1. Clinical Inquiry at the Bedside: Using PICO
Donna Felber Neff, RN, PhD, DSNAP
Associate Professor of Nursing

2. Objectives Discuss barriers to conducting clinical research
Asking the ‘question’
Using a PICO question
What’s Next?
Sharing examples
What’s Next? Some final helpful(?) points

3. What are the barriers? Time. Is this a proxy term? In FACT:
Lack of approval by colleagues
Lack of interest
Lack of support from administration
In FACT:
Administrative & collegial support may be MORE important than workload demands on time!*
Nurses consistently report lack of time as a significant barrier to clinical research and research utilization
Is this the real problem OR is time a proxy for other issues that the clinical nurse faces?
Administrative and collegial was found to be a more important is more important than workload demands on time.
Estabrooks et al., 2004; Tyden, 1996

4. Conceptual Map of Busyness*
EFFECTS
Reduced research use
Sacrifice of personal time
Inability to use or find resources
OBJECTIVE
SUBJECTIVE
Organizational Cultural
factors
Interpersonal factors
Environmental
Intrapersonal factors
Physical
busyness
Thompson et al conducted a secondary analysis of qualitative data to create a conceptual map of busyness in nursing .
Busyness is based on the nurses’ perception of pressure created by a situation where there is a shortage of time to accomplish valued work and often results in reduced energy.
Cultural factors that influence busyness:
no retreat or protected time
management/administration support
Interpersonal factors:
difficult family/patient
support staff
preceptoring
interruptions – call bells, other professionals
Intrapersonal factors
personal life – family, education
personal attributes time/organizational skills
experience/confidence levels
coping ability unwilling to share work
Environmental factors
High activities on the unit
patient workload number and acuity
nursing shortage
non-nursing tasks
organizational change
busywork – outdated policy and procedure
restricted resources - medications, equipment, beds, nurse educators
management/administration
BUSYNESS
Psychological pressure
* Thompson et al., 2008

5. Effects of busyness – Reduced clinical inquiry and research utilization
Sacrifice of personal time
Inability to find or use resources
Missed opportunities
Inservices, meetings
Professional development
Compromised safety
Incomplete nursing care
Emotional and physical strain
EACH OF THESE FACTORS, ALONE OR COMBINED LEAD TO EFFECTS OF REDUCED RESEARCH INQUIRY AND UTILIZATION, MISSED OPPORTUNITIES AND INCOMPLETE NURSING CARE.
For example:
Researchers found that workload and time prevented nurses from attending meetings/inservices
Incomplete nursing care included some routine tasks or treatment being missed, unable to provide satisfactory care

6. Organizational factors:
Creation of a Culture of Learning
Learning is a key part of the mission and goals
Eliminate structural obstacle for learning
Individuals empowered to achieve
Transformation Leadership
Define a vision
Provide a meaningful work environment
Contribute indirectly to improving quality of care1, and greater staff and patient satisfaction2
Employees encouraged to challenge the status quo3
Resources – e.g. financial
I know I am preaching to the choir – These factors are key organizational factors that influence both clinical inquiry at the bedside and research utilization.
To create a culture of learning an organization must hold learning as a key component of their mission and goals
These organizations are receptive cultures, eliminate structural obstacles for learning and individuals are empowered to achieve.
The culture of learning is strongly influence by those in leadership positions.
Transformational leaders define a vision, and provide a meaningful work environment.
Studies have found that transformational leadership contributed indirectly to improving quality of care, and greater employee and patient satisfaction (Doran, 2004). Employees are also encouraged to challenge the status quo (Bass & Avolio, 1994).
Stodeur et al. 2000
Doran, 2004
Bass & Avolio, 1994

7. Are we asking WHY?
Did we identify a ‘problem’ in the practice setting?
By we I mean, bedside clinicians, management, administration and nurse researchers?
Organizational
Process
Outcomes
Can we identify the root of the problem? Does it originate at the organizational level? Is it a problem with the way care is delivered? Is it something we see everyday? Did we identify adverse outcomes?

8. What do we do next?
Develop a PICO Question

9. PICO Question
P Problem/population I Intervention of interest C Comparison O Outcome

10. Simultaneously conduct the review of literature: Like Finding a Needle in a haystack!!!

11. Literature Review
Does the evidence exist?
If not, what do you do?

13. Planning Who are the people who need to be at this table?
This is team work – not a one person job!
Examine clinical question
Group brainstorming before you jump into the haystack of information
More formal protocol development
Process that can be lengthy

14. Organization Buy-in Recruit a champion(s)
Initially run ideas by direct supervisor - usually the unit manager
Good to come with ideas as a team with a brief summary
Keep physicians and other disciplines (where appropriate) informed and involved
Have them join in the fun!
Run proposal by key stakeholders
Organized proposal (based on PICO)
Cite evidence

15. support Even for small projects Academic medical center affiliation
Nurse research faculty
Librarian(s)
Honor’s students
Research assistants
Printing of posters
No affiliation
Hospital resources – other nurses, administration (all levels), librarian, analyst(?), quality improvement, colleagues at other hospitals in your system?

16. Implementing the practice change intervention
Do we have a creative strategy to solve a problem?
Is it based on evidence?
e.g. evidenced based guidelines? Intervention based on prior research?
Who’s on first?
Roles of other investigators
Start and end times
Again is there evidence to support these timelines in order to see the effect of your practice change?
e.g. evidence to support Foley removal?

17. Data collection
Are there relevant strategies that exist → Why reinvent the wheel philosophy? Do they reflect best practice? Try not to increase workload!
Data collection using electronic health records
Existing data collected in routine care delivery
Blood test required for treatment – not additional blood draws
Pre and post collection time periods important

18. Examine strategies to analyze the data
Statistics are based on study design and research questions
Quantitative methods –
Descriptive statistics
Frequencies
Percentages
Range
Mean (average) and standard deviation (where your scores fall around the average Mean age = 49; SD = 18.2
T-test
Chi Square
Multivariate Statistics
Get the help of a statistician or an astute colleague

19. Qualitative methods Conducting interviews Video-taping
Thematic analysis
Content analysis – quasi qualitative methods where you can run quantitative analysis
Video-taping
Counting

20. Make the findings visible for your peers and patients!
Keep your unit and patients informed of progress
Charts displaying trends of outcomes
Line chart
Histogram
Publication
Hospital newsletter
Peer-reviewed Journal

21. Evaluate How did it go? Can it be simplified?
Data collection methods
What were the barriers and facilitators to getting the project implemented?
Go to Planning phase again – don’t make changes to practice until this is done!

22. Dissemination of your findings:
Celebrate successes with your peers
Recognition of staff accomplishments on your unit and in hospital at large
Evolution of projects
To like units
Adapt to other unique units in hospital

23. Sparks of Ideas

24. P -Post-operative complications presented in patients
PICO Question
Simultaneous Literature Review
P -Post-operative complications presented in patients
following bowel resection surgery: pain, GI dysfunction and
immobility
-Hospitalized Adult patients post-op following bowel
resection surgery
I Dedicated surgical unit with pre-op education, early
ambulation, limited use of NG tubes and Foley Catheters,
pain control, management of N&V (Fast Track Order Set)
C Retrospective chart review of patient admitted and received
traditional care prior to the intervention
O Length of stay, days of NG and Foley use, symptom
presentation and management, introduction of diet

25. P - Jeopardy of patient safety during shift report; poor and
PICO Question
Simultaneous Literature Review
P - Jeopardy of patient safety during shift report; poor and
inconsistent communication between nurses: nurses and
nurses: patients; little patient/family participation in
ongoing care
- RNs providing care in a hospital setting and
patient/families receiving this care
I Bedside shift report and handover
Direct patient observation during shift report
C Retrospective review of nurse and patient satisfaction data
O Nurse and Patient satisfaction

26. P -Ventilator Associated Pneumonia (VAP); no standardized
PICO Question
P -Ventilator Associated Pneumonia (VAP); no standardized
oral care regimen
-Mechanically ventilated critical care adult patients
I Oral Care regimen using 0.2% Chlorhexidine Preparation
C Retrospective chart review of outcomes of mechanically
ventilated adults in unit prior to use of 0.2% chlorhexidine
prep
O Decreased incidence of VAP

27. Using whiteboards: fixed Identities American Journal of Nursing (2008)
Bonnie Carlin, RN, MSN
Clinical Assistant Professor and Staff Nurse

28. Thanks for the Support:
Thanks to both of my employers for their support with key resources, time and materials!
I have certainly developed an even greater respect and appreciation for nurse researchers after this simple project!
Department of Nursing and Patient Services
College of Nursing

29. P -Prior to study, there was inconsistent nurses introductions to
PICO Question
P -Prior to study, there was inconsistent nurses introductions to
patients (verbal) and ID badges were not always visible; Received
informal feedback from hospitalized patients - Whiteboards in place
were “helpful and desirable” to “useless” due to not being kept
current; Differences in RN educational preparation in relation to patient outcomes making local/national news; Exploring the
sharing of RN credentials was also of interest
- Hospitalized Patient, Staff Nurses (all levels) other providers
I Patient room whiteboards as a tool offered the ease of updating with
real time and current information quickly with the ability to
standardize practice across units at a minimal cost..
C Patient without whiteboards in rooms
O Potential areas for significant impact: Patient satisfaction, Patient
rights & education, Patient outcomes, Staff productivity & efficiency,
Nursing image, & Marketing
Pre – post design
Different patients

30. Identification Whiteboards
MY project was a simple pre & post intervention design. Here’s a copy of the template which were mounted to a 2 X 3 whiteboard in the study rooms at the foot of each bed. The smiley face was to help staff and patients identify the study rooms (especially important for the control group before the whiteboards were in place to help them identify stay in study rooms). RNs and PCAs, were requested to complete the information on day shift. Participating patients completed a demographic survey and a questionnaire about their nursing care to indicate whether this board helped them know the name, educational degree , and role of assigned care providers.
Control group surveyed without whiteboards, then whiteboards posted for intervention group to determine if the information on boards was effective for patients

31. Findings
Significant differences with the patients’ knowledge of their day Patient Care Assistant’s (PCA) name & with the patients’ knowledge of educational level of their day RN
+ trends in assisting patients feel informed about which Nursing care providers to request for specific needs (roles of caregivers) & in increasing patients’ knowledge of their day RN’s name
+ increases in all areas surveyed including: 1) promptness of response after call light requests, 2) making periodic checks without a request, & 3) positive manner of responding
Overall nursing care rating increased from the baseline control group rating of 85% to 95%
58% (n=46) of total sample (N=79) wanted to know the educational preparation of RN caring for them. 10% responded “never”

32. Support Processes in place
Encouraging unit & departmental environment (Magnet qualities!)
Mini-grant award of $1000
Research Council
Mentor
IRB advisement
Support from many including
Librarian
Statistician
Editor(s)

33. Impact on Practice
Study findings shared to encourage bedside nurses to utilize this simple intervention through presentations & publication
Other Med-Surg & Pediatric units incorporated whiteboards and included for caregiver ID.
Many ICUs using similar strategy.
Roles & Responsibilities (R&R) brochure of RNs & PCAs roles
brochure in English & Spanish on study unit
posted & incorporated into written Patient & Family unit orientation
some other units have adopted the R & R.
Hospital has implement RN name badges with credentials!
Whiteboard postings have evolved –
by listing patient daily goals,
skin risk assessments & interventions,
providing a visual for patients and nurses of weights, vital signs, and more…

34. Transforming Care at the Bedside
RWJ Foundation and IHI Initiative
Transforming Care at the Bedside

35. Improve quality and safety of patient care and increase retention of experienced nurses in med-surge units.
WHY?
The many simple and complex problems Med-Surgical units face in today’s health care systems

36. TCAB: Transforming Care at the Bedside
10 hospitals in the U.S. participating in TCAB
Follow their journey
Online resources include video & toolkit