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C LINICAL I NQUIRY AT THE B EDSIDE : U SING PICO Donna Felber Neff, RN, PhD, DSNAP Associate Professor of Nursing.

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Presentation on theme: "C LINICAL I NQUIRY AT THE B EDSIDE : U SING PICO Donna Felber Neff, RN, PhD, DSNAP Associate Professor of Nursing."— Presentation transcript:

1 C LINICAL I NQUIRY AT THE B EDSIDE : U SING PICO Donna Felber Neff, RN, PhD, DSNAP Associate Professor of Nursing

2 O BJECTIVES Discuss barriers to conducting clinical research Asking the question Using a PICO question Whats Next? Sharing examples Whats Next? Some final helpful(?) points

3 W HAT ARE THE BARRIERS ? Time. Is this a proxy term? 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!* Estabrooks et al., 2004; Tyden, 1996

4 C ONCEPTUAL M AP OF B USYNESS * Organizational Cultural factors Interpersonal factors Environmental factors Intrapersonal factors Physical busyness BUSYNESS EFFECTS Reduced research use Sacrifice of personal time Inability to use or find resources Psychological pressure OBJECTIVESUBJECTIVE * Thompson et al., 2008

5 E FFECTS OF BUSYNESS – R EDUCED 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

6 O RGANIZATIONAL 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 care 1, and greater staff and patient satisfaction 2 Employees encouraged to challenge the status quo 3 Resources – e.g. financial 1.Stodeur et al Doran, Bass & Avolio, 1994

7 A RE WE ASKING WHY? Did we identify a problem in the practice setting?

8 W HAT DO WE DO NEXT ? Develop a PICO Question

9 PICO Q UESTION P Problem/population I Intervention of interest C Comparison O Outcome


11 L ITERATURE R EVIEW Does the evidence exist? If not, what do you do?


13 P LANNING 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 O RGANIZATION B UY - IN Recruit a champion(s) Initially run ideas by direct supervisor - usually the unit manager G ood 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) Honors 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 I MPLEMENTING 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? Whos 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 D ATA 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 E XAMINE 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 Thematic analysis Content analysis – quasi qualitative methods where you can run quantitative analysis Video-taping Thematic analysis Counting

20 M AKE 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 E VALUATE 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 – dont make changes to practice until this is done!

22 D ISSEMINATION 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


24 PICO Q UESTION 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 Simultaneous Literature Review

25 PICO Q UESTION 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 Simultaneous Literature Review

26 PICO Q UESTION 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 U SING WHITEBOARDS : FIXED I DENTITIES A MERICAN J OURNAL OF N URSING (2008) Bonnie Carlin, RN, MSN Clinical Assistant Professor and Staff Nurse

28 T HANKS FOR THE S UPPORT : College of Nursing Department of Nursing and Patient Services

29 PICO Q UESTION 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

30 I DENTIFICATION W HITEBOARDS Control group surveyed without whiteboards, then whiteboards posted for intervention group to determine if the information on boards was effective for patients

31 F INDINGS o Significant differences with the patients knowledge of their day Patient Care Assistants (PCA) name & with the patients knowledge of educational level of their day RN o + 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 RNs name o + 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 o Overall nursing care rating increased from the baseline control group rating of 85% to 95% o 58% (n=46) of total sample (N=79) wanted to know the educational preparation of RN caring for them. 10% responded never

32 S UPPORT P ROCESSES 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 I MPACT ON P RACTICE 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 T RANSFORMING C ARE AT THE B EDSIDE RWJ Foundation and IHI Initiative

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 todays health care systems

36 TCAB: T RANSFORMING C ARE AT THE B EDSIDE 10 hospitals in the U.S. participating in TCAB Follow their journey uct.jsp?id= uct.jsp?id=21069 Online resources include video & toolkit


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