Shaping Nursing Science and Improving Health: The Michigan Legacy

Translation and Implementation Science

My research in translation and implementation science began as I directed for 15 years the Research Translation and Dissemination Core of the federally funded (National Institute of Nursing Research) Gerontology Nursing Intervention Research Center (P30). As part of this work, we developed and disseminated more than 30 evidence-based practice guidelines for the care of older adults that were published and included in the National Guideline Clearinghouse.

I have been principal investigator (PI) on three translation studies funded by the Agency for Healthcare Research and Quality (AHRQ) (R01) and the Robert Wood Johnson Foundation (RWJF); co-PI on one funded by the National Cancer Institute (R01); and coinvestigator on numerous others funded by the National Institutes of Health, AHRQ, the Department of Veterans Affairs, and the Centers for Disease Control and Prevention. The impact of my translation and implementation studies has demonstrated that a multifaceted translation research into practice intervention improves processes and outcomes of care for older adults with acute pain and cancer pain and those at risk for falls (Titler et al., 2009). This research resulted in the translating research into practice (TRIP) model, developed from Rogers’s Diffusion of Innovations framework, to guide the development and testing of implementation interventions (Titler, 2010). The TRIP model is now used by other investigators testing implementation interventions in hospitals and community settings. We also developed, tested, and published two practice tools—­the Acute Pain Management Summative Index and the Cancer Pain Practice Index—­that measure the amount of evidence-based care the patient receives. We have demonstrated that the delivery of evidence-based care saves health care dollars (Brooks, Titler, Ardery, & Herr, 2009). These findings have impacted regulatory standards of the Joint Commission and the Centers for Medicaid and Medicare Services (Institute of Medicine, 2011). My program of research provides training for master’s and doctoral (PhD/DNP) students and has resulted in more than 35 publications in research and practice journals. These studies have also resulted in methods papers (Newhouse, Bobay, Dykes, Stevens, & Titler, 2013) and have promoted the integration of this emerging area of science into PhD education (Henly et al., 2015).

Evidence-Based Practice

Complementary to my research in translation science is my long-standing commitment to improving care delivery and patient outcomes through evidence-based practice (EBP). Nursing has a rich history of using research in practice, pioneered by Florence Nightingale, who used data to change practices that contributed to high mortality rates in hospitals and communities. Today, EBP is defined as the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. In contrast, translation science is the investigation of methods, interventions, and variables that influence the adoption of EBPs by individuals and organizations to improve clinical and operational decision making in health care (Titler, 2010).

I started my work in EBP as an advanced practice nurse in the early 1980s, when the term “research utilization” was common in this field. I was mentored by several individuals whose work was highly influenced by the Conduct and Utilization of Research in Nursing (CURN) project housed at the University of Michigan School of Nursing and led by Drs. Joanne Horsely and Joyce Crane (Horsley & Crane, 1983). In this year of celebrations, it is important to acknowledge and recognize the CURN project, the investigators, and the students who set the stage for many who learned from their pioneering work. For example, Dr. Margaret Reynolds, a PhD student on the CURN project, went on to lead interdisciplinary EBP at the Trinity Health System as well as participate in my implementation research. It is with humility that I note many of us today who are dedicated to EBP strive to have the global and far-reaching impact demonstrated by these scholarly pioneers.

My contributions to EBP are informed by my program of research in implementation science. I am the principal author of the Iowa Model of EBP to Improve Quality of Care, which is used nationally and internationally. I have presented EBP workshops around the world to educate staff nurses and students about EBP and implementation. To extend my expertise in EBP, I direct the National Nursing Practice Network (NNPN), a learning collaborative of more than 108 hospitals and health systems across the United States. The mission of NNPN is to advance professional nursing practice through the application of evidence in care delivery, support nursing leadership development for EBP, and conduct multisite research to increase the understanding of mechanisms and strategies that foster the use of evidence by those delivering health care services (http://www.nnpnetwork.org). The impact of my work has helped transform nursing practice from a tradition-based practice to an evidence-based practice where delivery of evidence-based care is now the expectation of all clinicians. My work in this field has resulted in multiple publications, including serving as guest editor for six special journal issues on EBP.

Outcomes Effectiveness Research

Outcomes effectiveness research is the study of the effect of various health care treatments on patient outcomes (Titler & Pressler, 2011). As PI of an NINR-funded R01, I led a multidisciplinary investigative team in examining the unique contributions of nursing interventions to patient outcomes of three hospitalized older adult populations—­those with heart failure or hip fractures and those at risk for falls. This study used 4 years of data from nine electronic repositories at a large Midwest medical center that included documentation of nursing interventions using the Nursing Interventions Classification. From these nine electronic repositories, we built a large effectiveness research database to examine interventions that affect patient outcomes. We published more than 20 papers in refereed journals that demonstrated the unique contributions of nursing interventions to patient outcomes after controlling for medical and pharmacological treatments, context of care, severity of illness, and patient characteristics. The impact of this research is that it demonstrated the unique contributions of various nursing interventions to a variety of patient outcomes such as adverse events (e.g., falls, medication errors), cost, failure to rescue, and discharge disposition (Titler et al., 2008). These studies demonstrated methods for measuring nursing intervention dose and the effect of nursing intervention dose on patient outcomes. The impact includes an outcomes effectiveness research model and the use of propensity scoring methods in outcomes effectiveness research.

The impact of this research on students was inclusion as investigators and coauthors on papers, learning analytic methods, and using the dataset for their research, resulting in three PhD dissertations. Additional outcomes effectiveness studies, funded by the American Organization of Nurse Executives (AONE) and the Robert Wood Johnson Foundation (RWJF), have demonstrated the need for the education and mentorship of nurse managers in creating EBP environments and the insufficient evidence-based care provided to older hospitalized adults to prevent falls (Kueny, Shever, Lehan Mackin, & Titler, 2015).

Cost

My program of research also addresses health care costs. For example, not only did we demonstrate the effectiveness of the TRIP intervention in improving processes of care and patient outcomes for hospitalized older adults with hip fractures (Titler et al., 2009), we also demonstrated a net-cost savings of $1,500 per patient in a cluster randomized trial (Brooks et al., 2009). A number of our outcomes effectiveness studies have demonstrated the costs and cost savings by type and dose of nursing interventions (Titler et al., 2008).

Summary

In summary, my program of research has impacted practice, advanced the science in the field, and provided a robust training environment for doctoral students. In acknowledgement of my contributions, I have been awarded several national honors including election to the National Academy of Medicine, the President’s Award in Translation Science from NINR, the Elizabeth McWilliams Miller Award for Excellence in Research from Sigma Theta Tau International (STTI), the National Nurse Researcher Award from AONE, and the Clinical Scholarship Award from STTI.

References

• Brooks, J. M., Titler, M. G., Ardery, G., & Herr, K. (2009). Effect of evidence-based acute pain management
• practices on inpatient costs. Health Services Research, 44(1), 245–263.
• Henly, S. J., McCarthy, D. O., Wyman, J. F., Heitkemper, M. M., Redeker, N. S., Titler, M. G., . . . Dunbar-Jacob, J. (2015). Emerging areas of science: Recommendations for nursing science education from the Council for the Advancement of Nursing Science Idea Festival. Nursing Outlook, 63(4), 398–407. doi:10.1016/j.outlook.2015.04.007
• Horsley, J. A., & Crane, J. (1983). Using research to improve nursing practice: A guide. New York, NY: Grune & Stratton.
• Institute of Medicine. (2011). Clinical practice guidelines we can trust. Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/catalog/13058/clinical-practice-guidelines-we-can-trust
• Kueny, A., Shever, L., Lehan Mackin, M., & Titler, M. G. (2015). Facilitating the implementation of evidence-based practice through contextual support for nursing leadership. Journal of Healthcare Leadership, 7, 29–39. doi:https://dx.doi.org/10.2147/JHL.S45077
• Newhouse, R., Bobay, K., Dykes, P. C., Stevens, K. R., & Titler, M. G. (2013). Methodology issues in implementation science. Medical Care, 51, S32–S40.
• Titler, M. G. (2010). Translation science and context. Research and Theory for Nursing Practice, 24(1), 35–55.
• Titler, M. G., Herr, K., Brooks, J., Xie, X.-J., Ardery, G., Schilling, M., . . . Clarke, W. (2009). Translating research into practice intervention improves management of acute pain in older hip fracture patients. Health Services Research, 44(1), 264–287.
• Titler, M. G., Jensen, G. A., Dochterman, J. M., Xie, X. J., Kanak, M., Reed, D., & Shever, L. L. (2008). Cost of hospital care for older adults with heart failure: Medical, pharmaceutical, and nursing costs. Health Service Research, 43(2), 635–655.
• Titler, M. G., & Pressler, S. J. (2011). Advancing effectiveness science: An opportunity for nursing. Research and Theory for Nursing Practice, 25(2), 75.