Category Archives: Professional Nursing

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

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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.

 

Is a Picture Worth 1,000 words?

Sometimes the best way to answer a research question is to have the participants draw pictures & explain them.  In fact, some have identified art as a powerful communication tool between children and researchers.   The pictures are then analyzed for themes that show up in the drawings.  No numbers or statistics are used.

Methods: When Brady (2009) wondered how children defined a “good nurse,” she asked 22 ethnically diverse, hospitalized girls and boys aged 7-12 years to draw a picture of a good nurse and a bad nurse.  After the children drew their pictures she asked them to tell her what the nurse was wearing and doing.

Results & discussion: What did the pictures say? Drawings and comments suggested that the children focused on these 5 thematic characteristics for a good nurse:  “communication; professional competence; safety; professional appearance; and virtues,” (p.543) such as honesty, listening, kindness, trustworthiness, & being reassuring & fun. 11-year-old Jason communicated some of it in GoodNurse_BadNurse2Figure 4 on page 552.   12-year-old Luke also showed a sharp contrast in Figure 7 on page 556 that is at the top of this blog.  Children valued a reciprocal relationship with their nurses, caring, and safe/professional behavior. Play was one of many things important to them.

Commentary: While the sample is not representative of a larger group and I would question the authors claim to use grounded theory, the study forms the basis for further research.  Additionally these ideas can help us listen more closely to our own pediatric patients.   It would be particularly interesting to compare these 5 themes to how adult patients of various ages describe a good nurse and a bad nurse.

Critical thinking:  How do you think these children’s perspectives compare with the perspectives of your own pediatric patient population?QUESTION

For more information: See Brady, M. (2009). Hospitalized children’s views of the good nurse, Nursing Ethics, 16(5). doi: 10.1177/0969733009106648

“Smile (or not). You’re on candid camera!” Patients’ covertly recording care

“What might happen if patients were to use digital devices such as smartphones to covertly record clinical encounters? Increasing reports of the practice of patient’s covertly recording clinical encounters suggest that these are no longer hypothetical questions.”(Tsulukidze et al, 2015).iphone camera2

Researchers in 2015 search Google & Google blog search engines to find written texts (excluding audio & video recordings) that were about patient covert recording of clinical encounters. They analyzed 62 texts from patients, clinicians, advocates, dentists, insurers, and lawyers. Four(4) themes emerged that represented the groups’ reactions.

  1. Such recording is a new behavior eliciting strong positive and negative reactions.  Comment –
    • e.g., “accept the prospect of covert recording as a product of the digital age and ensure that it does not work against you [clinicians]” (Contributor 3, editor, T40)
  2. Covert recording shows a lack of patient trust in providers or the system 
    • e.g.,…ALWAYS record EVERYTHING. These people [physicians] can lie, cheat and steal and act immorallyand do so regularly. (Contributor 13, T36)
  3. Through recording patients were asserting new control over and ownership of the clinical encounters.
    • e.g., When a patient seeks a consultation […], the information being processed is almost exclusively relating to the patient. Under the Data Protection Act, that data is therefore personal to the patient. By recording it, that patient is merely viewed as processing their own data. (Contributor 15, dental adviser, T42)
  4. Responses were confused & conflicting, with patients & providers seeking legal and ethical counsel about the recordings.
    • e.g., Would any of the practicing physicians here remove a patient from their care if you found out your patient was secretly recording you? (Contributor 22, physician, T30)   (Tsulukidze et al)

lightbuld among rocksCOMMENTARY: As with all qualitative studies, the value is on getting new, in-depth information on something that we know very little about, and their sample represented diverse perspectives.  A weakness is that the researchers used existing documents so that researchers couldn’t explore further and were limited to what these particular individuals chose to put out on a public site. Because RNs were not included, a parallel study of covert recording of RNs would be valuable.  RN-patient encounters are necessarily different from physician-patient encounters, and RNs have been rated by the public as the most trusted profession year after year in Gallup polls. I am unaware if anyone  knows the who, what, when, where, why, and how of covert recording of RNs.  Nonetheless, RNs should examine whether they would be comfortable with being recorded because we know that privacy standards, patient empowerment, and the proliferation of recording devices have changed.

CRITICAL THINKINGImagine that your most recent patient encounter had been recorded.  Clinically would you have done anything differently?  Ethically do you consider this right and good or wrong and bad?  Why?  Legally does your facility have and enforce policies/standards related to patients’ recording?   Whom in your facility would you go to for advice if you learned this was happening?  What are related patient privacy issues?  Should we fight against patients’ recording or assume that it will happen and find ways to make it work in provider/facility interests?  How would we do that?question

FOR MORE INFO: The FREE  full text is available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416897/   Tsulukidze, et al., (2015,  May 1).Patients Covertly Recording Clinical Encounters: Threat or Opportunity? A Qualitative Analysis of Online Texts. PLoS One. 2015; 10(5): e0125824.

Stand & Deliver: Evidence for Empathy in Action

Patient Pain Satisfaction.  It’s a key outcome of RN empathy in action.CARE

Imagine that you are hospitalized and hurting.   During hourly rounds the RN reassures you with these words:We are going to do everything that we can to help keep your pain under control. Your pain management is our number 1 priority. Given your [condition, history, diagnosis, status], we may not be able to keep your pain level at zero. However, we will work very hard with you to keep you as comfortable as possible.” (Alaloul et al, 2015, p. 323).

Study? In 2015 a set of researchers tested effectiveness of the above pain script using 2 similar medical-surgical units in an academic medical center—1 unit was an experimental unit & 1 was a control unit.  RNs rounded hourly on both units.  handsOn the experimental unit RNs stated the script to patients exactly as written and on room whiteboards posted the script, last pain med & pain scores.  Posters of the script were also posted on the unit.   In contrast, on the control unit RN communication and use of whiteboard were dependent on individual preferences.  Researchers measured effectiveness of the script by collecting HCAHPS scores 2 times before RNs began using the script (a baseline pretest) and then 5 times during and after RNs began using it (a posttest) on both units.

Results? On the experimental units significantly more patients reported that the team was doing everything they could to control pain and that the pain was well-controlled (p≤.05). And while experimental unit scores were trending up, control unit scores trended down. Other findings were that the RNs were satisfied with the script, and that RNs having a BSN or MSN had no effect.

Conclusions/Implications?When nurses used clear and consistent communication with patients in pain, a positive effect was seen in patient satisfaction with pain management over time. This intervention was simple and effective. It could be replicated in a variety of health care organizations.” (p.321) [underline added]

Commentary: While an experiment would have created greater confidence that the script caused the improvements in patient satisfaction, an experiment would have been difficult or impossible.  Researchers could not randomly assign patients to experimental & control units.  Still, quasi-experimental research is relatively strong evidence, but it leaves the door open that something besides the script caused the improvements in HCAHPS scores.

questionCritical thinking? What would prevent you from adopting or adapting this script in your own personal practice tomorrow?  What are the barriers and facilitators to getting other RNs on your unit to adopt this script, including using whiteboards?  Are there any risks to using the script?  What are the risks to NOT using the script?

Want more info? See original reference – Alaloul, F., Williams, K., Myers, J., Jones, K.D., & Logsdon, M.C. (2015).Impact of a script-based communication intervention on patient satisfaction with pain management. Pain Management Nursing, 16(3), 321-327. http://dx.doi.org/10.1016/j.pmn.2014.08.008

Don’t Just Wish Upon Falling Stars: Take Evidence-based Action

The Joint Commission (TJC) published, Preventing falls and fall-related injuries in health care facilities, a new Sentinel Alert #55 on September 28, 2015 at http://www.jointcommission.org/assets/1/18/SEA_55.pdf

What’s the problem? Falls with serious injuries are among the top 10 events reported to TJC.   Analysis of that data shows that contributing factors are related to:

  • Inadequate assessment
  • Communication failures
  • Lack of adherence to protocols and safety practices
  • Inadequate staff orientation, supervision, staffing levels or skill mix
  • Deficiencies in the physical environment
  • Lack of leadership (page 1)

What to do?   Here are TJC recommendationsAction Plan

  1. Raise awareness of falls resulting in injury
  2. Establish an interprofessional falls committee
  3. Use a reliable, valid risk assessment tool
  4. Use EBP
    1. Standardized handoff including risk for falls
    2. One-to-one, bedside education of patients (& families?)
  5. Conduct post-fall management, which includes: a post-fall huddle; a system of honest, transparent reporting; trending and analysis of falls which can inform improvement efforts; and reassess the patient (page 2)

questionCritical thinking:  How would you apply AHRQ toolkit: Preventing Falls in Hospitals to your unit.

Want more info?   For tools, resources, & more details on above, see Joint Commission (2015, September 28). Preventing falls and fall-related injuries in health care facilities, Sentinel Event Alert, Issue 55.  Retrieved from Joint http://www.jointcommission.org/assets/1/18/SEA_55.pdf

Introduction to Introductions!

I have a lot of new readers, so let’s revisit the standard sections of a research article.  They are:

  • Introduction (or Background)
  • Review of literature
  • Methods
  • Results (or findings)
  • Discussion & Implications
  • Conclusion

If we begin at the beginning, then we should ask: “What’s in an Introduction?”  Here’s the answer:

“[a] …Background of the problem or issue being examined,

[b] …Existing literature on the subject, and

[c] …Research questions, objectives, and possibly hypothesis” (p. 6, Davies & Logan, 2012)

This is the very 1st section of the body of the research article.  In it you will find a description of the problem that the researcher is studying, why the problem is a priority, and sometimes what is already known about the problem.  The description of what is already known may or may not be labelled separately as a Review of Literature.

KEYKey point #1: Articles & research that are reviewed in the Intro/Background should be mostly within the past 5-7 years.  Sometimes included are classic works that may be much older OR sometimes no recent research exists.   If recent articles aren’t used, this should raise some questions in your mind.   You know well that healthcare changes all the time!!  If there are no recent studies the author should explain.

KEY
Key point #2The last sentence or two in the Intro/Background is the research question or hypothesis.  If you need to know the research question/hypothesis right away, you can skip straight to the end of the Intro/background—and there it should be!

Happy research reading!

Critical Thinking: Do the sections of the abstract AND the sections of the research article match above headings?  Does it match the description of Introduction? Take a look at the free article by Kennedy et al. (2014). Is there a relationship between personality and choice of nursing specialty: An integrative literature, BMC Nursing, 13(40). Retrieved from the link http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267136/.  question

 

A 33,000 foot view: The Abstract

 Abstracts are great; abstracts are not enough!
An abstract will not give you enough information to accurately apply the study findings to practice.   An abstract typically summarizes all the other sections of the article, such as  the question the researcher wanted to answer, how the researcher collected data to answer it, and what that data showed.  This is great when you are trying to get the general picture, but you should Never assume that the abstract tells you what you need to know.
airplaneWingIsland
Abstracts can mislead you IF you do not read the rest of the article.  They are only a short 100-200 words and so the authors have to leave out key information.   You may misunderstand study results if you read only the abstract.   An abstract’s 33,000 foot level FootprintsInSand
description of a study, cannot reveal the same things that you can learn from an up-close look at details.  You want to know exactly who was in the study, exactly what the researcher did, & exactly how outcomes were measured!  You want to follow the researcher’s footprints up close, not just do a fly-over.
So…what is the takeaway?  Definitely read the abstract to get the general idea.  Then read the article beginning to end.  Don’t give up reading the full article just because some parts of the study may be hard to understand.  Just read and get what you can. Then try a re-read or get some help understanding any difficult sections.   This is an important step toward EBP.   [revised from my former blogsite]
Critical thinking:  What info is missing from this abstract at this link that you would want to know before using the findings of this pain study to practice?
http://www.ncbi.nlm.nih.gov/pubmed/25659796QUESTION

Finding the Needles in the Haystacks: Evidence Hunting Efficiently & Effectively

Searching for the right evidence is an art & a science.   In an effective search, the RN: twoOnComputer

  1. Identifies excellent key words based on a clear problem statement
  2. Systematically searches the best databases for those words
  3. Keeps a record of the search strategy.

This is actually a pretty simple time-saver because it keeps you from having to repeat searches because you can’t remember where you looked!!

Let’s take an example that we used previously.  Here’s how it was laid out in PICO (which stands for Population/problem, Intervention, Comparison intervention, & Outcome)

  • Population/problem= Postoperative patients with ileus (Patient population &Problem)
  • Intervention= Gum chewing postop (Intervention to try out)
  • Comparison intervention= NPO with gradual diet progression when bowel sounds start returning
  • Outcome= Reduce time of postop ileus with sooner return to nutritious eating

We would:magnifyingGlass

  1. Using PICO, identify key concepts (words), such as “postoperative ileus” “gum chewing” and “NPO.” Note that you can pick single words or combinations of words.
  2. Search for this set of words in the very comprehensive databases of PubMed and also in CINAHL. CINAHL is more nursing specific, and PubMed is one of the most comprehensive out there. Search from MOST RECENT to earlier.  Go for only most recent 5 years unless 5 years doesn’t give you enough articles.
  3. Keep notes of exactly which words and phrases you used to search each database

This 5 minute video shows you a GREAT way to make sure that your search is complete with minimal effort. It’s an easy-peasy tracking strategy for where you’ve already looked. https://www.youtube.com/watch?v=233DzkmimV4&list=PLE3A977BE32CF3956

CRITICAL THINKING: What are the key words of your clinical problem of interest.  (You can choose to use PICO or not.)  Plug them into PubMed.  Did you get enough articles?QUESTION

“The Sky is Falling!” (or Don’t be an EBP Chicken Little)

We all know the story of Chicken Little, right?  Chicken Little is walking through the forest, an acorn falls and hits her on the head, then Chicken Little  runs about in a panic telling everyone, “The sky is falling! The sky is falling!” A lot of the animals are convinced, and the fox—who knows the truth that it was only an acorn—convinces Chicken Little & some other animals to come into his den to be safe from the falling sky. There he eats them. Interestingly the fox used the correct evidence well. Chicken Little & fox chicken littlecompany used evidence poorly and created a safety hazard for themselves!

Moral of the story? Don’t be a Chicken Little when it comes to reading and applying research to practice. Get all the facts before you share the research findings with others. Don’t read only the “acorn” of abstract, introduction, and discussion, and then assume that you know what the research study shows and that you can apply it to your work. Don’t turn an acorn into a falling sky!

How to avoid being an EBP Chicken Little? To avoid being an Evidence-Based Practice (EBP) Chicken Little, you should follow the example of Samantha in this research fairy tale: “Samantha…read the study abstract. Then, while Chicken Little and her friends waited anxiously, she read the introduction, the literature review, the research questions, the methods section, the findings, and the discussion section. Then she went back and read all the sections again. Finally, as Chicken Little hopped around her impatiently, she reread the findings. “Chicken Little, have you and your friends read the entire study?” asked Samantha.” (source: https://www.son.rochester.edu/student-resources/research-fables/chicken-little.html)

Why go to all this trouble? I’m busy. The reasons to take time and effort to read the WHOLE study are many. First, the subjects may not be at all like your own patient population—what if the researchers studied only “left-pawed albino hamsters”? Second, the research might not be a strong meta-analysis or randomized controlled trial whose results can actually be applied to other times and places—what if the researchers just watched subjects walk around, but didn’t test what makes them walk better?  A third reason is that the results might be statistically significant, but clinically irrelevant!—what if researchers were studying pain, but everyone in the study had 1-2 on the pain scale?

You don’t want to endanger patient safety by misunderstanding and misapplying research and then be “eaten alive” by adverse patient outcomes or by critics, who will see through your mistakes. Remember in the fairy tale Chicken Little and his careless friends misunderstood the facts, and hence were susceptible to being eaten by a fox.

What if you don’t know how to read research? No problem. Everyone who knows how to read research now had to learn it—no one was born knowing.  So,…you can learn it, too!  It doesn’t take magical powers.  Countless resources are online; others are in your hospital or in a university research course. If you check the box on this page to follow the EBP blog, (I hope) it will help, too. Go back and read earlier blogs on sections of a research report.

For more information on how to be an EBP Chicken Little (NOT) see the very creative research fairy tale by Jeanne Grace (copyright Rochester College) at https://www.son.rochester.edu/student-resources/research-fables/chicken-little.html

Critical thinking:

  1. After reading Grace’s fairy tale at the above link list at least three (3) things that Chicken Little might have learned, had she read the whole article!
  2. Compare an abstract with a full article, and check out the differences. Specifically compare the abstract at  http://www.ncbi.nlm.nih.gov/pubmed/2606078 with what you learn about them from the full article at http://www.ncbi.nlm.http://www.ncbi.nlm.nih.gov/pubmed/2606078nih.gov/pmc/articles/PMC4449996/. Did reading the whole article change the way you understand how orQUESTION whether the study might apply to your work? If so, how? And if not, why not?

Ask King Charles II: “Why do we need evidence-based practice?”

Want to know the value of evidence in practice?  You might ask King Charles II (or at least his physicians who survived him).   Check out what happens when much of the evidence for practice was based on tradition & experts: https://www.youtube.com/watch?v=OeA_OKqqBJ4 (5:27).

Everyone agrees…..patients deserve the best care we can give now, even though we won’t know everything about anything until we know everything about everything (RCH personal communication)

Critical thinking:  What is one practice that you learned in nursing school, that has already changed?   Why did it change?QUESTION

For some evidence that you can probably put to use right away to give patient-centered, family-centered care, check out this user friendly summary from UCSD! https://www.youtube.com/watch?v=Q_hs-uNBdPQ (4:48)