Asking the right clinical questions is second nature for a nurse, but asking clinical questions in ways that are amenable to scientific solutions is a critical skill that takes time, expertise and mentorship to develop. Faculty at Duke University School of Nursing and Duke University Health System (DUHS) are partnering to help clinical inquiry flourish through collaboration between bedside nurses and nurse scientists. Fruits of the partnership are leading to improved rigor in research and quality improvement design that, in turn, help to improve outcomes for patients and families.  

Bradi B. Granger, MSN, PhD, RN, FAAN, FAHA, professor and director of Duke Heart Center Nursing Research Program, Staci Reynolds, PhD, RN, ACNS-BC, CCRN, CNRN, SCRN, CPHQ, associate professor and clinical nurse specialist at Duke University Hospital, and Anna Mall, MSN, RN, CCRN, CNL, a nurse at DUHS, recently co-authored an article on clinical inquiry in the “American Association of Critical-Care Nurses (AACN) Advanced Critical Care” Summer 2022 journal.  

Their work is one of many projects and activities that are an outcome of DANCE, or the Duke Advancement of Nursing, Center of Excellence, an academic practice partnership between nurses in the School of Nursing and DUHS, which leverages the experience, knowledge, and aspirations of nurses across both entities. 

In an example of the relationships DANCE fosters, Granger immediately thought of Reynolds and Mall when a question came up at a national conference: How can any small-scale, single-site study be valuable to growing and expanding nursing science?  

The authors answered that question by creating a pyramid structure outlining a step-by-step approach to clinical inquiry that results in generalizable data that can impact the national or even global health care research priorities for improving health and patient care.  

“There is, at the end of the day, a randomized trial that can contribute causal evidence to a patient problem and provide data to change practice and leverage policy,” Granger said. 

Mall works in the cardiac catheterization lab at Duke University Hospital. She and her team noticed that patients consistently experience discomfort in response to the catheter insertion, despite the administration of pre-procedural pain medicine.  

“My whole question was, why are we giving this medication? Is it doing what we need it to do? Can we do it a different way,” she said.  

The first step of the pyramid examined current research and recommendations in the literature about what to do when there was breakthrough pain during the procedure. The next step was designing a study to analyze existing cath lab data for clues to the precursors of pain during the procedure. The next step was designing and conducting the randomized trial that compared two pre-procedural sedation intervals. The last step was taking the results of that trial and building further questions based on focus groups with the nurses and the patients, expanding the inquiry to include additional studies, each addressing the patient experience from different angles. 

Reynolds’s study focused on central line-associated bloodstream infections, or CLABSIs. Because the infections are costly to treat and create a longer, and possibly more complicated recovery for patients, Reynolds was interested in how to mitigate the rate of infections. Protocol calls for chlorohexidine gluconate (CHG) bathing, but Reynolds found that there was low compliance by nurses across the U.S., partly because patients didn’t like the baths, which some find uncomfortable or because they dislike the smell.  

Reynolds partnered with Granger, who had connections with Wake Med, and conducted a collaborative study that found that, with greater compliance and procedural understanding, the rate of infection decreased. But they took results of the study a step further to talk to patients and nurses about their experiences.  

“There were just a lot of little one-offs from that larger study that we were able to do to keep the ball rolling and answer further clinical inquiry questions as they came up,” she said, noting that having a randomized trial as the primary source was critical. “It’s not until you get to talking to the bedside nurses and patients that you get into the nitty gritty details of maybe why the intervention of CHG bathing treatments, as recommended in the evidence-based CDC guideline, isn’t working so well [in real world clinical practice].”  

Implementing the pyramid approach to clinical inquiry requires the type of collaboration DANCE offers.

“The whole premise of DANCE as an academic health system partnership is to bring academicians on the school side, who are experts in the science and design of clinical inquiry, together with the health system nurses to support health system science,” Granger said. “Clinical inquiry, when it’s done well, requires a rigorous scientific design so that the study can effectively inform practice.” 

Mall agrees that the questions can often come from clinical nurses, but they need the support and structure that a nurse scientist offers.  

“I think what’s very unique in the partnership with DANCE is we have those relationships established,” she said. “It makes that nurse scientist accessible to the bedside nurse.”  

Mall said her experience collaborating with the nurse scientists has improved her leadership skills by allowing her time to help with the design study, data collecting, team-building and number-crunching that she would not have been able to do otherwise. 

Granger is interested in ensuring that more health systems, including those without academic-practice partnerships like DANCE, have opportunities for collaboration with nurse scientists. 

“That’s one thing we’re working on at Duke through DANCE, to make the resources of a nurse scientist more accessible for our smaller community hospitals, and also around the country, to share this model we’re using at Duke,” she said.  

The co-authors' work helps to demonstrate how nurse scientists and researchers have a key role in advancing nurses’ leadership skills, autonomy, and decision-making skills, in turn, improving professional practice environments and health outcomes for real people, families and communities.