Journal of Pediatric Nursing (2015) 30, 508–515
The Great American Cookie Experiment: Engaging Staff Nurses in Research1,2,3 Marlene Walden PhD, RN, NNP-BC, CCNS ⁎, Constance E. Cephus PhD, RN, NNP-BC, CPNP-AC/PC, Mary D. Gordon PhD, RN, CNS-BC, Joseph Hagan ScD Texas Children's Hospital, Houston, TX Received 18 June 2014; revised 7 November 2014; accepted 18 November 2014
Key words: Nursing research; Nursing staff; Research methods; Teaching methods; Attitude of health personnel
Purpose: The purpose of this study was to engage staff nurses in research in an informative and fun way by determining nurses' preference for sugar-free chocolate chip cookies versus regular chocolate chip cookies. Design and Methods: A descriptive, crossover, double-blinded study was performed using a convenience sample of 300 staff nurses. Results: Nurses preferred the texture, flavor, and overall preference of the regular chocolate chip cookie as compared with the sugar-free chocolate chip cookie (p b 0.001). Implications: The Great American Cookie Experiment remains a creative teaching strategy to enhance knowledge and engage nurses in the research process. © 2015 Elsevier Inc. All rights reserved.
OVER THE PAST decade, research has become increasingly recognized as an important part of clinical practice and a key component to quality patient care. Hospitals seeking Magnet Recognition, administered by the American Nurses Credentialing Center, must demonstrate that direct care nurses are familiar with and engaged in research and evidence-based processes (American Nurses Credentialing Center, 2013). Most nurses acquire basic didactic knowledge about research in their nursing programs, but few nurses have actual experience in developing and conducting a research study in the clinical setting (Wright, 2005). Lack of experience and fear of "research" can interfere with staff nurses' participation in clinical research (Brown, Johnson, & Appling, 2011; Sawatzky-Dickson & Clarke, 2008; Hudson-Barr, Weeks, & Watters, 2002; Thiel, 1987). Several publications have outlined effective, innovative strategies for decreasing anxiety and increasing interest in research among nursing students and practicing nurses. Thiel
⁎ Corresponding author: Marlene Walden, PhD, RN, NNP-BC, CCNS. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2014.11.007 0882-5963/© 2015 Elsevier Inc. All rights reserved.
(1987) described a cookie experiment that was used as an experiential learning strategy to involve undergraduate nursing students in research in a way that was engaging and that desensitized them to the negative perceptions about research. Since this original research, several other publications have reported success in using the Great American Cookie Experiment (GACE) in the hospital setting to demystify research concepts and to teach and engage staff nurses in the research process (Brown et al., 2011; Hagle & Millenbruch, 2011; Hudson-Barr et al., 2002; Morrison-Beedy & CoteArsenault, 2000; Sawatzky-Dickson & Clarke, 2008). A south Texas urban pediatric and obstetric hospital explored strategies for how to engage staff nurses in clinical research. Under the guidance of the hospital's nursing research council, a research scholars program was developed to teach the research process and allow nurses to design and conduct research projects under the guidance of doctorally prepared research faculty. The GACE was used throughout the curriculum to teach basic research concepts and engage the research scholars in research in a way that was both informative and fun. During the 12-month research scholars program, 14 registered nurses and advanced practice registered nurses (APRNs) learned how to conduct a
The Great American Cookie Experiment Table 1
509
Research concepts and teaching points related to the Great American Cookie Experiment (GACE).
Research concepts
Teaching points
Blinded
Blinding is the process of preventing those involved in a study (researchers, participants, data collectors) from having information that could bias study results by knowing which treatment group a participant is in (e.g. which cookie is sugar-free or regular chocolate chip). Convenience A convenience sample involves selection of the most readily available persons to participate in the study as sample opposed to randomly selecting the sample of participants. Crossover design Crossover studies employ an experimental design in which each participant participates in two or more treatment conditions, preferably in random order. Informed consent Informed consent is based on an ethical principle requirement that researchers obtain participants' voluntary consent to participate in the study without coercion, after informing them of the possible risks and benefits of their participation. Institutional review An institutional review board's (IRB) purpose is to protect the rights of people and animals who are board participants of research. The IRB makes sure participants are selected equitably, have adequate information about the research, and that risks to participants are minimized. The IRB also ensures that the privacy of participants is protected and that additional safeguards protect vulnerable populations. Literature review A literature review is a critical summary of research on a topic of interest, highlighting what is currently known about the research problem and identifying gaps in the evidence. Power analysis A power analysis determines the sample size needed to conduct a meaningful study. If the sample size is too small, the researcher will probably not be able to obtain sufficient evidence to support the research hypothesis, even if the hypothesis is correct. Random order In a crossover study, random order is the assignment of the treatment condition in a random manner. This is important to minimize the potential for systematic bias from “order” effects, since it is possible that the order in which the “treatments” (i.e. cookie type) are introduced may affect study results. Research question The central query of the research study. Most research questions can be expressed using a general question template: “In (population), what is the relationship between the (independent variable [IV] and (dependent variable [DV])?” The IV is thought to influence or be related to the dependent or outcome variable. In this study, the IV is the cookie type. DVs are the outcome variables being measured. In this study, the DVs are overall preference, texture (moistness), and flavor ratings. Significance level Significance level is the cutoff for deciding whether or not an observed relationship is due to chance or if, instead, there really is a relationship between the IV and DV. A 5% significance level indicates that relationships with less than a 5% probability of being observed strictly due to chance will be deemed statistically significant. Wilcoxon Signed Nonparametric statistical method that can be used to compare two paired groups, based on the relative ranking of Ranks Test differences in the paired values between the groups.
comprehensive literature search, write a research proposal, obtain institutional review board approval to conduct the study, implement the study, collect and analyze data, interpret the results, and disseminate the study findings. Following completion of the GACE, Nursing Grand Rounds was held to present the study findings and to use the GACE to educate the nursing staff who served as research participants in the study. The GACE was an effective strategy to both engage nurses in actual research and to educate the general nursing staff about the research process. This article presents the results of the GACE conducted at Texas Children's Hospital. To enhance learning, important research concepts are italicized in the text as they apply to the GACE, with corresponding teaching points presented in Table 1.
Conceptual Framework A blended version of Benner's model of novice-to-expert and Wright's conceptual framework for teaching research in nursing was used as the conceptual framework for this study (Benner, 1984; Wright, 2005). Figure 1 depicts the blended conceptual model used in this study. According to Benner, as
nurses gain experience, they become more proficient and confident in their professional role and nursing practice. For example, a new graduate nurse or novice researcher is dependent on colleagues and mentors for consultation and supervision in the research process whereas a more experienced nurse researcher may feel confident in assuming a more independent role in research and evidence-based practice. As a novice, the new graduate nurse or novice researcher may identify potential areas of research related to clinical practice while a more experienced nurse researcher may be expected to write and implement a clinical research study or seek grant funding. Wright (2005) proposes four pillars for teaching research in nursing: theoretical knowledge of research; scientific writing; psychological support; and, experiential learning. Much like Benner, Wright's model proposes a developmental continuum in which nurses' progress from being knowledgeable “consumers" of research to “doers" of research. In the first pillar, theoretical knowledge, nurses are taught the theoretical basis and steps of the research process. In the second pillar, scientific writing, the nurse is guided through the process of writing the
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Figure 1
Conceptual model for study.
research proposal. In the third pillar, psychological support, nurses are mentored and supported while they are learning how to develop and conduct research in the clinical setting. Psychological support is critical as nurses' attitudes toward research will not change until their feelings of fear and intimidation of research are addressed. Therefore, it is crucial that nurses are mentored and feel supported while they are learning how to do research (Wright, 2005). Faculty and mentors need to be passionate about the importance of nurses conducting research and model the way by establishing their own programs of research. The last pillar, experiential learning, is where nurses gain valuable experience by actually implementing a research project. Benner's and Wright's frameworks provided the basis for teaching and engaging nurses in the research process. Nurses in this large academic pediatric and obstetric hospital were provided with the didactic and experiential knowledge to develop and conduct research in the clinical setting. Mentored research projects allowed the nurses to overcome fears and resistance to becoming active participants in nursing research. Nursing Grand Rounds also allowed a forum by which faculty could use the GACE to teach research principles to the nursing staff who participated in the study.
Review of the Literature One of the most important early steps in a research project is to conduct a literature review. For the GACE research project, there was a knowledge gap about which type of chocolate chip cookie staff nurses preferred. While performing a literature review, several relevant research articles were identified. Sawatzky-Dickson and Clarke (2008) examined nursing staff's preference for cookies with carob chips versus cookies with regular chocolate chips. The researchers demonstrated that the carob chip cookie was preferred by 73 (15%) participants, while the majority of nursing staff
preferred the regular chocolate chip cookie (81%). Eighteen participants (4%) reported that they did not like either type of chocolate chip cookie. Another study comparing types of chocolate chip cookies was conducted by Hudson-Barr et al. (2002). These researchers compared regular and low-fat chocolate chip cookies. The majority of participants (n = 894) preferred the regular chocolate chip cookie (72%). More participants rated the regular versus the low-fat chocolate chip cookie, respectively, as having very good/ good texture (87% vs. 36%), moistness (90% vs. 20%), flavor (74% vs. 46%), and appearance (87% vs. 53%). No studies were located that examined staff nurses preference for sugar-free chocolate chip cookies versus regular chocolate chip cookies. Therefore, the purpose of the GACE study was to examine whether pediatric and obstetrical nurses preferred the texture, flavor, and overall taste of sugar-free or regular chocolate chip cookies.
Research Design and Methods A crossover, double-blinded study design was employed to examine the perceived quality and overall preference for two chocolate chip cookies that were identical, except that one cookie was sugar-free and the other cookie was regular (contained sugar). The research questions examined were: 1) Do staff nurses prefer sugar-free chocolate chip cookies or regular chocolate chip cookies?; 2) Do staff nurses prefer the texture (moistness) of the sugar-free chocolate chip cookie or the texture (moistness) of the regular chocolate chip cookie?; and, 3) Do staff nurses prefer the flavor of the sugar-free chocolate chip cookie or the flavor of the regular chocolate chip cookie? Research participants were used as their own control, meaning that each participant taste tested each of the two cookies as opposed to a study design in which each participant was randomly assigned to a “sugar-free group” or a “regular”
The Great American Cookie Experiment group and the results compared between the two groups. Using participants as their own control ensures equivalence among participants taste testing the two different cookie types and allows the researcher to conduct the study with a smaller sample size. An alternative to the within-subjects randomization of cookie types implemented in this crossover study design would be to use a between-subjects randomization study design. But unlike the crossover study design, the betweensubjects design would not be guaranteed to be balanced in terms of participant characteristics (Piantadosi, 2005). Additionally, the crossover study design can more efficiently estimate differences in cookie preferences because there is less between-subject variability than would occur with a randomized between-subjects study design (Piantadosi, 2005). A potential disadvantage of crossover studies is that the sequential effects of treatments can be a problem when the order of treatments affects the response. For this reason, the sequence of the two cookie types was randomized. Treatment carryover can also be an issue in crossover studies if the effect of the first treatment lingers and affects the research participant's response to the second treatment. Treatment carryover can be avoided by use of a washout period, which means to allow enough time between treatments for the effects of the first treatment to completely wear off before administering the second treatment (Piantadosi, 2005). A washout period of sorts was employed in the current study since research participants rinsed their mouth with water before tasting the second cookie.
Sample and Setting The study was conducted in the acute and critical care units at Texas Children's Hospital. Texas Children's Hospital is licensed for over 650 beds and employs close to 2500 registered nurses and over 250 APRNs. A convenience sample of 300 pediatric and obstetric staff nurses were recruited to participate in this study. Although using a convenience sample is sometimes the most feasible approach to recruiting research participants, results derived from a convenience sample are susceptible to sample bias since the sample of research participants might systematically differ from the target population because a random sample from the target population was not obtained. All research participants enrolled in the study had to speak and read English. The only exclusion criterion for participation in the study was known allergies to any ingredients in the chocolate chip cookies. An a priori power analysis was conducted to estimate the sample size needed to detect a difference in cookie preferences given the null hypothesis that 50% of the staff nurses prefer regular cookies and 50% prefer sugar-free cookies. The power analysis revealed that 300 participants would provide 80% statistical power to detect a difference in cookie preferences, at the 5% significance level, if the true population proportion of staff nurses who prefer regular chocolate chip cookies is above 58% or below 42%.
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Procedure The Baylor College of Medicine's Institutional Review Board (IRB) approved this study. Research participants were recruited at nursing staff meetings and by email invitation, and posters advertising the study were displayed in the staff lounges/conference rooms. Data collection occurred during one day shift, one evening and night shift, and one weekend day shift at the Texas Children's Hospital's Main Campus and during one day shift at the Texas Children's Hospital's community West Campus. Data collectors were familiar with the study, but were blinded as to the composition of the cookies. The catering staff at the hospital prepared the sugar-free and regular chocolate chip cookies and placed the cookies in bakery boxes labeled “Cookie A” or “Cookie B”. Informed consent was obtained from staff nurses interested in participating in the study. The nurses were informed that their participation was voluntary and whether they decided to participate or not would in no way influence their employment or performance review. The potential risk of loss of confidentiality was minimized by anonymous survey completion and ensuring that all data were locked up and secured on a password protected network server. Nurses were also informed that all data obtained in this study would be reported as group data and that it would not be possible to identify individual responses. A list of cookie ingredients was posted at each data collection site. Once the research participant acknowledged that she/he had no allergies to any ingredients in the cookies and signed the consent form, she/he was allowed to participate in the study. Research participants were provided with one sugar-free chocolate chip cookie and one regular chocolate cookie. Participants were asked to take at least one bite from the first cookie (randomly ordered) and record their responses on the cookie assessment tool (Table 2). The participant was instructed to rinse their mouth with water before tasting the other cookie and recording their responses on the cookie assessment tool.
Instrument The cookie assessment tool was used in this study to examine whether pediatric and obstetrical nurses preferred the texture, flavor, and overall taste of sugar-free or regular chocolate chip cookies. Originally developed by Thiel (1987), the cookie assessment tool has been modified for use in a number of hospital-based GACE research studies (Hagle & Millenbruch, 2011; Hudson-Barr et al., 2002; Morrison-Beedy & Cote-Arsenault, 2000; Thiel, 1987). Five of the 10 questions were retained from the original survey. The first 4 questions asked the participant to rate each cookie in terms of its moistness and flavor. Using a Likert scale, the participant rated “Cookie A” and “Cookie B” from “very good” to “very bad”. Question 5 asked participants which cookie they liked better overall. Research participants also provided demographic information including age, gender, education level, job
512 Table 2
M. Walden et al. Cookie assessment tool.
category, certification status, hospital unit, work shift, and years of experience in their current position. Face validity for all questions on the modified survey was assessed by the hospital's nursing research council.
Data Analysis To determine if staff nurses prefer sugar-free or regular chocolate chip cookies, participant preferences for “Cookie A” and “Cookie B” from the cookie assessment tool were coded as 1 and − 1, respectively, while a value of 0 was assigned to research participants who did not indicate a preference. A one-sample Wilcoxon Signed Ranks Test was used to test the null hypothesis that the population median
value is 0. To determine if staff nurses prefer the texture (moistness) and flavor of sugar-free or regular chocolate chip cookies, the Likert scale responses “Very Bad”, “Bad”, “Neutral”, “Good” and “Very Good” to items 1 through 4 on the cookie assessment tool were assigned scores of 1, 2, 3, 4 and 5, respectively. For both texture and flavor, differences between the score for the regular versus the sugar-free chocolate chip cookie were computed for each participant. The Wilcoxon Signed Ranks Test was used to determine if there was a significant difference in the texture and flavor ratings of regular and sugar-free chocolate chip cookies. The Wilcoxon Signed Ranks Test is a nonparametric analogue to the paired t-test, but the former method is preferred to the
The Great American Cookie Experiment Table 3
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Demographic characteristics of study subjects (n = 300).
Characteristic Campus Main West Work shift Day Evening Night Gender Female Male Highest level of education High school/Associate Bachelor's Master's Doctorate Certification in role
n (%) 268 (89%) 32 (11%) 223 (75%) 12 (4%) 61 (21%) 275 (92%) 24 (8%) 74 (25%) 215 (72%) 5 (2%) 2 (1%) 195 (65%)
latter when the responses are not normally distributed. The Wilcoxon Signed Ranks Test was the appropriate method to use for the current study since the data obtained were ordinal categories (i.e., assuming values of − 1, 0 and 1 or 1, 2, 3, 4 and 5) and, therefore, could not be normally distributed. A 5% significance level was used for all hypothesis tests. IBM SPSS Statistics 20.0 (IBM Corporation, 2011) was used for data analysis.
flavor scores for the regular chocolate chip cookie was 4.3 (0.8) compared to 3.9 (0.8) for the sugar-free cookie.
Discussion Results from the GACE study indicate that the majority of staff nurses prefer regular chocolate chip cookies over sugar-free chocolate chip cookies. A statistically significant number of staff nurses preferred the texture (moistness) and flavor of regular chocolate chip cookies over sugar-free chocolate chip cookies. These findings are similar to past study results in which nurses preferred regular chocolate chip cookies over carob chip cookies (Sawatzky-Dickson & Clarke, 2008) or fat-free chocolate chip cookies (Hudson-Barr et al., 2002). With the increased emphasis on quality and outcomes, evidence-based nursing care has become an important health care initiative (Thiel & Ghosh, 2008). Bedside nurses are expected to incorporate research findings into delivery of daily nursing care (Plach & Paulson-Conger, 2007). The purposes of this research study were to engage staff nurses in research, and to give the research scholars experience in working through the entire research process under the guidance of doctorally prepared nurse researchers. Nursing Grand Rounds was used as a forum to present the study findings to the research participants while educating nursing staff about the research process. The anecdotal response to the GACE was overwhelmingly positive from both research scholars as well as research participants.
Implications for Practice Results Demographic categories of the 300 study participants are summarized in Table 3. The mean age was 37.2 (range 21–73) years, and the average time employed at Texas Children's Hospital was 8.7 (range 0–37) years. Staff nurses preferred regular chocolate chip cookies significantly more (p b 0.001) than sugar-free cookies (Figure 2) with 186 (62%) research participants preferring regular chocolate chip cookies, 84 (28%) preferring sugar-free cookies and 30 (10%) indicating no preference. Staff nurses rated regular chocolate chip cookies significantly better in terms of texture (p b 0.001, Figure 3) and flavor (p b 0.001, Figure 4). The mean (standard deviation) of the texture (moistness) scores for the regular chocolate chip cookie was 4.4 (0.7) compared to 3.9 (1.0) for the sugar-free cookie. The mean (standard deviation) of the
Regular Sugar-Free No Preference
Figure 2 Percentage of subjects preferring regular chocolate chip cookies, sugar-free cookies, and having no preference.
Creating practice environments that fully engage nurses in their practice is a central issue for the nursing profession and is critical for the delivery of safe, high quality nursing care. Maintaining high standards of professional practice in nursing is dependent on the ongoing generation and dissemination of knowledge. Unfortunately, nursing practice is too often guided solely by knowledge gained in nursing school, communication with other nurses, tradition, and preferences of medical providers (Davidson & Brown, 2014). For novice nurses, the thirst for knowledge and acquisition of new skills is often buried under the demands of the clinical nursing role. If nurses are to advance and lead care at the bedside, nurses have to embrace research as a critical element of their professional practice (Bournes, 2013). Nurses must move beyond viewing their roles merely as patient caregivers, but should also envision themselves as nurse researchers (Wright, 2005). Developing a culture of nursing research and evidencebased practice in a hospital setting is a formidable task (Bournes, 2013; Brown et al., 2011; Wright, 2005). Nurses intuitively want to provide the best care for their patients, but often do not feel they have the knowledge and skills to incorporate research and evidence-based principles into their nursing practice (Brown et al., 2011). The research conceptual framework that guided this study can be used by nurse educators in healthcare organizations to facilitate the development of a culture of inquiry and
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Frequency
150 100 50 0
Sugar-Free Very Bad
Regular Sugar-Free
Figure 3
Bad
Very Bad 0 4
Neutral
Bad 6 28
Regular Good
Neutral 21 65
Very Good
Good 132 113
Very Good 141 90
Texture (moistness) rating frequencies of regular and sugar-free chocolate chip cookies.
scholarship (Benner, 1984; Wright, 2005). This model can guide the assessment of research knowledge and skills and inform the research curriculum and professional development activities. A structured educational program supports the development of theoretical knowledge and skills. For novice nurse researchers, it is important to not only provide didactic instruction in research methodology, but to also provide mentored experiential learning activities (Wright, 2005). Nurses who are more proficient in conducting clinical research may serve as mentors for novice researchers. From our experience, creating teams that include nurses with varied levels of research experience may ensure continued engagement in selected projects. The learning needs for didactic education and experiential learning will also be determined by the level and area of research expertise of the individual nurse. Because Benner's model is situational, research knowledge and skills may vary based on the particular individual's background experience and knowledge of research methods (Benner, 2004). For example, a nurse skilled in quantitative methods at the expert level may not be at that same level of skill when conducting
qualitative research and will need professional development opportunities and mentored learning experiences to gain the skills needed to successfully conduct qualitative research. Even for nurse researchers with expertise in some areas, there could be varying levels of skill in certain aspects of research such as selecting the appropriate study design, estimating sample size, or choosing the appropriate statistical methods, thereby necessitating learning opportunities to improve the expert's knowledge and skills in relatively weak areas. A structured educational program can help nurses to develop knowledge, skills, and confidence in their research abilities. Creative educational programs can produce knowledgeable consumers of research as well as productive scholars who embrace their “inner researcher” and willingly engage in nursing research (Wright, 2005). The GACE provided experiential learning activities for the research scholars. Moving forward with other clinical research projects was an easier transition because of the knowledge and skills that the research scholars acquired during the GACE. Building on the research experience acquired by the GACE, four subsequent clinical research projects were initiated and completed during the research scholars
Frequency
200 150 100 50 0
Sugar-Free Very Bad
Bad
Neutral
Regular Good Very Good
Regular Sugar-Free
Figure 4
Very Bad 0 1
Bad 9 20
Neutral 27 54
Good 129 156
Very Good 135 69
Flavor rating frequencies of regular and sugar-free chocolate chip cookies.
The Great American Cookie Experiment program. So why not take a “bite out of research” by developing your own “Great American Cookie Experiment”.
Acknowledgment We would like to thank the following research scholars who implemented this study as part of their research course requirements: Justin Austin, Deborah Davis, Jenny Gonzalez, Jennifer Hansbro, Jane Head, Mary Hradecky, Tracey Johnson, Tarra Kerr, Ryan Krasnosky, Amber Lovell, Elvie Mirabueno, Geneva Shores, Sydney Thompson, Veronica Victorian, and Elizabeth Wuestner.
References American Nurses Credentialing Center (2013). 2014 Magnet application manual. Silver Spring, MD: Author. Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing. Benner, P. (2004). Using the Dreyfus Model of Skill Acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society, 24, 188–199. Bournes, D. (2013). Cultivating a spirit of inquiry using a nursing leadingfollowing model. Nursing Science Quarterly, 26, 182–188. Brown, C. R., Johnson, A. S., & Appling, S. E. (2011). A taste of nursing research: An interactive program introducing evidence-based practice and research to clinical nurses. Journal for Nurses in Staff Development, 27, E1–E5.
515 Davidson, J. E., & Brown, C. (2014). Evaluation of nurse engagement in evidence-based practice. AACN Advanced Critical Care, 25, 43–55. Hagle, M. E., & Millenbruch, J. L. (2011). Retooling the Great American Cookie Experiment for nursing grand rounds. Clinical Nurse Specialist, 25, 220–223. Hudson-Barr, D., Weeks, S. K., & Watters, C. (2002). Introducing the staff nurse to nursing research through the Great American Cookie Experiment. Journal of Nursing Administration, 32, 440–443. IBM Corporation (2011). IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corporation. Morrison-Beedy, D., & Cote-Arsenault, D. (2000). The cookie experiment revisited: Broadened dimensions for teaching nursing research. Nursing Education, 25, 294–296. Piantadosi, S. (2005). Cinical trials: A methodological perspective. New York, NY: John Wiley & Sons. Plach, S. K., & Paulson-Conger, M. (2007). Demystifying the research process with participatory learning: A taste of research. Journal for Nurses in Staff Development, 23, 45–48. Sawatzky-Dickson, D. M., & Clarke, D. E. (2008). Increasing understanding of nursing research for general duty nurses: An experiential strategy. Journal of Continuing Education in Nursing, 39, 105–109. Thiel, C. A. (1987). The cookie experiment: A creative teaching strategy. Nurse Educator, 12, 8–10. Thiel, L., & Ghosh, Y. (2008). Determining registered nurses’ readiness for evidence-based practice. Worldviews on Evidence-Based Nursing, 5, 182–192. Wright, S. C. D. (2005). A conceptual framework for teaching research in nursing. Curationis, 28, 4–10.
The Great American Cookie Experiment: Engaging Staff Nurses in Research1,2,3 Marlene Walden PhD, RN, NNP-BC, CCNS ⁎, Constance E. Cephus PhD, RN, NNP-BC, CPNP-AC/PC, Mary D. Gordon PhD, RN, CNS-BC, Joseph Hagan ScD Texas Children's Hospital, Houston, TX Received 18 June 2014; revised 7 November 2014; accepted 18 November 2014
Key words: Nursing research; Nursing staff; Research methods; Teaching methods; Attitude of health personnel
Purpose: The purpose of this study was to engage staff nurses in research in an informative and fun way by determining nurses' preference for sugar-free chocolate chip cookies versus regular chocolate chip cookies. Design and Methods: A descriptive, crossover, double-blinded study was performed using a convenience sample of 300 staff nurses. Results: Nurses preferred the texture, flavor, and overall preference of the regular chocolate chip cookie as compared with the sugar-free chocolate chip cookie (p b 0.001). Implications: The Great American Cookie Experiment remains a creative teaching strategy to enhance knowledge and engage nurses in the research process. © 2015 Elsevier Inc. All rights reserved.
OVER THE PAST decade, research has become increasingly recognized as an important part of clinical practice and a key component to quality patient care. Hospitals seeking Magnet Recognition, administered by the American Nurses Credentialing Center, must demonstrate that direct care nurses are familiar with and engaged in research and evidence-based processes (American Nurses Credentialing Center, 2013). Most nurses acquire basic didactic knowledge about research in their nursing programs, but few nurses have actual experience in developing and conducting a research study in the clinical setting (Wright, 2005). Lack of experience and fear of "research" can interfere with staff nurses' participation in clinical research (Brown, Johnson, & Appling, 2011; Sawatzky-Dickson & Clarke, 2008; Hudson-Barr, Weeks, & Watters, 2002; Thiel, 1987). Several publications have outlined effective, innovative strategies for decreasing anxiety and increasing interest in research among nursing students and practicing nurses. Thiel
⁎ Corresponding author: Marlene Walden, PhD, RN, NNP-BC, CCNS. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2014.11.007 0882-5963/© 2015 Elsevier Inc. All rights reserved.
(1987) described a cookie experiment that was used as an experiential learning strategy to involve undergraduate nursing students in research in a way that was engaging and that desensitized them to the negative perceptions about research. Since this original research, several other publications have reported success in using the Great American Cookie Experiment (GACE) in the hospital setting to demystify research concepts and to teach and engage staff nurses in the research process (Brown et al., 2011; Hagle & Millenbruch, 2011; Hudson-Barr et al., 2002; Morrison-Beedy & CoteArsenault, 2000; Sawatzky-Dickson & Clarke, 2008). A south Texas urban pediatric and obstetric hospital explored strategies for how to engage staff nurses in clinical research. Under the guidance of the hospital's nursing research council, a research scholars program was developed to teach the research process and allow nurses to design and conduct research projects under the guidance of doctorally prepared research faculty. The GACE was used throughout the curriculum to teach basic research concepts and engage the research scholars in research in a way that was both informative and fun. During the 12-month research scholars program, 14 registered nurses and advanced practice registered nurses (APRNs) learned how to conduct a
The Great American Cookie Experiment Table 1
509
Research concepts and teaching points related to the Great American Cookie Experiment (GACE).
Research concepts
Teaching points
Blinded
Blinding is the process of preventing those involved in a study (researchers, participants, data collectors) from having information that could bias study results by knowing which treatment group a participant is in (e.g. which cookie is sugar-free or regular chocolate chip). Convenience A convenience sample involves selection of the most readily available persons to participate in the study as sample opposed to randomly selecting the sample of participants. Crossover design Crossover studies employ an experimental design in which each participant participates in two or more treatment conditions, preferably in random order. Informed consent Informed consent is based on an ethical principle requirement that researchers obtain participants' voluntary consent to participate in the study without coercion, after informing them of the possible risks and benefits of their participation. Institutional review An institutional review board's (IRB) purpose is to protect the rights of people and animals who are board participants of research. The IRB makes sure participants are selected equitably, have adequate information about the research, and that risks to participants are minimized. The IRB also ensures that the privacy of participants is protected and that additional safeguards protect vulnerable populations. Literature review A literature review is a critical summary of research on a topic of interest, highlighting what is currently known about the research problem and identifying gaps in the evidence. Power analysis A power analysis determines the sample size needed to conduct a meaningful study. If the sample size is too small, the researcher will probably not be able to obtain sufficient evidence to support the research hypothesis, even if the hypothesis is correct. Random order In a crossover study, random order is the assignment of the treatment condition in a random manner. This is important to minimize the potential for systematic bias from “order” effects, since it is possible that the order in which the “treatments” (i.e. cookie type) are introduced may affect study results. Research question The central query of the research study. Most research questions can be expressed using a general question template: “In (population), what is the relationship between the (independent variable [IV] and (dependent variable [DV])?” The IV is thought to influence or be related to the dependent or outcome variable. In this study, the IV is the cookie type. DVs are the outcome variables being measured. In this study, the DVs are overall preference, texture (moistness), and flavor ratings. Significance level Significance level is the cutoff for deciding whether or not an observed relationship is due to chance or if, instead, there really is a relationship between the IV and DV. A 5% significance level indicates that relationships with less than a 5% probability of being observed strictly due to chance will be deemed statistically significant. Wilcoxon Signed Nonparametric statistical method that can be used to compare two paired groups, based on the relative ranking of Ranks Test differences in the paired values between the groups.
comprehensive literature search, write a research proposal, obtain institutional review board approval to conduct the study, implement the study, collect and analyze data, interpret the results, and disseminate the study findings. Following completion of the GACE, Nursing Grand Rounds was held to present the study findings and to use the GACE to educate the nursing staff who served as research participants in the study. The GACE was an effective strategy to both engage nurses in actual research and to educate the general nursing staff about the research process. This article presents the results of the GACE conducted at Texas Children's Hospital. To enhance learning, important research concepts are italicized in the text as they apply to the GACE, with corresponding teaching points presented in Table 1.
Conceptual Framework A blended version of Benner's model of novice-to-expert and Wright's conceptual framework for teaching research in nursing was used as the conceptual framework for this study (Benner, 1984; Wright, 2005). Figure 1 depicts the blended conceptual model used in this study. According to Benner, as
nurses gain experience, they become more proficient and confident in their professional role and nursing practice. For example, a new graduate nurse or novice researcher is dependent on colleagues and mentors for consultation and supervision in the research process whereas a more experienced nurse researcher may feel confident in assuming a more independent role in research and evidence-based practice. As a novice, the new graduate nurse or novice researcher may identify potential areas of research related to clinical practice while a more experienced nurse researcher may be expected to write and implement a clinical research study or seek grant funding. Wright (2005) proposes four pillars for teaching research in nursing: theoretical knowledge of research; scientific writing; psychological support; and, experiential learning. Much like Benner, Wright's model proposes a developmental continuum in which nurses' progress from being knowledgeable “consumers" of research to “doers" of research. In the first pillar, theoretical knowledge, nurses are taught the theoretical basis and steps of the research process. In the second pillar, scientific writing, the nurse is guided through the process of writing the
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Figure 1
Conceptual model for study.
research proposal. In the third pillar, psychological support, nurses are mentored and supported while they are learning how to develop and conduct research in the clinical setting. Psychological support is critical as nurses' attitudes toward research will not change until their feelings of fear and intimidation of research are addressed. Therefore, it is crucial that nurses are mentored and feel supported while they are learning how to do research (Wright, 2005). Faculty and mentors need to be passionate about the importance of nurses conducting research and model the way by establishing their own programs of research. The last pillar, experiential learning, is where nurses gain valuable experience by actually implementing a research project. Benner's and Wright's frameworks provided the basis for teaching and engaging nurses in the research process. Nurses in this large academic pediatric and obstetric hospital were provided with the didactic and experiential knowledge to develop and conduct research in the clinical setting. Mentored research projects allowed the nurses to overcome fears and resistance to becoming active participants in nursing research. Nursing Grand Rounds also allowed a forum by which faculty could use the GACE to teach research principles to the nursing staff who participated in the study.
Review of the Literature One of the most important early steps in a research project is to conduct a literature review. For the GACE research project, there was a knowledge gap about which type of chocolate chip cookie staff nurses preferred. While performing a literature review, several relevant research articles were identified. Sawatzky-Dickson and Clarke (2008) examined nursing staff's preference for cookies with carob chips versus cookies with regular chocolate chips. The researchers demonstrated that the carob chip cookie was preferred by 73 (15%) participants, while the majority of nursing staff
preferred the regular chocolate chip cookie (81%). Eighteen participants (4%) reported that they did not like either type of chocolate chip cookie. Another study comparing types of chocolate chip cookies was conducted by Hudson-Barr et al. (2002). These researchers compared regular and low-fat chocolate chip cookies. The majority of participants (n = 894) preferred the regular chocolate chip cookie (72%). More participants rated the regular versus the low-fat chocolate chip cookie, respectively, as having very good/ good texture (87% vs. 36%), moistness (90% vs. 20%), flavor (74% vs. 46%), and appearance (87% vs. 53%). No studies were located that examined staff nurses preference for sugar-free chocolate chip cookies versus regular chocolate chip cookies. Therefore, the purpose of the GACE study was to examine whether pediatric and obstetrical nurses preferred the texture, flavor, and overall taste of sugar-free or regular chocolate chip cookies.
Research Design and Methods A crossover, double-blinded study design was employed to examine the perceived quality and overall preference for two chocolate chip cookies that were identical, except that one cookie was sugar-free and the other cookie was regular (contained sugar). The research questions examined were: 1) Do staff nurses prefer sugar-free chocolate chip cookies or regular chocolate chip cookies?; 2) Do staff nurses prefer the texture (moistness) of the sugar-free chocolate chip cookie or the texture (moistness) of the regular chocolate chip cookie?; and, 3) Do staff nurses prefer the flavor of the sugar-free chocolate chip cookie or the flavor of the regular chocolate chip cookie? Research participants were used as their own control, meaning that each participant taste tested each of the two cookies as opposed to a study design in which each participant was randomly assigned to a “sugar-free group” or a “regular”
The Great American Cookie Experiment group and the results compared between the two groups. Using participants as their own control ensures equivalence among participants taste testing the two different cookie types and allows the researcher to conduct the study with a smaller sample size. An alternative to the within-subjects randomization of cookie types implemented in this crossover study design would be to use a between-subjects randomization study design. But unlike the crossover study design, the betweensubjects design would not be guaranteed to be balanced in terms of participant characteristics (Piantadosi, 2005). Additionally, the crossover study design can more efficiently estimate differences in cookie preferences because there is less between-subject variability than would occur with a randomized between-subjects study design (Piantadosi, 2005). A potential disadvantage of crossover studies is that the sequential effects of treatments can be a problem when the order of treatments affects the response. For this reason, the sequence of the two cookie types was randomized. Treatment carryover can also be an issue in crossover studies if the effect of the first treatment lingers and affects the research participant's response to the second treatment. Treatment carryover can be avoided by use of a washout period, which means to allow enough time between treatments for the effects of the first treatment to completely wear off before administering the second treatment (Piantadosi, 2005). A washout period of sorts was employed in the current study since research participants rinsed their mouth with water before tasting the second cookie.
Sample and Setting The study was conducted in the acute and critical care units at Texas Children's Hospital. Texas Children's Hospital is licensed for over 650 beds and employs close to 2500 registered nurses and over 250 APRNs. A convenience sample of 300 pediatric and obstetric staff nurses were recruited to participate in this study. Although using a convenience sample is sometimes the most feasible approach to recruiting research participants, results derived from a convenience sample are susceptible to sample bias since the sample of research participants might systematically differ from the target population because a random sample from the target population was not obtained. All research participants enrolled in the study had to speak and read English. The only exclusion criterion for participation in the study was known allergies to any ingredients in the chocolate chip cookies. An a priori power analysis was conducted to estimate the sample size needed to detect a difference in cookie preferences given the null hypothesis that 50% of the staff nurses prefer regular cookies and 50% prefer sugar-free cookies. The power analysis revealed that 300 participants would provide 80% statistical power to detect a difference in cookie preferences, at the 5% significance level, if the true population proportion of staff nurses who prefer regular chocolate chip cookies is above 58% or below 42%.
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Procedure The Baylor College of Medicine's Institutional Review Board (IRB) approved this study. Research participants were recruited at nursing staff meetings and by email invitation, and posters advertising the study were displayed in the staff lounges/conference rooms. Data collection occurred during one day shift, one evening and night shift, and one weekend day shift at the Texas Children's Hospital's Main Campus and during one day shift at the Texas Children's Hospital's community West Campus. Data collectors were familiar with the study, but were blinded as to the composition of the cookies. The catering staff at the hospital prepared the sugar-free and regular chocolate chip cookies and placed the cookies in bakery boxes labeled “Cookie A” or “Cookie B”. Informed consent was obtained from staff nurses interested in participating in the study. The nurses were informed that their participation was voluntary and whether they decided to participate or not would in no way influence their employment or performance review. The potential risk of loss of confidentiality was minimized by anonymous survey completion and ensuring that all data were locked up and secured on a password protected network server. Nurses were also informed that all data obtained in this study would be reported as group data and that it would not be possible to identify individual responses. A list of cookie ingredients was posted at each data collection site. Once the research participant acknowledged that she/he had no allergies to any ingredients in the cookies and signed the consent form, she/he was allowed to participate in the study. Research participants were provided with one sugar-free chocolate chip cookie and one regular chocolate cookie. Participants were asked to take at least one bite from the first cookie (randomly ordered) and record their responses on the cookie assessment tool (Table 2). The participant was instructed to rinse their mouth with water before tasting the other cookie and recording their responses on the cookie assessment tool.
Instrument The cookie assessment tool was used in this study to examine whether pediatric and obstetrical nurses preferred the texture, flavor, and overall taste of sugar-free or regular chocolate chip cookies. Originally developed by Thiel (1987), the cookie assessment tool has been modified for use in a number of hospital-based GACE research studies (Hagle & Millenbruch, 2011; Hudson-Barr et al., 2002; Morrison-Beedy & Cote-Arsenault, 2000; Thiel, 1987). Five of the 10 questions were retained from the original survey. The first 4 questions asked the participant to rate each cookie in terms of its moistness and flavor. Using a Likert scale, the participant rated “Cookie A” and “Cookie B” from “very good” to “very bad”. Question 5 asked participants which cookie they liked better overall. Research participants also provided demographic information including age, gender, education level, job
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M. Walden et al. Cookie assessment tool.
category, certification status, hospital unit, work shift, and years of experience in their current position. Face validity for all questions on the modified survey was assessed by the hospital's nursing research council.
Data Analysis To determine if staff nurses prefer sugar-free or regular chocolate chip cookies, participant preferences for “Cookie A” and “Cookie B” from the cookie assessment tool were coded as 1 and − 1, respectively, while a value of 0 was assigned to research participants who did not indicate a preference. A one-sample Wilcoxon Signed Ranks Test was used to test the null hypothesis that the population median
value is 0. To determine if staff nurses prefer the texture (moistness) and flavor of sugar-free or regular chocolate chip cookies, the Likert scale responses “Very Bad”, “Bad”, “Neutral”, “Good” and “Very Good” to items 1 through 4 on the cookie assessment tool were assigned scores of 1, 2, 3, 4 and 5, respectively. For both texture and flavor, differences between the score for the regular versus the sugar-free chocolate chip cookie were computed for each participant. The Wilcoxon Signed Ranks Test was used to determine if there was a significant difference in the texture and flavor ratings of regular and sugar-free chocolate chip cookies. The Wilcoxon Signed Ranks Test is a nonparametric analogue to the paired t-test, but the former method is preferred to the
The Great American Cookie Experiment Table 3
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Demographic characteristics of study subjects (n = 300).
Characteristic Campus Main West Work shift Day Evening Night Gender Female Male Highest level of education High school/Associate Bachelor's Master's Doctorate Certification in role
n (%) 268 (89%) 32 (11%) 223 (75%) 12 (4%) 61 (21%) 275 (92%) 24 (8%) 74 (25%) 215 (72%) 5 (2%) 2 (1%) 195 (65%)
latter when the responses are not normally distributed. The Wilcoxon Signed Ranks Test was the appropriate method to use for the current study since the data obtained were ordinal categories (i.e., assuming values of − 1, 0 and 1 or 1, 2, 3, 4 and 5) and, therefore, could not be normally distributed. A 5% significance level was used for all hypothesis tests. IBM SPSS Statistics 20.0 (IBM Corporation, 2011) was used for data analysis.
flavor scores for the regular chocolate chip cookie was 4.3 (0.8) compared to 3.9 (0.8) for the sugar-free cookie.
Discussion Results from the GACE study indicate that the majority of staff nurses prefer regular chocolate chip cookies over sugar-free chocolate chip cookies. A statistically significant number of staff nurses preferred the texture (moistness) and flavor of regular chocolate chip cookies over sugar-free chocolate chip cookies. These findings are similar to past study results in which nurses preferred regular chocolate chip cookies over carob chip cookies (Sawatzky-Dickson & Clarke, 2008) or fat-free chocolate chip cookies (Hudson-Barr et al., 2002). With the increased emphasis on quality and outcomes, evidence-based nursing care has become an important health care initiative (Thiel & Ghosh, 2008). Bedside nurses are expected to incorporate research findings into delivery of daily nursing care (Plach & Paulson-Conger, 2007). The purposes of this research study were to engage staff nurses in research, and to give the research scholars experience in working through the entire research process under the guidance of doctorally prepared nurse researchers. Nursing Grand Rounds was used as a forum to present the study findings to the research participants while educating nursing staff about the research process. The anecdotal response to the GACE was overwhelmingly positive from both research scholars as well as research participants.
Implications for Practice Results Demographic categories of the 300 study participants are summarized in Table 3. The mean age was 37.2 (range 21–73) years, and the average time employed at Texas Children's Hospital was 8.7 (range 0–37) years. Staff nurses preferred regular chocolate chip cookies significantly more (p b 0.001) than sugar-free cookies (Figure 2) with 186 (62%) research participants preferring regular chocolate chip cookies, 84 (28%) preferring sugar-free cookies and 30 (10%) indicating no preference. Staff nurses rated regular chocolate chip cookies significantly better in terms of texture (p b 0.001, Figure 3) and flavor (p b 0.001, Figure 4). The mean (standard deviation) of the texture (moistness) scores for the regular chocolate chip cookie was 4.4 (0.7) compared to 3.9 (1.0) for the sugar-free cookie. The mean (standard deviation) of the
Regular Sugar-Free No Preference
Figure 2 Percentage of subjects preferring regular chocolate chip cookies, sugar-free cookies, and having no preference.
Creating practice environments that fully engage nurses in their practice is a central issue for the nursing profession and is critical for the delivery of safe, high quality nursing care. Maintaining high standards of professional practice in nursing is dependent on the ongoing generation and dissemination of knowledge. Unfortunately, nursing practice is too often guided solely by knowledge gained in nursing school, communication with other nurses, tradition, and preferences of medical providers (Davidson & Brown, 2014). For novice nurses, the thirst for knowledge and acquisition of new skills is often buried under the demands of the clinical nursing role. If nurses are to advance and lead care at the bedside, nurses have to embrace research as a critical element of their professional practice (Bournes, 2013). Nurses must move beyond viewing their roles merely as patient caregivers, but should also envision themselves as nurse researchers (Wright, 2005). Developing a culture of nursing research and evidencebased practice in a hospital setting is a formidable task (Bournes, 2013; Brown et al., 2011; Wright, 2005). Nurses intuitively want to provide the best care for their patients, but often do not feel they have the knowledge and skills to incorporate research and evidence-based principles into their nursing practice (Brown et al., 2011). The research conceptual framework that guided this study can be used by nurse educators in healthcare organizations to facilitate the development of a culture of inquiry and
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Frequency
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Figure 3
Bad
Very Bad 0 4
Neutral
Bad 6 28
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Neutral 21 65
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Good 132 113
Very Good 141 90
Texture (moistness) rating frequencies of regular and sugar-free chocolate chip cookies.
scholarship (Benner, 1984; Wright, 2005). This model can guide the assessment of research knowledge and skills and inform the research curriculum and professional development activities. A structured educational program supports the development of theoretical knowledge and skills. For novice nurse researchers, it is important to not only provide didactic instruction in research methodology, but to also provide mentored experiential learning activities (Wright, 2005). Nurses who are more proficient in conducting clinical research may serve as mentors for novice researchers. From our experience, creating teams that include nurses with varied levels of research experience may ensure continued engagement in selected projects. The learning needs for didactic education and experiential learning will also be determined by the level and area of research expertise of the individual nurse. Because Benner's model is situational, research knowledge and skills may vary based on the particular individual's background experience and knowledge of research methods (Benner, 2004). For example, a nurse skilled in quantitative methods at the expert level may not be at that same level of skill when conducting
qualitative research and will need professional development opportunities and mentored learning experiences to gain the skills needed to successfully conduct qualitative research. Even for nurse researchers with expertise in some areas, there could be varying levels of skill in certain aspects of research such as selecting the appropriate study design, estimating sample size, or choosing the appropriate statistical methods, thereby necessitating learning opportunities to improve the expert's knowledge and skills in relatively weak areas. A structured educational program can help nurses to develop knowledge, skills, and confidence in their research abilities. Creative educational programs can produce knowledgeable consumers of research as well as productive scholars who embrace their “inner researcher” and willingly engage in nursing research (Wright, 2005). The GACE provided experiential learning activities for the research scholars. Moving forward with other clinical research projects was an easier transition because of the knowledge and skills that the research scholars acquired during the GACE. Building on the research experience acquired by the GACE, four subsequent clinical research projects were initiated and completed during the research scholars
Frequency
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Sugar-Free Very Bad
Bad
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Regular Sugar-Free
Figure 4
Very Bad 0 1
Bad 9 20
Neutral 27 54
Good 129 156
Very Good 135 69
Flavor rating frequencies of regular and sugar-free chocolate chip cookies.
The Great American Cookie Experiment program. So why not take a “bite out of research” by developing your own “Great American Cookie Experiment”.
Acknowledgment We would like to thank the following research scholars who implemented this study as part of their research course requirements: Justin Austin, Deborah Davis, Jenny Gonzalez, Jennifer Hansbro, Jane Head, Mary Hradecky, Tracey Johnson, Tarra Kerr, Ryan Krasnosky, Amber Lovell, Elvie Mirabueno, Geneva Shores, Sydney Thompson, Veronica Victorian, and Elizabeth Wuestner.
References American Nurses Credentialing Center (2013). 2014 Magnet application manual. Silver Spring, MD: Author. Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing. Benner, P. (2004). Using the Dreyfus Model of Skill Acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society, 24, 188–199. Bournes, D. (2013). Cultivating a spirit of inquiry using a nursing leadingfollowing model. Nursing Science Quarterly, 26, 182–188. Brown, C. R., Johnson, A. S., & Appling, S. E. (2011). A taste of nursing research: An interactive program introducing evidence-based practice and research to clinical nurses. Journal for Nurses in Staff Development, 27, E1–E5.
515 Davidson, J. E., & Brown, C. (2014). Evaluation of nurse engagement in evidence-based practice. AACN Advanced Critical Care, 25, 43–55. Hagle, M. E., & Millenbruch, J. L. (2011). Retooling the Great American Cookie Experiment for nursing grand rounds. Clinical Nurse Specialist, 25, 220–223. Hudson-Barr, D., Weeks, S. K., & Watters, C. (2002). Introducing the staff nurse to nursing research through the Great American Cookie Experiment. Journal of Nursing Administration, 32, 440–443. IBM Corporation (2011). IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corporation. Morrison-Beedy, D., & Cote-Arsenault, D. (2000). The cookie experiment revisited: Broadened dimensions for teaching nursing research. Nursing Education, 25, 294–296. Piantadosi, S. (2005). Cinical trials: A methodological perspective. New York, NY: John Wiley & Sons. Plach, S. K., & Paulson-Conger, M. (2007). Demystifying the research process with participatory learning: A taste of research. Journal for Nurses in Staff Development, 23, 45–48. Sawatzky-Dickson, D. M., & Clarke, D. E. (2008). Increasing understanding of nursing research for general duty nurses: An experiential strategy. Journal of Continuing Education in Nursing, 39, 105–109. Thiel, C. A. (1987). The cookie experiment: A creative teaching strategy. Nurse Educator, 12, 8–10. Thiel, L., & Ghosh, Y. (2008). Determining registered nurses’ readiness for evidence-based practice. Worldviews on Evidence-Based Nursing, 5, 182–192. Wright, S. C. D. (2005). A conceptual framework for teaching research in nursing. Curationis, 28, 4–10.
