Tag Archives: evidence based practice

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

 

Literature review, reading research

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

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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.

experiment, RCT, reading research, Research design

True or False: Experiment or Not

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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/ )

Data, Data collection, Evidence based nursing, Questionnaires, reading research

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

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[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/

 

 

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

 

content analysis, Evidence based nursing, Professional Nursing, qualitative, recording

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

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“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 immorally…and 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 THINKING: Imagine 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.

Evidence based nursing, nonrandom trials, Pain management, Pain script, Professional Nursing, reading research

Stand & Deliver: Evidence for Empathy in Action

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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

Evidence based nursing, Literature review, nonrandom trials, reading research

“Oh Baby!” Evidence-based Naming Prevents Events

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EBP Preventive Action:  Evidence-based, distinct infant naming can avoid sentinel events related to misidentification of newborns (TJC, 2015).

Problem:  Misidentification errors of NICU babies are common newborn3(Gray et al., 2006).   About 12% of the 4 million born in U.S. hospitals were admitted to NICU’s.  At birth every infant requires quick application of an armband, and when parents have not yet decided on a name the assigned name is often quite nondistinct (e.g., BabySmith).


Evidence: A pretest/posttest of a new, more infant-specific naming system was “conducted in order to examine the effect of a distinct naming convention that incorporates the mother’s first name into the newborn’s first name (e.g., Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient within the next 10 minutes” (Adelman et al., 2013). newborn2Their results? RAR events were reduced by 36.3%.   Their recommendations? Switch to a distinct naming system.

Using something like Judysgirl Smith is infant specific. “In the case of multiple births, the hospital adds a number in front of the mother’s first name (ex: 1Judysgirl and 2Judysgirl)” (TJC).

TJC recommends:

  • “Stop using Babyboy or Babygirl as part of the temporary name.
  • Change to a more distinct naming convention.
  • Train staff on the distinct naming convention.
  • Follow the recommendation in National Patient Safety Goal 01.01.01 and implement use of two patient identifiers at all times.
  • As soon as parents decide on their baby’s name, enter that name into the medical record instead of the temporary name.”

Commentary: While this is just one study, RNs should evaluate whether it is riskier to continue any current practice of non-distinct naming or to switch practices to distinct naming. No risks were identified to the distinct naming system & it likely requires only the resource investment of educating staff.  Adelman et al.’s (2013) study is current, moderately strong, quasi-experimental evidence that showed a significant decrease in errors that could have sentinel event outcomes. Any who make the switch should monitor outcomes. All who don’t make the switch should, too!

Critical Thinking: Examine the risks, resources, & readiness of staff in your facility to make the switch to a distinct NICU infant naming system?  question Should the naming system be extended to all infants?

Want more information?  See