Cultivating Mindfulness in Research and Clinical Practice

Elaine Larson is a pioneer in promoting hand hygiene for infection prevention and control. She is a fellow in the National Academy of Medicine and has advised the World Health Organization on global guidelines for hand hygiene. Larson has been editor of the American Journal of Infection Control since 1995 and has published more than 350 journal articles, four books and a number of book chapters in the areas of infection prevention, epidemiology and clinical research. She served on the President's Committee for Gulf War Veterans' Illnesses, the Board of Scientific Counselors for the National Center for Infectious Diseases at the U.S. Centers for Disease Control and Prevention; and was a chair of the CDC's Healthcare Infection Control Practices Advisory Committee. Larson has also served as a consultant in infection control internationally, contributing to prevention and education efforts in countries such as Kuwait, Jordan, Singapore, Japan, Australia, Ghana, Peru, Brazil, Spain, Portugal, France, and Egypt. She holds a joint appointment at the Mailman School of Public Health, where she is a professor of epidemiology. In 2014, she was the first nurse to receive the John Stearns Medal for Distinguished Clinical Practice from the New York Academy of Medicine.

Tell us about how your early clinical work influenced you to become a researcher and epidemiologist.

When I first started out as a staff nurse, I faced a number of problems that I couldn’t figure out. It seemed to me that my professional role as a nurse wasn’t just about taking care of patients, but also helping to find solutions about how to take care of them.

One of my early patients was a woman in her 30s who had heart disease. She called me in to her bedside and told me she wasn’t feeling very well. I took her pulse and listened to her heart; remember, this was before we had the more advanced kinds of monitoring we have today. She seemed to be OK. I gave her a pillow, set her up with her bedside stand and told her she would be OK. Within five minutes she was in acute distress and she died.

I decided right there that I should learn about her condition—acute pulmonary edema—and never let that happen again. Within six months of graduating nursing school, I wrote and submitted a paper on the condition to a nursing journal. They published it and I got a call from them saying “We want more nurses to write papers like this.” Even though the paper wasn’t research in the true sense, it was my first time using a real clinical problem to identify the need for me to know more and, by extension, for my nursing colleagues to know more, too.

Are today’s nurses asking these types of questions? Are they looking for better ways to deliver patient care?

The challenge for nurses at the bedside today is that they’re so busy. Every single day they encounter important decisions and it’s very easy to get in the habit of making the same decision, doing the same thing from one patient to the next. Some of this is essential—if we stop with every routine task to question it, our patients won’t get the care they need. But we need to encourage mindfulness among staff nurses. When something comes up and you’re not sure of the answer, don’t skip over it or do what you’ve always done. Think, “Is this something that I should learn more about, and question, or even study?” That kind of mindfulness should start in nursing school, but it needs to extend to clinical nurses.

How do you establish this kind of mindfulness in nurses?

It starts in the classroom. At Columbia Nursing we strongly encourage mindfulness. We talk about the value of learning from near misses—that situation where something bad almost happens, but fortunately it doesn’t. Nurses need to learn from these situations so they don’t happen again. The technical skills of nursing are absolutely necessary but not sufficient to make a good nurse. Learning and questioning also need to extend beyond the classroom and into the workplace. A nursing work environment should always be a learning culture where mistakes and errors are used as opportunities to ask, “What can we learn from this and how can we do better?”

You’ve been the principal investigator on dozens of studies. How has your perspective as a nurse scientist informed your research?

Again, going back to an early time in my career, I was a nurse specialist in a surgical ICU working on a project looking at infection rates. One of the things we noticed—talking about mindfulness—was that hand washing was lacking.

I went to the surgeon in charge of the ICU and said “We need to do something about this!” and he asked, “What’s the evidence that hand washing makes any difference?” I was appalled. We learn as kids how important it is to wash our hands, how could he question its value? But then I started to think, “Well, what is the evidence that hand washing does any good?”

And from that I published a literature review that I believe was one of the first papers to show a causal relationship between hand washing and infection rates. I had accepted the value of hand washing without question up to that point, but I realized from that the importance of having good data to inform our decisions.

Being at the center of the patient care environment gives nurses a unique perspective that can be very valuable to developing research ideas.

As an infection control expert and since we’re heading into winter respiratory season, can you give us some tips about flu prevention?

The term hand washing has now become hand hygiene because we have more tools such as waterless hand sanitizers to prevent infection. By all means, wash your hands frequently, but especially in crowded places like New York City—you can also carry and use hand sanitizer which doesn’t require a sink, towel, or running water and actually works faster and at least as effectively as soap and water. Coughing and sneezing are important ways the influenza virus is spread, but it also spreads on hands. Here’s a real New York example. You hold a subway pole after someone with the flu held it and then you touch your mouth, nose or eyes—this can transmit the flu. And remember, there’s an incubation period where people can pass the flu before they get sick, so it does little good to think you can just avoid sick people.

But if you do get sick, and I know this is hard for many of us in the healthcare setting—stay home. If you have flu symptoms, and that’s usually serious aches and fever, not head cold symptoms, don’t expose others. And please--cover your cough, but don’t sneeze into your hands.

Of course, the single most important thing is to get vaccinated. As healthcare professionals, it is our duty to be vaccinated so we don’t pass influenza on to our patients. For all diseases for which there is a vaccine, that is by far the best way to protect yourself. Influenza vaccine isn’t 100 percent effective, but even if you get the flu, you won’t be nearly as sick if you weren’t vaccinated.

As a long-term researcher, how do you stay in touch with the clinical realities of nursing today?

It’s easy to get out of touch when you’re not daily in a clinical setting, but my research is clinical, which means I still see patients as part of my research. I still see what’s going on in hospitals and the communities. And I also talk with clinical nurses regularly about the problems they face. There’s room and a real need for every kind of expertise in nursing. All of our expertise is essential to good patient care. The idea is to partner—clinicians and academics need to work together and complement each other’s skills. This is the driving principle behind our recently launched LINK Project.

Can you tell us about what you’re working on now at Columbia Nursing and how your work aims to improve clinical care and make a difference in global health?

There is a body of research showing that nurse staffing is associated with patient outcomes—poor staffing is associated with adverse patient outcomes such as higher morbidity or mortality, higher infection rates, and so forth. That’s important information, but it’s only a start. We need more information to really zero in on ways to staff better for better patient outcomes.

We recently received a grant from the Agency for Healthcare Research and Quality to look at how we can use electronically available data from patient charts to hone in on the nursing care intensity needs of each patient. This is not always obvious. As an example, you can have two very different patients—one very close to the end of his or her life and another who is not very sick—and for a variety of reasons the healthier patient can require more intense care and time from the nurses. 

What we want to do is to find better ways to predict the right amount of nurse staffing needed to optimize patient outcomes. The ultimate goal is to find an automated, quick way to use patient chart data to accurately predict unit staffing needs. This research might also inform the kinds of skills nurses need on a particular unit. In effect, this could lead to a more accurate, real time way to link patient needs with the appropriate nursing staff and skills.