All posts by Martha "Marty" Farrar Highfield PhD RN

It is difficult to be simple! Research can be understood when explained well. That's my aim.

Who ya gonna call? Myth Busters!!

MYTH: There is no real payoff in engaging  patients and families.

FACT:  Health care organizations can reap many benefits fromMythBUSted
“activated” patients and families – those who have the knowledge, skills and confidence to manage their own care.

How does engaging patients help?   1) It may increase quality of life by reducing falls, helping patients learn to manage chronic conditions. 2) It can reduce Underuse or Overuse of health services. 3) It may increases reimbursement through improved HCAHPS scores.  And YOU may be more satisfied at work!

TWO EXAMPLES of positive results yielded from partnering with patients and families:
• One hospital that began involving patients and families in safety efforts after a highly publicized preventable death saw a culture shift that improved medication reconciliation and eliminated fatal medication errors during a 10-year period (Johnson & Abraham; Reinersten et al., 2008).
Satisfaction• A health system that began seeking input from patients and families decreased nurse turnover from 15 percent to 5 percent in three years and improved patient, staff and physician satisfaction (Johnson & Abraham).

WHAT CAN I DO TO ENGAGE PATIENTS?  Listen to your patients to identify their level of activation in their care as described, & communicate in ways that move them to the nextNURSEPatient level.

  • At stage 1, people do not yet grasp that they must play an active role in their own
    health, they may still believe that they can just be a passive recipient of care….
  • At stage 2, people may lack the basic facts or have not connected the facts into a larger understanding about their health or recommended health regimens….
  • At stage 3, people have the key facts and are beginning to take action but may lack confidence and skill to support new behaviors….
  • At stage 4, people have adopted new behaviors but may not be able to maintain them in the face of life stress or health crises.”  [source: Hibbard et al. at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955271/]

mythVStruth

FOR MORE INFO, check out the source of above:  Busting the Myths about Engaging Patients and Families in Patient Safetyquestion

CRITICAL THINKING: Think of a strategy that you ALREADY use or that you might start using to move patients up the stages of engagement in their own care. Be specific!

Afraid to Relieve Pain? You may have Opiophobia

fear5In pain management are you afraid to give comfort to your patients with appropriate medications?   Are you afraid to be comforted when in pain?  Have you encountered families or care partners, who are afraid to comfort their loved one in pain by giving pain medications?

In a classic 2002 qualitative study, “Fearing to Comfort,” Zerwekh, Riddell, & Richard identified that RNs, physicians, patients, families, and health systems were afraid to relieve pain with appropriate use of pain medications.  They were Not doing evidence-based practice, but fear-based practice. barrier

Fear barriers include, but are not limited to 1) patients’ fear of addiction, fear of distracting the MD from the main treatment plan, and loss of control; 2) MDs’ avoiding the needs of the dying, fear of rewarding drug-seekers, or equating pain management with euthanasia; 3) RNs’ avoiding pain, failing to switch to palliative goals at end of life,  and fear of killing the patient; 4) families’ fears of addiction, side effects, & killing their loved one; and 5) health facilities’ not giving unique consideration to those at end of life, inadequate staffing, & time constraints (Zerwekh et al., 2002).

This is an issue because irrational problems cannot be simply solved by giving rational Pain fistinformation.   We have to find evidence-based practices that can create a change of heart, if you will.  As Zerwekh et al wrote: “Because fear is so influential in decisions to keep pain under control, palliative educational approaches must go beyond providing information to fill deficits in palliative knowledge.”
We must learn evidence-based ways to overcome fear and control pain.  Why?  Because pain interferes with living life.  Who are we protecting when we fear appropriate pain medications?  Not the patient.

FearRemedy?  Palliative care education must confront the fears and remove them through cognitive restructuring that includes learning to question beliefs about addiction etc.  Role playing, role modeling, and an expert walking through this with the provider or family who is afraid.  Beyond this helping people to recognize their own fears of pain & death, and providing the very best available information on pain management (Zerwekh et al).

CRITICAL THINKING:  Have you been afraid?  Or seen others afraid?  How can you solve this problem using evidence-based practice that = BEST available evidence + Clinical judgment + Patient/family preferences & values? Be specific because if you haven’t yet encountered the problem of fearing to comfort, be assured that you will.fear4

FOR MORE INFORMATION:   Read full text Zerwekh et al (2002) online.   It could change your life & the life of those for whom you care!!

“IT’S A PAIN!” Use Evidence to Address Pain Management Myths

A new threat has emerged in evidence-based management of pain control.  Fear.

Evidence-based practice for pain control has 3 elements:  BEST available evidence + Clinical judgment + Patient/care partner values and preferences.

In the concern over opioid abuse by some patients & professionals, some federal agencies and nonprofits are suggesting that The Joint Commission (TJC) is inadvertently at fault (http://hosted.ap.org/dynamic/stories/U/US_PAINKILLERS_PAIN_MEASURES?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT).  HCAHPS questions are also under suspicion.

Pain fistWhile I am not an apologist either for TJC or HCAHPS, my fear is that the government/involved nonprofit fears ignore the data: pain relief is still inadequate for some patients, professionals often under-medicate or don’t believe patients, and some patients have pain crises.  Limiting opioids only to certain diagnoses undercuts evidence-based care.

As a professional RN, you need to check out the best available evidence yourself, use your judgment, and Question1practice pain assessment & management safely. We knowIdea2 that asking patients about suicidal intent does not cause them to commit suicide.  Does asking patients about pain cause them to have it or to treat pain they don’t have?  Hmmm…..

Here are the current TJC standards:  1) The hospital educates all licensed independent practitioners on assessing and managing pain. 2) The hospital respects the patient’s right to pain management. 3) The hospital assesses and manages the patient’s pain.”

Check out this link for truth about the following 5 myths identified by TJC about their standards:  http://www.jointcommission.org/joint_commission_statement_on_pain_management/

  • Myth#1: The Joint Commission endorses pain as a vital sign…. Vital sign
  • Myth #2: The Joint Commission requires pain assessment for all patients….
  • Myth #3: The Joint Commission requires that pain be treated until the pain score reaches zero….
  • #4: The Joint Commission standards push doctors to prescribe opioids.
  • OxycodoneMyth #5: The Joint Commission pain standards caused a sharp rise in opioid prescriptions. This claim is completely contradicted by data from the National Institute on Drug Abuse.”…  [Source=TJC link above]

Of course, RNs & the health team can always do things better, and the above concerns Hypothesissuggest that we might need new studies. I hope only that we won’t jump on the fear bandwagon.   Keep practice EVIDENCE BASED, listen to patient/carepartner preferences & values, & use your judgment.  

CRITICAL THINKING:  How do you assess patient pain?  How could you improve?  How do you apply TJC standards in your setting?

FOR MORE INFORMATION: Do you know what the TJC pain standards are?  Check out the 5 myth link above.

 

 

“What Difference Does it Make?” Plenty when it comes to Posters!

Congratulations—You and your team have completed a project!   

Now what?   Disseminate your work of course so that others can learn.  A poster is a great way to do this. Dissemination is a key step in research & evidence-based practice.  

But how should you present the information on your poster?  To quote a well-known
politician:  “What difference does it make”
how you hILARYpresent your  project in a poster.   Quite a bit, it turns out!   Some posters are definitely better than others.

For your poster you want to realize that you are dealing with a VISUAL medium, not text.  This means that you need:

  • A CLEAR FOCUS on the key ideas & results
  • CONTENT THAT FLOWS. You want to make sure the reader is guided through the poster–maybe by numbering steps or adding arrows.
  • Enough “WHITE SPACE” that the readers eye has time to “rest” and that draws attention to your focus. (e.g., think “Got Milk?” in bold white letters on a black background.  White space =any color blank space.)
  • USE VISUAL Employ short phrases, bullet points, active voice, and graphics that take advantage of the visual medium.   Some people say 50% should be graphics.

 

OK

For example, let’s look at 3 different ways that you could present your pretend research study on RN attitudes to electronic health records (EHR).   The NOVICE POSTER-MAKER may put the following on their poster:

“RN attitudes toward the new electronic health record were examined in a pretest, and class was taught on how to use the electronic health record.   After the class a posttest of their attitudes was conducted.”

The above example has several problems!  It is in passive voice.  It has too many extra words.  It is plain text and not the visual. It doesn’t give results. Is someone going to stand there and read your poster like an article?  Nope.  You need to make it different!

To make a difference, TRY THIS SOLUTION to present the same information as bullet point phrases:

Better?
  • Key variable: RN attitudes toward electronic health record (EHR)
  • Pretest of RN attitudes to EHR
  • Class on improved use
  • Posttest of RN attitudes toward EHR showed improvement (p<.05)

 

Best?

OR PERHAPS TO MAKE AN EVEN BETTER DIFFERENCE—KEEP IT REALLY VISUAL, WITH FLOW AND FOCUS (using graphics when possible instead of words)Poster graphic

So….“What difference does it make?”   You decide!

For more information:  Check out http://www.evergreen.edu/scicomp/docs/workshops/Poster_Tips2.pdf or do a quick search for other poster making tips.  There is LOTS of good info out there.

Critical Thinking:   QUESTIONCritique this poster or another using the “60 second poster evaluation” at http://dept-wp.nmsu.edu/nmsuhhmi/files/2013/06/60-Second-Poster-Evaluation.pdfIMG_0834

 

Google’s Beauty is Only Skin Deep: Go for the Database!

maxresdefaultGoogle–not to mention yahoo, bing & other web search engines–are mere popularity contests of literature.   Google Scholar is a step up, but it is still a search engine.  It can miss important articles entirely.

If you want to be sure that you are getting the BEST, you gotta look in the right place if you want to find the right articles on the right topic at the right time!Beauty contest winner

You need a Database!

Don’t believe me?  Watch “What are databases and why you need them?”(youtube 2:34)

Reputable publishers give away very few articles for free, so when you want the best literature out there you need a Database that will systematically help you to find quality articles that fit your topic.

PubMed.gov is a tax funded database that is highly comprehensive.  CINAHL is strong on nursing literature.  If you are enrolled in a university, you have access to lots of full-text articles at no added cost.  Check with your librarian if your database search is not turning up what you need–with a few hints, you could get the best.

Needle in haystackFor more info:  Look for that needle in the haystack.

True or False: Experiment or Not

Experiments are the way that we confirm that one thing causes another.   If the study is not an experiment (or combined experiments in a meta-analysis), then the research does not show cause and effect. imagesCALQ0QK9

Experiments are one of the strongest types of research.

So…how can you tell a true experiment from other studies?   Hazel B can tell you in 4:04 and simple language at https://www.youtube.com/watch?v=x2i-MrwdTqI&index=1&list=PL7A7F67C6B94EB97E

Go for it!

[After watching video:  Note that the variable that is controlled by the researcher is call the Independent variable or Cause variable because it creates a change in something else. That something else that changes is the Dependent variable or Outcome variable.]Learning

CRITICAL THINKING:  

  1. Based on the video, can you explain why true experiments are often called randomized controlled trial (RCT)?
  2. Take a look at The Effect of the Physical and Mental Exercises During Hemodialysis on Fatigue: A Controlled Clinical Trial, that is free in full-text via PubMed. How does it meet the criteria of a true experiment as described by Hazel B in the video?

FOR MORE INFORMATION:   Go to “What’s an RCT Anyway?” (https://discoveringyourinnerscientist.wordpress.com/2015/01/23/whats-a-randomized-controlled-trial/ )

“So much to read! So little time!” Literature Review How-To.

.


So much to read!!   So little time!!swirly clock.jpg

Here are some hints on how to get and put together literature on a problem that is “bugging” you!

  1. KEYUse key words to search PubMed or CINAHL especially.
  2. Select article titles or abstracts that have been published in the last 3-5 years and seem most on target with your topic. (Don’t be distracted by interesting, but irrelevant articles. Also, sometimes there are ‘classic’ articles published earlier, and you may need to get some advice on whether something is classic.)TOPIC candybar
  3. Get copies of the articles most relevant to your topic
  4. Divide the articles into two stacks:
    • Research studies – You can often identify these because they will say they are research or you will find sections in the articles with some of these titles: Introduction/Background, Methods/Procedures, Results/Findings, Discussion, Implications, and Conclusion
    • NON-research articles – These may cite a lot of other authors in describing an issue
  5. Read the NON-research articles first. Determine whether the articles are citing experts or the author is just giving you their own opinion.  Of course the ones citing experts are stronger.idea lightbulb
  6. Highlight or underline the key ideas or issues that are raised in those articles. Pay attention to where the authors Agree or Disagree.
  7. Now read the research articles and highlight key ideas & issues.
  8. Place articles in order from stronger to weaker research:
    • Stronger research articles are randomized controlled trials and meta-analyses
    • Next strongest are experiments without randomization or a control group (sometimes called quasi-experimental or sometimes pre/posttest surveys)
    • Next strongest are studies that show association or correlation between two variables.
    • And finally last are those studies that just describe something. The authors didn’t do any intervention and they are not trying to relate one variable to another.   These are called descriptive studies and the description may be a list of themes or it may be in numbers.  Meta-synthesis articles fall into this category.SanDiegoCityCollegeLearningResource_-_bookshelf
  9. You can create a table of evidence that can help you to sort out key ideas and strength of research studies.  (A sample is at http://guides.lib.unc.edu/ebpt-home/ebpt-pointers-evidence
  10. If you are writing a summary of literature, you should now be able to have a paragraph on each of the main ideas raised in the literature and to cite the sources of those ideas. If various authors disagree, be sure to present both sides of the issue.

QUESTIONCritical thinking: What is something in nursing that has been “bugging” you.  Missed care–e.g., inability to get all the tasks done on time?  Or discharge med teaching?  Or the
difficult colleague?   Go to PubMed and find a research and a non-research article.  Pick out the key ideas in each.  What did you learn?

For more information check out:  Finding the needles in the haystacks: Evidence hunting efficiently & effectively.

 

Self-Report Data: “To use or not to use. That is the question.”

[Note: The following was inspired by and benefited from Rob Hoskin’s post at http://www.sciencebrainwaves.com/the-dangers-of-self-report/]Penguins

If you want to know what someone thinks or feels, you ask them, right?

The same is true in research, but it is good to know the pros and cons of using the “self-report method” of collecting data in order to answer a research question.  Most often self-report is done in ‘paper & pencil’ or SurveyMonkey form, but it can be done by interview.

Generally self-report is easy and inexpensive, and sometimes facilitates research that might otherwise be impossible.  To answer well, respondents must be honest, have insight into themselves, and understand the questions.  Self-report is an important tool in much behavioral research.

But, using self-report to answer a research question does have its limits. People may tend to answer in ways that make themselves look good (social desirability bias), agree with whatever is presented (social acquiescence bias), or answer in either extreme terms (extreme response set bias) or always pick the non-commital middle Hypothesisnumbers.  Another problem will occur if the reliability  and validity of the self-report questionnaire is not established.  (Reliability is consistency in measurement and validity is the accuracy of measuring what it purports to measure.) Additionally, self-reports typically provide only a)ordinal level data, such as on a 1-to-5 scale, b) nominal data, such as on a yes/no scale, or c) qualitative descriptions in words without categories or numbers.  (Ordinal data=scores are in order with some numbers higher than others, and nominal data = categories. Statistical calculations are limited for both and not possible for qualitative data unless the researcher counts themes or words that recur.)

Gold_BarsAn example of a self-report measure that we regard as a gold standard for clinical and research data = 0-10 pain scale score.   An example of a self-report measure that might be useful but less preferred is a self-assessment of knowledge (e.g., How strong on a 1-5 scale is your knowledge of arterial blood gas interpretation?)  The use of it for knowledge can be okay as long as everyone understands that it is perceived level of knowledge.

Critical Thinking: What was the research question in this study? Malaria et al. (2016) Pain assessment in elderly with behavioral and psychological symptoms of dementia. Journal of Alzheimer’s Disease as posted on PubMed.gov questionat http://www.ncbi.nlm.nih.gov/pubmed/26757042 with link to full text.  How did the authors use self-report to answer their research question?  Do you see any of the above strengths & weaknesses in their use?

For more information: Be sure to check out Rob Hoskins blog: http://www.sciencebrainwaves.com/the-dangers-of-self-report/

 

 

Consistency wins! High reliability= Zero harm

priority“What’s important is not where an organization begins its patient safety journey, but instead the degree to which it exhibits a relentless commitment to improvement.” – TJC, 2016, p.68

The path to zero harm, according to TJC, begins with high reliability.   Reliability in research = consistency.  TJC says for zero harm we as providers must be consistent in these ways:

  • Never be satisfied with your safety record. Always be alert for danger
  • Be alert for early signs of potential danger. Don’t oversimplify your observations
  • Note small changes in the organization as having longer range or unintended effects
  • Commit to resilience so that when errors do happen, you bounce back quickly
  • When confronted by a threat, put its resolution in the hands of those with the most expertise in that area

Using evidence in practice can be part of our “relentless commitment to improvement,” especially when coupled with above 5 actions and can support zero harm to patients.   That evidence can be from research, from process improvement, from evaluation of clinical innovations, or from experts.

For more read TJC’s High Reliability: The Path to Zero Harm online at http://www.jointcommission.org/assets/1/18/HC_Exec_article.pdf  

Telling the Future: The Research Hypothesis

What is a research hypothesis?   A research hypothesis is a predicted answer; an educated guess.  It is a statement of the outcome that a researcher expects to find in an experimental study.Hypothesis

Why care?  Because it tells you precisely the problem that the research study is about!  Either the researcher’s prediction turns out to be true (supported by data) or not!
A hypothesis includes 3 key elements: 1) the population of interest, 2) the experimental treatment, & 3) the outcome expected.  It is a statement of cause and effect. The experimental treatment that the researcher manipulates is called the independent or cause variable.  The result of the study is an outcome that is called the dependent variable because it depends on the independent/cause variable.

For example, let’s take the hypothesis “Heart failure patients who receive exmeds2perimental drug X will have better cardiac function than will heart failure patients who receive standard drug Y.”  You can see that the researcher is manipulating the drug (independent variable) that patients will receive.  And patient cardiac outcomes are expected to vary—in fact cardiac function is expected to be better—for patients who receive the experimental drug X.

Ideally that researcher will randomly assign subjects to an experimental group that receives drug X and a control group that receives standard therapy drug Y.   Outcome cardiac function data will be collected and analyzed to see if the researcher’s predicted answer (AKA hypothesis) is true.

In a research article, the hypothesis is usually stated right at the end of the introduction or background section.

If you see a hypothesis, how can you tell what is the independent/cause variable and the dependent/effect/outcome variable?question   1st – Identify the population in the hypothesis—the population does not vary (& so, it is not a variable).   2nd – Identify the independent variable–This will be the one that is the cause & it will vary.  3rd – Identify the dependent variable–This will be the one that is the outcome & its variation depends on changes/variation in the independent variable.

PRACTICE:  What are the population, independent variable(s) & dependent variable(s) in these actual research study titles that reflect the research hypotheses:

FOR MORE INFORMATION:  See SlideShare by Domocmat (n.d.) Formulating hypothesis at http://www.slideshare.net/kharr/formulating-hypothesis-cld-handout