Authors

  1. Ridge, Richard A. PhD, RN, CENP

Article Content

As healthcare begins to recover from the COVID-19 pandemic and the industry begins to establish a new normal, it's important for nurse executives to understand innovation and the potential value of a robust and expanded vision for the nurse scientist role. Innovation is inherently unpredictable and necessary when traditional methods fail, and new capabilities are created to meet current and future needs.1 Innovations may incrementally enhance a current process to improve efficiency or effectiveness, or they may be disruptive or radical, allowing an organization to enter into or even create new markets for programs, products, or services. In a post pandemic world, healthcare delivery should have an opportunity to reimagine itself in the finest traditions of innovation to significantly impact healthcare costs, quality, service, and outcomes. Leveraging the nurse scientist in all aspects of innovation can be operationalized by implementing the nurse scientist role in sufficient depth and breadth within clinical inquiry endeavors.

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

In "Nurse Scientists: One Size Doesn't Fit All," Vessey and colleagues focused on selecting the right nurse scientist for the organization in terms of role, model, and organizational fit.2 They described how successful implementation of the nurse scientist role requires the nurse executive's active engagement and transformational leadership skills to support a culture of clinical inquiry and innovation. Clinical inquiry encompasses research, but also includes evidence-based practice (EBP), quality improvement (QI), and clinical innovation. The nurse scientist role extends beyond the traditional nurse researcher to include creating cultures that support other elements of clinical inquiry beyond conducting original research.2 For example, the University of California, San Francisco Medical Center describes clinical inquiry as "approaches that answer a question, solve a problem, or investigate an issue" within the context of improving patient care.3

 

This article expands on the differentiation between the nurse scientist role and the traditional nurse researcher role and provides a model for nurse executives to establish priorities and build action plans to promote successful implementation of a nurse scientist program aimed at supporting innovation of all types in the quest to improve staff, patient/family, organizational, and population health outcomes.

 

The nurse scientist role and the Nursing Science Impact Model

The Nursing Science Impact Model is a framework to describe the relationship between evidence, standards, and practice and explain how research, EBP, QI, and nursing professional development (NPD) relate to generating evidence and closing the gaps between evidence, standards, and practice.2 As shown in Figure 1, evidence drives standards, which in turn drive practice. Evidence is generally produced by research, incorporated into standards of practice, and then implemented in nursing practice. Systematic, scientific inquiry is used to answer specific research questions or test hypotheses using disciplined rigorous methods. Literature reviews used in research identify gaps in knowledge. Resulting studies are focused on closing these knowledge gaps.

  
Figure 1:. Nursing S... - Click to enlarge in new windowFigure 1:. Nursing Science Impact Model

EBP projects translate evidence and apply it to clinical decision-making by way of a standard, usually in the form of a practice guideline, policy, or procedure. Literature reviews used in EBP are focused on structured and systematic selection and critical appraisal of the literature in the quest to answer a specific practice question, usually in the form of PICOT (population, intervention, comparison, outcome, time frame).4 A standardized format or framework for asking questions helps highlight the key elements and guides the literature search for identifying, evaluating, and applying evidence to the development of standards.4,5

 

Most of the major EBP models incorporate implementation, which is the process by which standards reach the patient through nursing practice. However, implementation science has evolved as a distinct discipline and process of systematically adopting and integrating evidence-based health interventions.6 Some authors claim that implementation science is separate and distinct from QI, whereas others view QI as one element of implementation science.7

 

Titler identified several theories to guide implementation science and numerous implementation strategies that vary according to the characteristics of the practice change, the impacted users, how the change is communicated, and the social system within which the implementation occurs.8 The Nursing Science Impact Model views QI-systematic, data-guided approaches used to improve processes or outcomes-as an integral component of implementation science and as one of the tools used to improve the quality, safety, and value of healthcare through the adoption of EBP.

 

NPD, in close collaboration with QI partners, supports practice improvement by developing, implementing, and evaluating processes and programs that engage nurses in lifelong learning to maintain competencies and learn new skills. Robust learning needs assessments that guide NPD specialists are based, in part, on organizational data related to workflows, processes, and outcomes.9

 

The nurse scientist has the knowledge, skills, and ability to support all aspects of the Nursing Science Impact Model. Traditionally focused on research, the nurse scientist is also prepared to lead and support the other key clinical inquiry elements of EBP, QI, and NPD.

 

The nurse scientist not only conducts research, but also provides direct and indirect support to clinical staff conducting research. The nurse scientist may provide guidance, direction, or leadership to others in all aspects of EBP. Regardless of the EBP model, steps will likely include formulating the PICOT question and performing the literature review and evidence ratings. The nurse scientist is a valuable resource to help nurses focus their interests, formulate research questions, and design and implement meaningful clinical studies that impact knowledge in nursing science. The nurse scientist can also create, support, and evaluate structures and processes that allow staff to develop and apply skills related to EBP.

 

The nurse scientist provides direct and indirect support to apply evidence to all aspects of the QI process, including problem identification, conceptual models, intervention design, and evaluation methodologies. Examples include identifying evidence for causal linkages between QI interventions and outcomes, determining sample sizes for monitoring improvements, and selecting appropriate benchmarking metrics.

 

Finally, the nurse scientist can provide direct and indirect support to NPD specialists in several aspects of their work. Examples include the conceptual development of behavioral and outcome metrics to evaluate the impact of educational programming on patients and staff. Nurse scientists can be especially helpful in guiding NPD specialists in developing and implementing formative and summative program evaluations.

 

Executive leadership for entrepreneurial innovation

Once committed to a vision of having a robust nurse scientist function in the organization, the chief nurse executive assumes the leadership role for all aspects of development and implementation. You may begin with the specific goal of establishing a nurse scientist role; request a given set of resources; and set goals, objectives, and timelines. However, as an alternative, consider the five principles of Sarasvathy's Effectuation Model of Innovation, espoused by the Society for Effectual Action, based on a systematic evaluation of how entrepreneurs initiated, developed, and launched successful innovative products and services.10-13 (See Table 1.)

  
Table 1: Effectuatio... - Click to enlarge in new windowTable 1: Effectuation Model of Innovation principles

The process starts with a vision of possibilities and a broader sense of purpose, in this case, the full depth and breadth of the nurse scientist role. Instead of putting together a proposal to meet a preconceived nurse scientist role within a particular organization, this innovation model emphasizes the iterative nature of the process. As creative partnerships and collaborations are formed, the available resources change, which in turn likely leads to the reformulation of previously established and preconceived goals and objectives. The available means and goals shift dynamically as stakeholder relationships are formed and goals are redefined. Higher levels of collaboration and creativity within the organization are achieved, directly leading to increased value to the overall organization.

 

The following discussion of examples and possibilities draws from the personal direct and indirect experiences of the author in several settings, including academic medical centers and a community hospital member of a three-hospital system. The Effectuation Model of Innovation doesn't prescribe a linear process, but rather an approach that embeds five principles to be applied in an iterative and dynamic manner. However, a good starting point to develop and implement the nurse scientist role is to gain an understanding of how the nurse scientist can have a positive impact on the organization through applications within the Nursing Science Impact Model. Being open to all possibilities, you can assess organizational strategic priorities and related potentially available resources.

 

Bird in Hand

One of the important points of this principle is not to wait for the ideal time or resources to act. Begin with what you have available and aim high, continuously working to get others involved in your enterprise. This may mean inserting yourself in places where the nurse scientist can have an impact beyond nursing research, such as on committees and councils related to EBP, QI, and NPD. Within the research focus, offering nurse scientist partnerships to physician researchers and other disciplines to strengthen their efforts can enhance the potential for future collaboration.

 

At an academic medical center, my involvement began with a resource allotment of one full-time equivalent (FTE) nurse researcher and one FTE statistician. In a department with a single nurse researcher, there was insufficient demand for the statistician's expertise and time. On assessment, I learned that the statistician dedicated approximately 80% of his time to projects outside the nursing research department, including supporting numerous projects in nursing QI and research projects in several medical departments. I was able to transfer the statistician full-time to a medical department in exchange for a commitment to availability of ongoing consultant services as needed to support nursing until we evolved to requiring a full-time statistician. The statistician's FTE was converted to a nurse scientist position. Thus, the revised starting point in terms of resources was two nurse scientist FTEs.

 

Affordable Loss

In terms of making decisions based on whether the downside is acceptable, the risks are primarily associated with opportunity costs related to the nurse scientist's time and expertise. With constrained resources, it's important to engage the nurse scientist in programs and activities that are strategically important for moving the program forward. In this dynamic nonlinear process, it may sometimes seem like taking one step back to take two steps forward, but the nurse scientist's time must be prioritized based on future potential and not necessarily immediate results.

 

Opportunity costs also relate to expertise and competency development. The time it may take for a nurse scientist to learn and develop new skills for a particular project may not be worth it at a particular time. For example, it may or may not be important for a quantitative focused nurse scientist to dedicate time to learning how to use qualitative research software to support a project. However, if by doing so the nurse scientist is forming partnerships and collaborating with others, it may make sense as a gateway to future projects.

 

Continuing with the previous statistician example, the risk of losing a statistician FTE was offset by the benefits promised by the addition of a second nurse scientist. As implied in the Nursing Science Impact Model, the demand for the nurse scientist's time reaches deep and broad. A department with minimal nurse scientist resources is unlikely to overcome the demand for supporting clinical nurses in their clinical inquiry efforts. The nurse scientist may not be able to fulfill other aspects of the role, including developing his or her own program of research. However, if the demand for statistician services exceeded the consultant time available, several potential no-cost statistical consultant resources in other departments were identified.

 

Lemonade

Embracing surprises may lead to future activities and direction for the enterprise. These surprises may be completely serendipitous and come to the attention of the team seemingly out of nowhere or they may happen as the result of deliberate positioning and planned interactions in meetings, committees, and councils. Regardless, the important point is to be flexible and assess these potential relationships, partnerships, and other opportunities for their value to the nurse scientist enterprise and not to dismiss them without full consideration of the potential upside.

 

One of the most potentially impactful surprises could be a change in senior executive leadership at any stage of development. In my role as director of nursing innovation and outcomes, I experienced an unexpected change in CNO. The previous CNO had hired me to develop the nurse scientist role, but the new CNO had been involved in my hire and agreed with the general direction in which we were heading. Otherwise, I would have needed to educate the new CNO about the possibilities and potential of the program and then advocate for continued support.

 

Another common example of a surprise in the nurse scientist world is the unexpected invitation to partner on grant applications from within and external to the organization. This may offer desirable opportunities that can significantly alter and drive future decisions and directions. Deploying resources may be driven by choosing between two equally acceptable options.

 

Crazy-Quilt

The focus should be less on potential competing interests and more on the readiness and ability to make a mutual commitment to a joint venture. Opportunities for partnership and collaboration may be initiated by the organization or by other parties. For example, supply and equipment manufacturers may approach the organization or vice versa to conduct formal research or evaluations of supplies or equipment. Each opportunity is evaluated based on potential value to the organization and never dismissed prematurely without full consideration.

 

As planning for the nurse scientist program continued, several other traditional and nontraditional partnerships and collaborations were formed. Traditional connections included internal informal partnerships with nursing QI, the organization's office of sponsored research, the affiliated medical school's institutional review boards, and research departments at local nursing schools. Several less traditional resources outside formal employed positions contributed significantly to the evolving department's bandwidth. These included a part-time PhD-prepared human factors scientist, who was assigned through the volunteer office, and a novice psychologist, who felt underused in her own department of mostly physicians. Other partnerships were formed with local, regional, and national researchers around specific projects of varying magnitude and formality.

 

Pilot in the Plane

The fifth principle should be a constant reminder to the entire team to focus only on the aspects of a venture within control and not waste time and energy worrying about factors and conditions beyond direct control. Once creative and innovative partnerships are formed and initiatives launched, the unexpected may be beyond the immediate control of the nurse leader. The innovative leader will focus on the aspects of the venture that can be controlled and let the other four principles guide interactions with environmental factors.

 

As an example, an unexpected budgetary freeze on external conference and education expenses initially interfered with several plans to travel and collaborate with a nationwide collaborative of pediatric nurse scientists. Securing organizational funding was unsuccessful and plans to collaborate had to be postponed. Other channels for local collaboration were explored and established, which didn't require travel funds.

 

On the journey

As the champion for the nurse scientist enterprise, the chief nurse executive not only educates the other members of the senior executive team and board members on the potential value to the organization, but he or she also creates organizational legitimacy for the nurse scientist vision by communicating the potential value of the role to all stakeholders within nursing and others throughout the organization involved in research, EBP, and QI. The vision should be clearly aligned with organizational needs, strategies, and requirements. The nurse executive integrates the perspectives of all stakeholders, including frontline staff, into a shared vision for a nurse scientist program.

 

As opposed to the strategic visioning at the effectuation and innovation level, traditional causal reasoning and fundamental project management and LEAN approaches are useful and necessary at the tactical level. A significant amount of effort is applied to the development of job descriptions, funding proposals, related shared governance councils, and formal internal and external collaborative agreements. Annual strategic planning will still require concrete short-term, mid-range, and long-term goals. However, in the spirit of the innovation model, always keep in mind and be guided by the five principles.

 

In conclusion, the innovative nurse executive, committed to leveraging the value of the nurse scientist role, should understand the full scope of the nurse scientist's capability as inspired by a robust application of the Nursing Science Impact Model. As an innovative leader, the nurse executive can inspire others to cultivate and apply new competencies to address challenges facing the organization, staff, patients and families, and the community. By embracing proven innovation principles within the Effectuation Model of Innovation, the nurse executive can create a powerful nurse scientist program with immediate and sustained impact on clinical practice and outcomes.

 

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