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Evidence based nursing, Professional Nursing, tjc, Uncategorized

Who ya gonna call? Myth Busters!!

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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!

Evidence based nursing, Grounded theory, pain assessment, Pain management, Qualitative research, Uncategorized

Afraid to Relieve Pain? You may have Opiophobia

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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!!

Evidence based nursing, pain assessment, Pain management, Pain script, Uncategorized

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

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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.

 

 

Disseminating findings, Evidence based nursing, Poster presentation, Professional Nursing, Uncategorized

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

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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

 

Evidence based nursing, Literature review, Professional Nursing, reading research, Uncategorized

“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.

 

Evidence based nursing, RCT, reading research, Research design, Uncategorized

Telling the Future: The Research Hypothesis

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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

 

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“I wonder as I wander…. ” DNP or PhD? What’s the diff?

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Ever wonder what the difference is between the new Doctorate of Nursing Practice (DNP) and the Doctorate of Philosophy in nursing (PhD)?      examine baby

In short the focus of PhD education is to prepare the RN to create original research.  In contrast, DNP education is to prepare the RN to apply existing research to nursing practice.

Being a nurse practitioner (NP) is NOT the difference.  Also while some PhDs become skilled in applying research to practice & some DNPs do research,…their doctoral course preparation & final projects are quite different!

For more information:  Here’s a great comparison chart from one doctoral program:  https://nursingandhealth.asu.edu/degree-programs/doctoral-vs-phd-degrees-at-asu

Critical reflection: Based on your own personal career goals….questionIf you were to return for a doctorate, which would you find most useful?

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“Is it?” “It is!” Expert opinion as valuable evidence for practice.

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“Is it?” “It is!” Expert opinion as valuable evidence for practice..

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“I like my coffee (and my evidence) strong!”

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Let’s say you are still working to solve the issue of whether gum chewing reduces post-operative ileus. You identified titles of all relevant articles using PubMed database (http://www.ncbi.nlm.nih.gov/pubmed), and had the librarian pull the full articles for you.

Now you find yourself looking at a formidable stack of articles on the topic. You are sure that some are probably better quality than coffee2others, but how can you tell?

Professionals have agreed on which types of evidence are strongest. Here’s one well-accepted hierarchy form strongest #1 to weakest #6 (Melnyk & Fineout-Overholt, 2005).

  1. Systematic reviews, Meta-analyses, or Evidence-based clinical practice guidelines based on systematic review of RCTs
  2. Randomized controlled trial
  3. Controlled trials without randomization
  4. Case controlled or cohort studies
  5. Systematic review of descriptive studies
  6. Single descriptive or qualitative study
  7. Expert opinion of individuals or committees

Number 1= Strongest.   Number 6=Weakest

When you are trying to solve a problem, FIRST look for the three (3) types of evidence that are the very strongest (#1). These are:

  1. Systematic reviews that are summaries of research findings from many studies;
  2. Meta-analyses that are summaries of research findings in which the data from those other studies are combined into one big study;
  3. Evidence-based clinical practice guidelines that are clinical recommendations based on a summary of research and other evidence. An expert panel has often agreed on the summary and recommendations.

Your next strongest option, #2, is at least one randomized controlled trial (RCT). In an RCT a group of subjects is randomly separated into at least two groups. One group gets the experimental treatment—whether it is a drug or teaching plan or something else—and the other group usually gets standard treatment or a placebo. Then the group outcomes are compared statistically to see which did better.

Usually the title or first few lines of the article will tell you that the article is a systematic review, a meta-analysis, an evidence-based clinical practice guideline, or an RCT. Rarely is this left a mystery! (Never assume that a research study article is strong just because you LIKE the findings, or that it is weak because you DON’T like the findings.)

I’ll comment on other levels of evidence soon, but let’s focus on the strongest types first. Try the critical thinking for practicing the ideas above.

Critical Thinking:  Using the article titles below, rank these three (3) research studies in order from Strongest evidence to Weakest evidence:

Want to read more?  A good summary of one hierarchy is and why it’s important is at this 5 minute youtube video: https://www.youtube.com/watch?v=5H8w68sr0u8 . While that hierarchy does not precisely match the one above, the video still has lots of good information.

 

 

Uncategorized

If The (EBP Practice Guideline) Shoe Fits, Wear It! Definitely!

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If you want to solve a priority clinical problem using the best research evidence out there, you & your team have at least a couple of options:

1) You can DIY (do it yourself), which means finding, critiquing, synthesizing, and translating the research into clinical practice recommendations: OR

2) You can take advantage of experts’ work by finding evidence-based clinical practice guidelines that you can simply adopt or adapt to your setting.

Either option is good, but in this post I want to focus on option #2: Evidence-based practice guidelines.

What are practice guidelines?  Clinical practice guidelines are “systematically developed statements” that help RNs, other providers, and patients to decide on the best course of care. When the guideline authors use research to write them, then we call them evidence-based practice guidelines (http://www.agreetrust.org/resource-centre/practice-guidelines/).

What’s the advantage?  In evidence-based practice guidelines, experts have already done the hard work of finding, critiquing, synthesizing, and translating the research into practice recommendations for you.   You need only to adopt or adapt them to fit your setting, and establish a regular review time to make sure they are supporting excellent care and still in date.

Where can you find EBP practice guidelines to adopt or adapt?  A few places are:

Consider “bookmarking” these sites or adding them to your “favorites” in your internet browser.

You may even find multiple guidelines on your subject.  Then you and your team get to choose the one that BEST fits your setting & solves the clinical problem!  How cool is that?  (Note: The gold standard for critiquing guideline quality is the AGREE II tool, but ….more on that another day.)

Critical thinking exercise

  1. Go to National Guidelines Clearinghouse.
  2. Search for “family presence during resuscitation”
  3. Look at the ENA clinical practice recommendations on that page and see how strong the evidence is to support each one. (You can also take a look at the process of guideline development & the research used to support it.)
  4. Then decide how might you adopt or adapt one of those recommendations in your own setting?
  5. Have an informal conversation with a colleague about your thoughts on this.

If you can use one or more of the recommendations, you have now brought more research evidence into your practice.  Congratulations!!