirium. Importantly, the study provided valuable insight into the most effective and resource-efficient elements of ICU delirium training for nurses.
“LINK allowed me the opportunity to engage in robust research and to improve nursing practice in ways I hadn’t considered,” DeForge says. “What I gained most during my Academic Practice Research Fellowship,” she adds, “was mentorship from nursing faculty at Columbia, who demonstrated what a successful academic nursing career looked like and how nurse-scientists can make meaningful contributions to patient care.”
The next decade and beyond
Since 2014, when LINK oversaw only one or two studies, it has supported hundreds of them, all across NYP’s network of hospitals. These have included investigations of minimizing stress among nurses; extubating patients on an ECMO (extracorporeal membrane oxygenation) machine, which takes over their heart and lung function when those organs don’t work on their own; comparing Spanish-speaking oncology patients’ understanding of clinical information in English versus Spanish; and the stigma that psychiatric and medical-surgical nurses attach to patients with mental illness.
With 10 years under their belt, LINK’s leadership looks forward eagerly to the next decade, during which they aim to delve into some of the most pressing issues in today’s health care world—such as access to care; nursing job satisfaction; and diversity, equity, and inclusion in the provider workforce, according to Reynaldo Rivera, DNP, the director of nursing research and innovation at NewYork-Presbyterian. “Nurses identifying and being able to research what they see has significant impact on practice,” Rivera says. “When our Academic Practice Research Fellows propose a study, we make sure it has implications clinically that are relevant in today’s health care climate. For example, we need to focus on the well-being of the health care provider workforce. There should be more workforce studies and studies of different models of care with a focus on diversity, equity, and belonging,” he says.
LINK’s future is exciting, agree those involved with the program. “In the next decade, we want to go international with this model, which we’ve already started by presenting in the Philippines and Saudi Arabia,” Norful says.
Rivera adds, “LINK is a tremendous partnership that we can replicate in other hospitals. We have come a long way, and in the future there will be even more robust academic-clinical partnerships and more advanced technological research and innovation, dissemination, and continuous learning, all to be aligned with what is going on in today’s health care climate.”
As the program grows, Larson believes it will educate, excite, and enlighten nurses about their professional potential and their contributions to patients’ health. “Nurses more and more are realizing that no single discipline can improve care by itself,” she says. “Nurses are part of a system of care, and it is important for them to learn that to make changes, they must take a systems approach. I hope the LINK program expands so that clinical nurses understand how important it is to ask questions and so that academic nurses aren’t separated from clinical nurses. Columbia Nursing is taking the lead to make sure the two arms are always talking to each other.”
Illustration by Maximillian Olson.
This article originally appeared in the Fall/Winter 2024 issue of Columbia Nursing Magazine.