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17 Articles in Volume 19, Issue #4
Analgesics of the Future: Inside the Potential of Nerve Growth Factor Antagonists
Best Practices Are Still Largely Undefined in Task Force Report
Brief Behavioral Interventions for Chronic Pain
Cervicogenic Headache: Diagnosis and Management
Chronic Headache and Central Pain Conditions
Considering Comorbidities When Selecting Medications for Pain (Part 4)
For APPs: How to Contribute to Clinical Research
Gabapentin and Suicidal Ideation: Is There a Link?
Intranasal Ketamine for the Relief of Cluster Headache
Letters: Slipping Rib Syndrome; Burning Leg Pain; CGRP Complications
Pain Assessment Tools for Malingering in Patients with Chronic Pain
Refractory Chronic Migraine: Mild, Moderate, or Severe
Should Probuphine be considered for MAT?
Special Report: The Abuse Potential of Gabapentin & Pregabalin
Tension-Type Headache: Evidence for Trigger Points
Treatment Alternatives for Migraine
Trigeminal Neuralgia: Current Diagnosis and Treatment Options

For APPs: How to Contribute to Clinical Research

Our resident advanced nurse practitioner answers the question: As an advanced practice provider working in pain management, can I contribute to clinical research?
Pages 21-22

This question on the role of advanced practice providers (APPs) in research initially surprised me. Having spent my entire career in an academic medical center, I essentially “grew up” in medicine by participating in research in one form or another. As a registered nurse in the perioperative setting, I was asked to document pain scores (collect data) for patients undergoing surgery on a specific study protocol. Coming full circle as a nurse practitioner (NP) specializing in pain medicine, I am now participating in a study protocol where I am delivering the active intervention in a research study looking at pain recovery and opioid reduction after surgery.

However, as I sat down to write this column, my ever-supportive, yet misinformed husband noted, “As an NP, your options surely must be limited when it comes to the ability to do real research.” Hence, I intend to use this space to clear up some broad misunderstandings as to what “real” research involves and how APPs can not only contribute to this work but, in many cases, lead research in the pain management field.

A few APPs share their experience of how they manage working in pain management and participating in research. (Source: 123RF)

Care Decisions: The Need to Know Why

The beginning of nursing research is attributed to Florence Nightingale, whose research during the Crimean War in the 1850s ultimately shaped healthcare as we know it today, including nursing practice. Modern research, like clinical care, is influenced by technological, societal, organizational, and environmental changes.1 There is an evolutionary expectation to our role development in that APPs are clinical leaders, professionally inquisitive, and research active.2-5

No matter the specialty, APPs incorporate best-practice evidence into their day-to-day activities. Whether assessing, retrieving, or evaluating, APPs are always applying research outcomes to their clinical decision-making. These skills accumulate over time, bolstered by each patient encounter where more of the “unofficial research” occurs. But if you find yourself questioning, “Why do I do things this way?” or “If I do something differently, might I expect to achieve a different outcome?” then you have the heart and soul of a clinical researcher and just need some direction to take your instinct and curiosity to the next level.

There are many ways to get involved with clinical research while still maintaining your day job. All research begins with an idea, generally applied to one of the following goals:

  • changing aspects of practice for improved outcomes
  • looking at populations with an objective of identifying needs to improve aspects of healthcare evaluating efficacy and safety of a new therapy (such as with pharmaceutical research).

Much research is still conducted within strictly controlled parameters, such as with the familiar “double-blinded, placebo-controlled” trials.6 An expanding body of research, however, is being done in the “real-life” clinical environment, with the objective of giving it more clinical applicability.7 Funding opportunities abound for research, and particularly in the field of pain management given its current landscape (see examples in “Clinical Research Opportunities”).

APPS in Action

Kathleen Broglio, DNP, NP

Kathleen is a palliative medicine NP at Dartmouth Hitchcock Medical Center, an assistant professor of medicine at the Geisel School of Medicine at Dartmouth, and a scholar at the Dartmouth Collaboratory for Implementation Science, all in New Hampshire. “Over the years, I developed multiple programs, starting with a pain resource nurse champion program at Kaiser Permanente in Hawaii, to palliative education programs for homecare nurses in New York, to an interprofessional palliative education program at Columbia University Medical Center,” she told me. “All these programs were successful, but I never had a way to measure and report outcomes as they had not been set up as research studies.”

Kathleen continued, “I developed some knowledge in bedside clinical research (ie, quality improvement) while completing my doctorate in nursing practice. At that time, I developed an online introduction to palliative care for acute care nurses [read about how to set up an acute pain service in the March 2019 For the APP column8]. I tested knowledge pre/post and then at a later point. At Dartmouth Hitchcock, I was given the opportunity to become a scholar where I have mentorship from research scientists and support from research staff. For my first study, I developed an interprofessional palliative education program that measured collaboration, knowledge, burnout, and retention over time. In terms of pain management, I have evaluated the implementation of opioid management guidelines in palliative care and conducted a feasibility pilot to perform opioid risk screening in oncology.”

In 2018, Kathleen was awarded a National Institute on Drug Abuse grant to research the prevalence of substance use disorder screening in oncology. Following an online survey of oncology clinicians, she found that about 30% of physicians and NPs perform such screenings around 70% of the time.

Susan M. Fernandes, LPD, PA-C

Susan is an associate dean for physician assistant education and a clinical professor of pediatric cardiology at Stanford School of Medicine in California. She was awarded the “Outstanding Research Award” at the 2018 International Symposium on Adult Congenital Heart Disease. In addition to her accomplishments, much of her career has involved clinical research.

“I have only worked at large academic teaching hospitals, so research was always happening around me,” she explained. “About 20 years ago, I volunteered to help with a drug trial that many of my patients qualified for. I was involved in recruitment, consenting, and monitoring their progress while they were in the drug trial. Little by little, I volunteered to take on bigger roles in the research, watching and learning as I went, until I was developing my own studies. Most of my work now is in patient-reported outcomes, health policy issues, and long-term sequela of chronic disease. My experiences in clinical drug trials helped me understand how to design clinical research, collect and store data, and report findings. I believe that all APPs should be involved in clinical research. APPs typically improve access to care and improve care for one patient at a time, but by engaging in clinical research, especially patient-centered research, they can help improve care to an entire population of patients,” she said.

Widen Your Pathways

Research drives innovation and addresses a range of issues that influence practice. APPs can actively participate in generating evidence as well as in reviewing the risks, benefits, and clinical relevance of research in pain medicine. However, they need to build the knowledge, skills, resources, and support to become research literate and research active. Where to start:

  • Identify problematic clinical practice issues within your own practice setting.
  • Develop research questions to address these concerns.
  • Evaluate potential barriers to implementing your proposed research in the clinical setting.
  • Get involved in implementing your study idea or another external study (eg, recruitment).
  • Assist with data collection.
  • Volunteer to read proposed research publications.

For example, I was recently asked to review a study for publication. The study did not require IRB approval. It also did not involve recruiting a patient sample or creating a study budget. It was a simple and impressive example of data collection, evaluation, and problem-solving that had a significant impact of positive change in a community pain clinic.

Specifically, an APP in a community pain clinic identified a problem with compliance in regard to clinician review of the local prescription drug monitoring program (PDMP) before filling opioid prescriptions. Data collection included monitoring how many prescriptions were written for opioids by the practice without a preview of the PDMP, and then surveying clinicians about barriers to PDMP review before prescribing. An evaluation of the data identified three areas for improvement that could easily be made to the clinic’s workflow. By making simple modifications with already available resources, the change led to increased compliance with PDMP review prior to opioid prescribing. Next steps in this project might focus on monitoring for compliance at 3, 6, and 12 months. This work has not only helped to improve the expectations and duties of the clinic but also the safety of its patients.

Last updated on: June 21, 2019
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