CLINICAL INQUIRY AT THE BEDSIDE:

USING PICO

Donna Felber Neff, RN, PhD, DSNAPAssociate Professor of Nursing

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

WHAT 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

CONCEPTUAL MAP OF BUSYNESS*

Organizational Culturalfactors

Interpersonal factors

Environmentalfactors

Intrapersonal factors

Physicalbusyness BUSYNESS

EFFECTSReduced research use

Sacrifice of personal time Inability to use or find resources

Psychological pressure

OBJECTIVE SUBJECTIVE

* Thompson et al., 2008

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

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

1. Stodeur et al. 20002. Doran, 20043. Bass & Avolio, 1994

ARE WE ASKING WHY?

Did we identify a ‘problem’ in the practice setting?

WHAT DO WE DO NEXT?

Develop a PICO Question

PICO QUESTION

P Problem/population

I Intervention of interest

C Comparison

O Outcome

SIMULTANEOUSLY CONDUCT THE REVIEW OF LITERATURE:

LIKE FINDING A NEEDLE IN A HAYSTACK!!!

LITERATURE REVIEW

Does the evidence exist? If not, what do you do?

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

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

summary

Keep physicians and other disciplines (where appropriate) informed and involved

Have them join in the fun!

Run proposal by key stakeholdersOrganized proposal (based on PICO)Cite evidence

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?

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?

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

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

Qualitative methods Conducting interviews

Thematic analysis Content analysis – quasi qualitative methods where

you can run quantitative analysis

Video-taping Thematic analysis Counting

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

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!

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

SPARKS OF IDEAS

PICO QUESTION

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

Sim

ultan

eou

s Literatu

re Review

PICO QUESTION

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

Sim

ultan

eou

s Literatu

re Review

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

USING WHITEBOARDS: FIXED IDENTITIES

AMERICAN JOURNAL OF NURSING (2008)

Bonnie Carlin, RN, MSNClinical Assistant Professor and Staff Nurse

THANKS FOR THE SUPPORT:

College of Nursing

Department of Nursing and Patient Services

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 thesharing 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

IDENTIFICATION WHITEBOARDSDATE: _____________ DAY of WEEK: __________CALL: _______________ PCA for: Meal assistance

(FIRST & LAST NAME) Patient Care Assistant Bathing needs Linen changes

Assisting you ____________ Water & drinks(SHIFT TIMES) Bathroom Assistance

Change in positionWalking assistanceTreatments & other care needs

CALL: _______________ RN, A.D.N. B.S.N. M.S.N for: Medications (FIRST & LAST NAME) Registered Nurse (CIRCLE ONE) Treatments

A “listening ear”Assisting you _____________ Changes in how you feel

(SHIFT TIMES) Alarm or equipment questionsQuestions about test or procedures

Still Undecided? Call with your request & someone will be in as soon as possible!

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

FINDINGS

o 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

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 RN’s 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”

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)

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…

TRANSFORMING CARE AT THE BEDSIDE

RWJ Foundation and IHI Initiative

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

TCAB: TRANSFORMING CARE AT THE BEDSIDE

10 hospitals in the U.S. participating in TCAB

Follow their journeyhttp://www.rwjf.org/qualityequality/pro

duct.jsp?id=21069

Online resources include video & toolkit