From left: Cindy Brockway, MSN, RN, CCRP and Cheryl Monturo, PhD, MBE, ACNP-BC
A research department is a unique asset for a community hospital, and Chester County Hospital’s (CCH) research department is a small but mighty engine driving inquiry and evidence-based patient care. The hospital’s connection to the broader Penn Medicine academic medical research enterprise plus a spirit of curiosity among front-line clinicians means there are plenty of opportunities to learn and innovate.
Identifying a Knowledge Gap
Katie Luzi Costantini, MSN, RNC-MNN, the current director of Maternal Child Services for CCH, has been working with the hospital’s research department for the last few years on a question that affected how she cares for patients.
In April 2018, the American College of Obstetricians and Gynecologists (ACOG) proposed a new paradigm for postpartum care, updating the recommendation for the first OB/Gyn follow-up from six weeks after birth to no later than three weeks postpartum.
Costantini, who was then a CCH maternal child nurse, found the revised position lacking.
“It said that women should have some kind of contact with their obstetrics providers sooner than was previously recommended, but it didn’t really describe what that care should look like,” she says.
When Costantini turned to published studies to understand the full scope of a new mother’s experience and how to better meet those needs, there was very little available. That’s when she decided to take matters into her own hands.
In early 2020, Costantini organized a team to conduct research about the “fourth trimester,” the term used to describe the first 12 weeks postpartum. That’s where CCH’s research department came in.
‘A Culture of Inquiry’
The department was formed in 2007 with Cindy Brockway, MSN, RN, CCRP, as its director. Cheryl Monturo, PhD, MBE, ACNP-BC, senior nurse research scientist, was added in 2015, the year after the hospital first received Magnet designation from the American Nurses Credentialing Center (ANCC). Overall, CCH’s Research and Evidence-Based Practice Council (REC) is interprofessional and includes nurses, physicians, pharmacists, finance, quality improvement, and administrators.
According to Brockway, the research department’s continued growth and development were important to the process of earning Magnet redesignation in 2019 – and will be an essential part of its renewal application once more in 2023. More specifically, the team’s goals were to conduct research facilitated by the nursing department and to publish studies. Brockway and Monturo assist the hospital’s staff with their own research, and also participate in national, multi-institution studies.
Shortly after Monturo’s hiring, the pair attended a weeklong immersion on evidence-based practice (EBP) at the Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare in Columbus, Ohio.
“It’s a term that gets thrown around a lot,” Monturo says. “What we realized is that evidence-based practice is the building block for our research program, and we needed to make sure that people understood that.”
The training informed the department’s two largest initiatives to date, both of which recently came to fruition. The first is an intranet site that went live in September after a few years in development. It’s designed as a kind of portal to the vast expanse of resources, both inside and outside of CCH and Penn Medicine, to support EBP and research processes. The second is a systemwide, multidisciplinary group of EBP mentors. Its 36 members span a variety of roles across Penn Medicine, including administrators, finance directors, frontline nurses, educators, pharmacists, and advance practice nurses. Brockway and Monturo brought instructors from the Helene Fuld Health Trust National Institute to CCH to provide the mentors with the same training they received.
Their aim with both endeavors is the same: to ease access to existing research, which, in turn, will encourage greater, and swifter, adaptations to evidence-based practices across the hospital.
“One of the challenges with research is that it can take 17 to 20 years to get the published studies to the bedside. That’s way too long,” Monturo says. “If there’s sufficient evidence out there, we can start to make changes in practice. So we’re helping our people find the relevant research and critically appraise it, to know what’s reliable, but also what aligns with our practices and resources here.”
“Our overall goal is to develop a culture of inquiry here across all disciplines, to make it a safe place to say, ‘Why do we do it this way?’” Brockway says.
A New Mother’s ‘New Normal’
The research department supported the S.A.M. (Support-Admit-Monitor) nurses in updating the nurse-driven protocol for remote telemetry removal with the latest evidence, resulting in the team winning CCH’s third annual Evidence-Based Practice Award. From left: Cheryl Monturo, Linda Sullivan, BSN, RN, PCCN, Cindy Brockway, and Kristin Taylor, BSN, RN, PCCN, CV-BC.
Costantini turned to these research pros when she wanted more answers than the scientific literature could provide on new recommendations for postpartum care: How did new moms perceive their adjustment during this time? She teamed up with two maternal childbirth educators, three lactation consultants, and a nurse manager.
Because Costantini’s team was largely inexperienced as researchers, Brockway and Monturo mapped out and oversaw every step of the process, including the prerequisite regulatory education needed to even begin.
“We taught them what consent really means,” Brockway says. “Is it having someone sign? No. It’s more than that. It’s having an interaction with them and helping them understand what they’re saying yes to.”
She and Monturo recommended a design for the study: phenomenology, a type of qualitative research that explores a person’s lived experiences. Then they helped the team develop a semi-structured interview guide they would use to conduct phone interviews with patients who consented, a few days after they left the hospital. And once the interviews were completed, Brockway and Monturo instructed the group on how to analyze the responses. But first they helped them spot and note their own biases.
“For example, we know the lactation consultants are focused on breastfeeding,” Monturo says. “But maybe the mom’s focus is not on that, so we want to note it and try not to impose that perspective on the data.”
Starting last fall, team members conducted a total of eight interviews with first-time breastfeeding mothers and analyzed their results in a structured way that gave qualitative insight into what the researchers describe as a new mother’s “new normal.” They noted four major influences on these new mothers’ feelings in the first week postpartum:
- the advice and support of others in her life
- role division with her partner
- her physical and emotional state
- and her own perceived ability to care for her baby.
Team members are currently writing a manuscript and plan to submit it to a peer-reviewed journal before the end of the year. Brockway and Monturo helped them divide the writing and select the journal. For now, the study will be used to stress the importance to CCH’s maternal child care team of maintaining a connection with first-time breastfeeding mothers in the immediate postpartum period, Costantini says. The results, she notes, affirm for her that more support is needed during the fourth trimester.
“We’re hoping to help our care team start to focus not just on getting through the labor and delivery portion of a pregnancy but also help patients set up a sufficient support system at home,” Costantini says. “We also plan to encourage patients to start having discussions with their partner about their expectations for this support as part of our prenatal education.”
Future steps building on this research could entail identifying or developing a tool to measure postpartum adjustment, assessing the available mechanisms for connection between provider and patient, and continued exploration of health equity.
No More Throwing Spaghetti
Monturo says it’s clear that the research department has helped inspire a cultural change at the hospital.
“Oftentimes, when people talk about changing a practice, they talk about it like throwing spaghetti against the wall – let’s see what sticks – versus going to the literature and figuring out what works,” Monturo says. “If anything, we’ve seen a distinct change in the language. At a meeting now, people are less likely to say, ‘Let’s try this’ or ‘Let’s try that.’ Instead, they’re asking, ‘Has anybody looked at the evidence?’ And that’s been a big, big change.”