Presentation on theme: "Clinical Inquiry at the Bedside: Using PICO"— Presentation transcript:
1 Clinical Inquiry at the Bedside: Using PICO Donna Felber Neff, RN, PhD, DSNAPAssociate Professor of Nursing
2 Objectives Discuss barriers to conducting clinical research Asking the ‘question’Using a PICO questionWhat’s Next?Sharing examplesWhat’s Next? Some final helpful(?) points
3 What are the barriers? Time. Is this a proxy term? In FACT: Lack of approval by colleaguesLack of interestLack of support from administrationIn 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 utilizationIs 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* EFFECTSReduced research useSacrifice of personal timeInability to use or find resourcesOBJECTIVESUBJECTIVEOrganizational CulturalfactorsInterpersonal factorsEnvironmentalIntrapersonal factorsPhysicalbusynessThompson 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 timemanagement/administration supportInterpersonal factors:difficult family/patientsupport staffpreceptoringinterruptions – call bells, other professionalsIntrapersonal factorspersonal life – family, educationpersonal attributes time/organizational skillsexperience/confidence levelscoping ability unwilling to share workEnvironmental factorsHigh activities on the unitpatient workload number and acuitynursing shortagenon-nursing tasksorganizational changebusywork – outdated policy and procedurerestricted resources - medications, equipment, beds, nurse educatorsmanagement/administrationBUSYNESSPsychological pressure* Thompson et al., 2008
5 Effects of busyness – Reduced clinical inquiry and research utilization Sacrifice of personal timeInability to find or use resourcesMissed opportunitiesInservices, meetingsProfessional developmentCompromised safetyIncomplete nursing careEmotional and physical strainEACH 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/inservicesIncomplete nursing care included some routine tasks or treatment being missed, unable to provide satisfactory care
6 Organizational factors: Creation of a Culture of LearningLearning is a key part of the mission and goalsEliminate structural obstacle for learningIndividuals empowered to achieveTransformation LeadershipDefine a visionProvide a meaningful work environmentContribute indirectly to improving quality of care1, and greater staff and patient satisfaction2Employees encouraged to challenge the status quo3Resources – e.g. financialI 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 goalsThese 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. 2000Doran, 2004Bass & 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?OrganizationalProcessOutcomesCan 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?
13 Planning Who are the people who need to be at this table? This is team work – not a one person job!Examine clinical questionGroup brainstorming before you jump into the haystack of informationMore formal protocol developmentProcess that can be lengthy
14 Organization Buy-in Recruit a champion(s) Initially run ideas by direct supervisor - usually the unit managerGood to come with ideas as a team with a brief summaryKeep physicians and other disciplines (where appropriate) informed and involvedHave them join in the fun!Run proposal by key stakeholdersOrganized proposal (based on PICO)Cite evidence
15 support Even for small projects Academic medical center affiliation Nurse research facultyLibrarian(s)Honor’s studentsResearch assistantsPrinting of postersNo affiliationHospital 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 investigatorsStart and end timesAgain 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 collectionAre 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 recordsExisting data collected in routine care deliveryBlood test required for treatment – not additional blood drawsPre and post collection time periods important
18 Examine strategies to analyze the data Statistics are based on study design and research questionsQuantitative methods –Descriptive statisticsFrequenciesPercentagesRangeMean (average) and standard deviation (where your scores fall around the average Mean age = 49; SD = 18.2T-testChi SquareMultivariate StatisticsGet the help of a statistician or an astute colleague
19 Qualitative methods Conducting interviews Video-taping Thematic analysisContent analysis – quasi qualitative methods where you can run quantitative analysisVideo-tapingCounting
20 Make the findings visible for your peers and patients! Keep your unit and patients informed of progressCharts displaying trends of outcomesLine chartHistogramPublicationHospital newsletterPeer-reviewed Journal
21 Evaluate How did it go? Can it be simplified? Data collection methodsWhat 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 peersRecognition of staff accomplishments on your unit and in hospital at largeEvolution of projectsTo like unitsAdapt to other unique units in hospital
24 P -Post-operative complications presented in patients PICO QuestionSimultaneous Literature ReviewP -Post-operative complications presented in patientsfollowing bowel resection surgery: pain, GI dysfunction andimmobility-Hospitalized Adult patients post-op following bowelresection surgeryI Dedicated surgical unit with pre-op education, earlyambulation, 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 receivedtraditional care prior to the interventionO Length of stay, days of NG and Foley use, symptompresentation and management, introduction of diet
25 P - Jeopardy of patient safety during shift report; poor and PICO QuestionSimultaneous Literature ReviewP - Jeopardy of patient safety during shift report; poor andinconsistent communication between nurses: nurses andnurses: patients; little patient/family participation inongoing care- RNs providing care in a hospital setting andpatient/families receiving this careI Bedside shift report and handoverDirect patient observation during shift reportC Retrospective review of nurse and patient satisfaction dataO Nurse and Patient satisfaction
26 P -Ventilator Associated Pneumonia (VAP); no standardized PICO QuestionP -Ventilator Associated Pneumonia (VAP); no standardizedoral care regimen-Mechanically ventilated critical care adult patientsI Oral Care regimen using 0.2% Chlorhexidine PreparationC Retrospective chart review of outcomes of mechanicallyventilated adults in unit prior to use of 0.2% chlorhexidineprepO Decreased incidence of VAP
27 Using whiteboards: fixed Identities American Journal of Nursing (2008) Bonnie Carlin, RN, MSNClinical 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 ServicesCollege of Nursing
29 P -Prior to study, there was inconsistent nurses introductions to PICO QuestionP -Prior to study, there was inconsistent nurses introductions topatients (verbal) and ID badges were not always visible; Receivedinformal feedback from hospitalized patients - Whiteboards in placewere “helpful and desirable” to “useless” due to not being keptcurrent; Differences in RN educational preparation in relation to patient outcomes making local/national news; Exploring thesharing of RN credentials was also of interest- Hospitalized Patient, Staff Nurses (all levels) other providersI Patient room whiteboards as a tool offered the ease of updating withreal time and current information quickly with the ability tostandardize practice across units at a minimal cost..C Patient without whiteboards in roomsO Potential areas for significant impact: Patient satisfaction, Patientrights & education, Patient outcomes, Staff productivity & efficiency,Nursing image, & MarketingPre – post designDifferent 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 FindingsSignificant 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 respondingOverall 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 $1000Research CouncilMentorIRB advisementSupport from many includingLibrarianStatisticianEditor(s)
33 Impact on PracticeStudy findings shared to encourage bedside nurses to utilize this simple intervention through presentations & publicationOther Med-Surg & Pediatric units incorporated whiteboards and included for caregiver ID.Many ICUs using similar strategy.Roles & Responsibilities (R&R) brochure of RNs & PCAs rolesbrochure in English & Spanish on study unitposted & incorporated into written Patient & Family unit orientationsome 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 InitiativeTransforming 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 TCABFollow their journeyOnline resources include video & toolkit