THE BACK PAGE

Embracing All Types of Clinical InquiryGuest Editorial

Daphne Stannard, PhD, RN, CNS, FCCM

THE STANDARDS, PRACTICE Recommenda-

tions, and Interpretive Statements published by

the American Society of PeriAnesthesia Nurses

(ASPAN)1 have a dedicated standard (Standard V)for Research and Clinical Inquiry. This standard

states, ‘‘Clinical inquiry is described as a constella-

tion of research and research-related activities,

which include research, evidence-based practice,

quality improvement initiatives and small tests of

change that test innovation.’’ Because there are

multiple and competing definitions and concep-

tions of these activities, the Nursing Researchand Innovation Council at the University of Califor-

nia San Francisco (UCSF) Medical Center defined

these terms and provided workflows. These work-

flows assist clinicians in making distinctions and

aid in decision making as to when a particular ac-

tivity would be more beneficial than another in

answering a clinical question. The purpose of

this guest editorial is to describe the UCSF MedicalCenter Clinical InQuERI Model and provide an

overview of the different clinical inquiry activities.

Clinical practice is varied, complex, and often pre-

sents with thorny clinical problems that clinicians

struggle to solve. As part of the UCSF Medical Cen-

ter ANCCMagnet journey, members of the Nursing

Research and Innovation Council were chargedwith describing our research approach for the

Department of Nursing. A thorough literature

review revealed a number of helpful models,

including the Stetler model, the Ottawa Model of

Research Use, the Promoting Action on Research

Daphne Stannard, PhD, RN, CNS, FCCM, is a Director at

UCSF Medical Center Institute for Nursing Excellence and at

UCSF JBI Centre for Evidence-Based Patient and Family

Care, San Francisco, CA.

Conflict of interest: None to report.

Address correspondence to Daphne Stannard, UCSF Medi-

cal Center Institute for Nursing Excellence, 2233 Post Street,

Suite 201, Box 1834, San Francisco, CA 94115; e-mail address:

Daphne.Stannard@ucsfmedctr.org.

� 2014 by American Society of PeriAnesthesia Nurses

1089-9472/$36.00

http://dx.doi.org/10.1016/j.jopan.2014.05.006

334 Journ

Implementation in Health Services (PARIHS)

framework, the Iowa model of evidence-based

practice, and the Joanna Briggs Institute (JBI)

model of evidence-based health care. Because ofour new JBI affiliation as the UCSF Centre for

Evidence-based Patient and Family Care, the coun-

cil members found the JBI model appealing and

alignedwith our medical center approach. Howev-

er, members also felt that additional guidance and

granularity regarding the different approaches to

solving a problem was necessary. As such, the

Nursing Research and Innovation Council createda new model in 2011 called the UCSF Medical

Center Clinical InQuERI Model (Figure 1).

This model starts with the patient and family in the

center as members of the council felt that any clin-

ical inquiry activity in the medical center was ulti-

mately related in some fashion to the patient and

family. Testing an innovative staffing model, forinstance, would examine staffing patterns but

would also include patient and family outcomes.

For that reason, the council felt strongly that the

patient and family should be in the center of

the graphic. The four clinical inquiry activities,

namely, quality improvement, evidence-based

practice, research, and innovation, are all sup-

ported in the medical center, and no one type ismore important than another as it is a deeply

held belief that all four activities are necessary to

encompass and help solve the varied clinical ques-

tions that arise daily. The four clinical inquiry activ-

ities are embedded within the UCSF Medical

Center’s professional nursing practice and the

resources available at the medical center and the

greater UCSF community. Although the graphicprovided direction to our overall approach to

research and innovation, council members felt

additional guidance was necessary to aid clinicians

at the point of care. Workflows or graphical repre-

sentations of the different clinical inquiry activities

were created and are presented below.

Quality improvement is represented as the ‘‘Qu’’in the UCSF Medical Center Clinical InQuERI

al of PeriAnesthesia Nursing, Vol 29, No 4 (August), 2014: pp 334-337

Figure 1. UCSF Medical Center Clinical InQuERI

Model.

THE BACK PAGE 335

Model and is defined as the deliberate application

and/or implementation of knowledge in local set-

tings that has been previously discovered

(Figure 2). An example of this type of activity

might involve gathering baseline data on thermal

comfort in the preoperative and perianesthesia

areas (defined in this instance as the local setting),

implementing a forced air warming device thathad been tested in other facilities but might be

Figure 2. UCSF Medical Center Clinical InQuERI

Model Quality Improvement Workflow.

new to the local setting and gathering data post

implementation to assess whether the interven-

tion improved thermal comfort and regulation in

the local setting.

Evidence-based practice (EBP) at the point of care

is represented as the ‘‘E’’ in the UCSF Medical Cen-

ter Clinical InQuERI Model and is defined as the

utilization of best available evidence, combined

with clinical expertise and patient and family

values and preferences (Figure 3). This has often

been described as the three-legged stool that

should guide clinician practice at all times. Howev-er, because all three components of EBP are ever

changing, EBP is an interactive and dynamic pro-

cess. For example, suppose the best available liter-

ature on a specific patient diagnosis suggests

treatment A or B. Based on clinician expertise, it

is decided that treatment A is the best option for

this particular patient. Both options are presented

to the patient and family and the patient opts fortreatment B. Because the patient and family’s

values and preferences are one of the legs of the

three-legged EBP stool, the patient’s desires should

be honored and the treatment plan should be

revised accordingly.

Research is represented as the ‘‘R’’ in the UCSF

Medical Center Clinical InQuERI Model andcan take many forms depending on the discipline

Figure 3. UCSF Medical Center Clinical InQuERI

Model Evidence-Based Practice (EBP) Workflow.

Figure 5. UCSF Medical Center Clinical InQuERI

Model Secondary Research Workflow.Figure 4. UCSF Medical Center Clinical InQuERI

Model Primary Research Workflow.

Figure 6. UCSF Medical Center Clinical InQuERI

Model Innovation Workflow.

336 DAPHNE STANNARD

and the research question. In nursing, research

is divided into two major categories: primary

research and secondary research. Primary research

is defined as the discovery-oriented systematic

investigation to develop or contribute to generaliz-

able knowledge (Figure 4). Most primary research

in nursing involves living beings (either animals or

humans) and, as such, requires approval from aninstitutional review board (IRB) to ensure protec-

tion of animal and human research subjects. The

discovery-oriented nature of primary research is

one of the important distinctions between this ac-

tivity and quality improvement. For example, ima-

gine a new forced air warming device that needs

testing for FDA approval. Because no other

research exists on this device, a quality improve-ment project would not be appropriate; rather,

discovery-oriented primary research is needed to

systematically test the safety and effectiveness of

the device.

Secondary research can be further divided into two

activities: secondary analysis and systematic re-

views (Figure 5). A secondary analysis involvesthe summary and analysis of an existing research

data set. Often, a research data set collected to

answer question X can be used to also answer sub-

sequent research questions, such as questions Yor

Z. A systematic review, on the other hand, involves

the identification, selection, critical appraisal, and

summary of the existing primary research studies

on a specific topic. Systematic reviews rely on the

existence of primary research studies that have

been conducted on a particular topic. If only one

or no primary research study exists on a given

topic, it is not appropriate to conduct a systematic

review until additional primary research has been

conducted. In both cases, because no animal or hu-man contact is involved, IRB approval may not be

THE BACK PAGE 337

necessary for secondary research, although it is

recommended that one consult with the local IRB

for direction.

Innovation is represented as the ‘‘I’’ in the UCSFMedical Center Clinical InQuERI Model

(Figure 6). Innovation means new, but new is not

necessarily always better. For that reason, innova-

tion should be paired with quality improvement

activities and/or research. This is to ensure that

the innovative practices adopted are ones that

have been shown to improve or enhance patient

and family care in the local setting.

All the different clinical inquiry activities have two

common themes: emphasis on patient and family

care and the collection of pre- and post-

intervention implementation data. Although it is

recognized that there are many types of research

designs that are far more robust than simple pre–

post design, a streamlined approach was used for

the purposes of distinguishing and clarifying the

workflows for clinicians at the point of care. ASPAN

is on the leading edge for recognizing that a variety

of clinical inquiry activities are necessary to assist

clinicians in the high acuity and high-pressureenvironments that characterize health care today.

Keeping the patient and family in the center and

embracing all types of clinical inquiry activities

are important as we move into a new era of

health care financing and delivery.

Acknowledgments

Members of the 2011 UCSF Medical Center Nursing Research

and Innovation Council include Carrie Meer, RN, MSN, CNS

(facilitator); Janet Leiva, RN, CCRN (co-facilitator); Daphne

Stannard, PhD, RN, CNS, FCCM (coach); Lisa Richard, RN,

MSN, CCRN; Liz Clifton, RN, MSN; Amy Dunne, RN, BSN; Su-

zanne Tay-Kelley, RN, MS, MBA/MPH, NP, CNS; Deanna Sheeley,

RN-BC; Jeannie Addis, RN, MSN; Min-Lin Fang, MLS; and Gail

Sorrough, MLIS.

Reference

1. American Society of PeriAnesthesia Nurses (ASPAN).

2012-2014 Perianesthesia Nursing Standards, Practice

Recommendations and Interpretive Statements. Cherry Hill,

NJ: ASPAN; 2012.