Fostering Critical Nurse Observation as a Source of Research Topics: ‘Listen to your Nurse’

As healthcare systems develop, there is an explicit call towards interprofessional learning and working, valuing observations and perspectives of all disciplines. Such a multi-perspective is pivotal for innovation, leading to optimal and sustainable health care. In such an interprofessional work environment, it is obvious that the nurses engage in the formulation of research questions within clinical practice settings. This case report describes a case in which nurses observed important issues that no physician or midwife on the team would have noticed. In collaboration with other team members, the nurses subsequently engaged in research which resulted in new information to improve care. The aim of this paper is to explore strategies to promote nurse participation in at least the formulation of research questions based on their observation and perspectives.

For fostering critical nurse observation as a source of research topics, we propose four strategies. First, cultivating awareness through a culture of evidence-based practice and critical reflection on common practice. Second, stimulating persistence in addressing moral dilemmas concerning better care despite resistance. Third, facilitating interprofessional learning in an open culture, where diverse perspectives are valued, and it is psychologically safe to bring them in. Fourth, overcoming funding disparities and facilitating nurse-led research, acknowledging the underrepresentation of nurses in funding agencies.

These measures aim to empower nurses to observe critically, use their unique perspectives, and bring in research topics.

As many healthcare departments strive to enter the era of interprofessional learning and working [1], it seems obvious to embrace the opportunity to value nurses’ observations in healthcare not only for patient care but also for research. Traditionally, physicians’ perspectives are usually focused on fundamental research and research to avoid or cure diseases, while nurses often have their special topics for research in better care, either very practical or humanistic. In many parts of the world, nurses' research is not as commonplace as it could be and topics nurses raise may disappear because of power distance, which may be part of the culture [2]. This situation may be improved by interprofessional practice in which physicians in the lead are replaced by team leadership [3]. Nurses who have the courage to speak up and do not take common practice for granted may prove an important source for innovative research. This asks for an open culture in which dysfunctional hierarchy is not present, an open mind is the norm, and speaking up is stimulated [4]. Nurses need a mindset to recognize relevant questions, perceive a moral dilemma urging them to act, and finally, the skills to conceptualize, phrase and effectively communicate the issue [5].

Nurses spend lots of time with patients and may observe extremely relevant issues for improvement of care. Our team was confronted with such an observation made by our lactation nurses. The following text will describe the case and subsequently summarize possibilities to foster the nurses’ observations as a source for research.

In a general hospital in Amsterdam, the Netherlands, in 2022, when the case was presented, we dealt with 5000 complicated deliveries in a bilocation model. The priority in such a hospital is patient care, the second priority is the education of health professionals in their clinical rotations, and the last priority is research. The hospital’s mission is to provide care based on interprofessional teamwork, shared leadership executed by nurses, midwives, obstetric medical specialists, and management, and shared decision-making with the patients. In the Dutch culture in which the power distance is commonly low [2], such a utopian way of creating an effective interprofessional team is workable to a large extent. Within the team, different groups have special expertise regarding their topic. An example of such a specialized group is the lactation nurses. They are the coaches of both the patients and the health professionals responsible for postpartum care, and they organize the quality care and accreditation of the ‘baby-friendly hospital initiative’ obstetric ward. As an aid to initiate and promote breastfeeding for the newborn, a breast pump is often used when the amount of milk is insufficient for the baby. The lactation nurses guide the fresh parents in using such a device. During the process of the sucking pattern of the breast pump and extracting milk from the breast, some issues are highly important. Number one is the delicate and hygienic handling of the nipples to create comfort and prevent nipple pain. Number two is to empty the breast as much as possible at the end of the pumping session to provide more breast milk to the baby and build milk production. The nurses had been working with the breast pump already for years but had noticed that both principles were not fully employed. The pump’s suction pattern caused moments of pain and discomfort as it strongly sucked, and the session was too short to empty the breasts completely in the first days postpartum. Three nurses approached obstetrician-gynecologist FS, asking him whether he could help to research the questions raised based on their observation. An interprofessional research team was formed and, with help from the manufacturer of the pump, we designed and executed three separate studies, confirming the findings and giving evidence for improvement of the device [6]. It had become clear that the nurses’ critical observation and the effective way they spoke up and incited the research was an important step in breastfeeding research. We believed that this could become the start of a larger series of nurses’ observations as a source of relevant research topics and asked ourselves how to foster such a movement. We achieved a strategy by discussing in and outside our research team, going back to the literature, and discussing again iteratively. The method could be classified as naturalistic utility-focused evaluation [7,8]. Naturalistic utility-focused evaluation is an approach that emphasizes the practical use and real-world application of evaluation findings, prioritizing the needs and contexts of primary intended users. This method combines naturalistic inquiry, which involves observing and interacting with subjects in their everyday environments, with a focus on utility, ensuring that evaluations are judged by their actual usefulness and impact on decision-making. The goal is to provide meaningful, actionable insights that facilitate effective action and informed decisions [8-10].

Strategies to foster nurses’ observations as a source of research topics

Awareness: To create a mindset that is ready for observation and critical evaluation of the status quo leading to critical consciousness is the foundation of our desire for relevant research topics from the nurses’ point of view [11,12]. This critical consciousness approach has at least two important elements. Initially, the movement of evidence-based nurses’ practice causes reflection on action and a review of relevant literature [13]. This is essential to increase awareness that common practice is not always best practice and to develop the ability to appraise literature and identify gaps in knowledge from the world literature. The other element is critical reflection which is connected to the concept of transformative learning and leads to a perspective transformation [14]. Transformative learning is a framework that occurs when individuals encounter experiences that challenge their existing beliefs, assumptions, and perspectives. Through critical reflection, they reassess these beliefs and develop new, more inclusive ways of understanding themselves and their world [15,16].

Acting on the moral dilemma: Nurses may observe that, to achieve optimal patient care, common practice has to change. Change is often difficult to achieve and new knowledge may be needed to convince health care professionals [17]. Early resistance to innovative ideas may cause nurses to back off and let the issue go [18]. However, it is crucial for persistent behavior to become normalized when encountering a moral dilemma. A moral dilemma suggests a psychological state of unease that arises when one becomes aware of a situation or problem conflicting with their moral values and feels compelled to address it. Nurse practitioners often face moral dilemmas when they recognize that social, economic, and societal inequalities affect patient care [5]. To achieve better care, it is essential for nurses to persist through resistance, and sometimes this normalization of persistent behavior will result from careful change management [12,19].

Interprofessional learning: In an organization in which incidents and questions about the quality of care are discussed regularly within the interprofessional team, preferably including the patients themselves, a structural basis for proposing research topics has been laid. Optimal interprofessional learning needs sufficient psychological safety, defined as a shared belief held by team members that they can take risks, express ideas and concerns, speak up with questions, and admit mistakes [20]. It also necessitates an open culture, characterized by an open mindset, awareness of biases, emphasis on team relationships and well-being, and a transparent system with role model supervisors and patient involvement, in which different perspectives are welcomed and valued [4]. The team has to open up for less conventional research topics and methods. For example, qualitative research methodology is more common for nurses than for physician researchers [21]. Once more, the normalization of both optimal interprofessional learning and an open culture on the work floor often needs careful change management [22].

Funding: In the case's hospital, the number of nurses is at least fivefold the number of physicians. The funding of their research by the hospital is less than half. National funding agencies are used to fund physician-led research and in committees of reviewers, almost no nurses are found to judge proposals. Apparently, in the Netherlands, nurses’ research topics are undervalued, and the funding is accordingly. These facts are reasons for nurses to stop acting on their moral dilemmas.

Future perspective

From our perspective, it is crucial that nurses are empowered to speak up about their observations and insights, as they often have a deeper understanding of patients than doctors and can identify subtle changes with significant impacts. This intimate understanding of patient needs and conditions enables nurses to make critical observations that can drive research and lead to improved healthcare practices. Hospitals must create a collaborative environment with the above strategies where interprofessional teams, including nurses, can openly discuss and integrate these valuable observations into practice and research initiatives. To facilitate this, interprofessional meetings should be held to integrate nurses’ perspectives into research and practice. This approach not only advances nursing practice but also enhances overall healthcare quality by using nurses’ unique insights to inform research and clinical improvements.

In conclusion, the nursing profession is in close contact with the patients. They are in a unique position to observe points of improvement and propose research topics if the literature falls short. Our case study highlights the positive impact of nursing advice, demonstrating the potential benefits of encouraging more research initiated by nurses. To foster critical nurses’ observations as a source of research topics, nurses themselves have to be equipped with evidence-based practice and persistence in perceived moral dilemmas. Their context has to facilitate nurses’ performance through the normalization of interprofessional learning and an open culture with psychological safety. Finally, funding is essential to foster the research attitude of nurses. We believe these investments will benefit health care and the relevance of clinical research.

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