Clinical Inquiry at the Bedside: Using PICO

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? • 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. Physical busyness Organizational Cultural factors Interpersonal factors Intrapersonal factors Environmental factors Conceptual Map of Busyness* EFFECTS Reduced research use Sacrifice of personal time Inability to use or find resources OBJECTIVE SUBJECTIVE 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

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 • Stodeur et al. 2000 • Doran, 2004 • Bass & Avolio, 1994

7. Are we asking WHY? • Did we identify a ‘problem’ in the practice setting?

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 • Thematic analysis • Content analysis – quasi qualitative methods where you can run quantitative analysis • Video-taping • Thematic analysis • 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. Simultaneous Literature Review 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 IDedicated 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) CRetrospective 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. 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 IBedside shift report and handover Direct patient observation during shift report CRetrospective review of nurse and patient satisfaction data O Nurse and Patient satisfaction

26. 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 IdentitiesAmerican Journal of Nursing(2008) Bonnie Carlin, RN, MSN Clinical Assistant Professor and Staff Nurse

28. Thanks for the Support: Department of Nursing and Patient Services College of Nursing

29. 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 IPatient 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.. CPatient without whiteboards in rooms O Potential areas for significant impact: Patient satisfaction, Patient rights & education, Patient outcomes, Staff productivity & efficiency, Nursing image, & Marketing

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

31. Findings • Significantdifferences 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

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 • http://www.rwjf.org/qualityequality/product.jsp?id=21069 • Online resources include video & toolkit