Courage to Soar in Clinical Research

At this year’s National Teaching Institute (NTI), incoming American Association of Critical-Care Nurses (AACN) president Jennifer Adamski introduced “Courage to Soar” as the new AACN theme.¹  Her address focused on the centrality of both professional and personal courage in advocating for patients, ensuring safe staffing, and nurturing healthy work environments in acute and critical settings. She asked critical care nurses to consider 3 questions. The first question asks each of us to identify a time when we did something that seemed courageous to us. The next question asks us to consider why we think this was courageous. The last question asks us to ponder what is stopping us from being courageous in the present moment. Pausing to reflect on these questions encourages us to bring courage to every situation. Adamski is not the first AACN president to note the importance of courage in critical care nursing practice. In 2016 President Karen McQuillan introduced the theme of “Courageous Care.”²  She said, “This means we—not others—own our practice. It means we—not others—design solutions that most effectively overcome barriers and drive improvements.” More than a decade ago, President Denise Thornby explored the importance of 7 aspects of courage in her presidential theme address, “Make Waves: The Courage to Influence Practice.”³  Thornby noted, “By having the courage to make waves—big waves—and to create the critical care nursing practice of our vision, we will achieve our desired future.”

What is courage? Webster’s Dictionary defines it as, “mental or moral strength to venture, persevere, and withstand danger, fear, or difficulty.”⁴  Although each of these AACN presidents has explored different aspects of courage, they are consistent in identifying courage as a clear and essential component of clinical practice that enables patient advocacy, improves patient and family outcomes, and facilitates healthy work environments.

But is courage also important in critical care clinical research? We argue that it is manifest in every aspect of critical care research that is meaningful and useful to patients, their families, nurses, and the health care team. Courage underpins a research project’s conception, planning, design, implementation, dissemination, and translation to practice. Courage enables researchers and teams of investigators to persist over time in lines of inquiry, diving deep to build trajectories of research that produce knowledge greater than the sum of individual projects.

Courage in research begins with honest curiosity about practice. Courageous investigators possess a willingness to admit where knowledge is lacking and to confront current practices. It takes courage to identify and call out gaps in knowledge underlying clinical practice. It takes courage to question what we could do differently, what we could do better, or whether some practices are ineffective or harmful and should be abandoned. Challenging established norms is problematic because many of our clinical practices are based on lower levels of evidence, or on older evidence that may (or may not) be outdated. In the absence of recent definitive research, praxis (common practice, “we’ve always done it this way”) or expert opinion may be the best available practical guidance for bedside practice and must serve until validated or refuted by more rigorous evidence. We need to be willing to create and examine better evidence for practice. Gina Kolata, a reporter whose work focuses on new medical treatments, recently wrote, “Medical history is stuffed with examples of treatments that everyone thought would work until a clinical trial showed they didn’t.”⁵  Practical guidance can become so ingrained in systems of care and health professions that challenging it is indeed an act of courage. Ignaz Semmelweis is a historical exemplar of the courage required to challenge established provider practice.⁶  His introduction in 1847 of hand-washing before examination of women drastically reduced puerperal fever (childbirth fever) deaths, but his ideas ran contrary to established medical understanding and physicians’ resistance was fierce.

It also takes courage to envision new approaches to clinical problems, particularly in the critical care setting, where patients are vulnerable and medically fragile. As we apply available evidence and personal experience to patient care and observe positive outcomes (or, at least, perceive that our actions led to the least negative outcome in a given situation), praxis can become a rationale for persisting with ingrained procedures that blinds us to conceptualizing truly innovative approaches to care. Our expert clinical knowledge, education, and training may impair our ability to think outside the box of our current practices. With courage, our knowledge, education, and training can be the foundation for development of novel interventions that have the potential to be superior to praxis rather than impediments to moving the science or critical care forward.

Courage is required in planning and executing clinical research. Critical care clinical research requires identifying and overcoming institutional and other hurdles, including constraints imposed by logistics, regulatory compliance, cost, personnel, and time. Substantial courage and persistence are necessary to completion of any research project in the critical care setting.

The critical care environment and team are appropriately focused on patient care. Whereas research is crucial to improving outcomes for future patients, the primary objective of meeting the needs of current individual patients and their families is paramount. Careful thought is needed about ways to protect the rights and welfare of both participants in research and those who are not research participants. It is essential to display courage when protecting the rights and well-being of participants in critical care clinical research. All critically ill patients have vulnerabilities related to their medical condition, but many also have vulnerabilities related to their race, ethnicity, gender, social determinants of health, or other factors. All of these vulnerabilities require particular attention to ethical decision-making. Obtaining informed consent for research can be challenging; enabling patient and family autonomy and decision-making about participation is nonnegotiable. The responsibility of nurses and physicians to protect the rights of patients who are participating in research is well articulated in the American Nurses Association’s code of ethics⁷  and the American Medical Association’s code of conduct.⁸  Importantly, these ethical duties related to research apply not only to those conducting the research, but also to those who are providing direct care to patients.

It takes courage for clinical researchers to listen to and accept what the data of a research project demonstrate. This aspect of courage is particularly important when the results of the study are out of alignment with what was anticipated. Researchers invest a great deal of time, energy, and passion in the ideas they propose. This investment can result in a perverse orientation to prove that their idea is correct, rather than letting the data speak as to whether or not the data actually support the idea. Being able to accept that one’s cherished ideas are flawed or not supported by the research conducted requires courage. Standardized research reports include a discussion of limitations. Although some authors present a perfunctory and brief limitations section or minimize potential criticisms, courageous investigators will use this section to truly evaluate and reflect on the work. Those who persist over time in research are perhaps the most courageous. Building depth of understanding in a specific area has the power to move science forward in ways that isolated, disjointed research projects cannot. Sustaining a program of research over the course of a career is difficult and requires courage and commitment. Every year, AACN chooses a Distinguished Research Lecturer, whose podium presentation at NTI summarizes their research career; the presentation is also published in the July issue of this journal. The examples of courage and sustained research programs provided by the Distinguished Research Lectures are informative and inspiring. The 2024 Distinguished Research Lecture, “Hospital-Based Electrocardiographic Monitoring: The Good, the Not So Good, and Untapped Potential,” was given by Dr Michele Pelter.⁹  The lecture is a profile in courage, reflecting on Pelter’s “36-year journey from a clinical nurse to nurse scientist and the trajectory of [her] program of research focused primarily on ECG [electrocardiography] and physiologic monitoring.”^{9 (p170)} Even though Distinguished Research Lecturers often speak about how their careers began, difficult lessons learned, and failures and missteps along the way, the shine of success can obscure the rocky path it took to get there.

Nurses begin their research trajectories when they are driven by a clinical problem or a failure that they have seen over and over again that the rest of the world—even other nurses—shrugs at and accepts as it is. Novice researchers are positioned to discern and address the most challenging topics that have become accepted praxis. Krumholz links the characteristics of novices, including courage, to the importance of the contributions they can make, stating,

When clinical practice and research move together in synergy, we are best able to embody the AACN vision of “creating a healthcare system driven by the needs of patients and families where acute and critical care nurses make their optimal contribution.”¹¹  Just as we need courage to soar in practice, we also need courage in examining current practice, developing and testing new interventions, and moving knowledge for practice forward. Research is a crucial manifestation of the courage of nurses—one of the most rigorous and powerful tools for advocacy that nurses can use to improve patient outcomes and positively impact the daily work of nurses. The American Journal of Critical Care is proud to contribute to AACN’s vision and mission through publishing the latest advances in clinical research that is highly relevant to bedside practice in acute and critical care. Along with AACN President Jennifer Adamski, we would ask: what is stopping us from being courageous (in research, as well as practice) right now?