Ferris State University NURS 350 Evidence-Based Nursing Practice EBNP Group Project

1. Ferris State UniversityNURS 350 Evidence-Based Nursing Practice EBNP Group Project Lai Harper Margaret Siler Gary Webster Jamie Ziemba

2. “Communication--the human connection--is the key to personal and career success.” Paul J. Meyer“It’s important to make sure that we’re talking with each other in a way that heals, not in a way that wounds.”-Barack Obama“Communication works for those who work at it.” John Powell“Unity is strength . . . when there is teamwork and collaboration, wonderful things can be achieved.” Mattie Stepanek

3. Introduction • Every day we have conversations between nurses and doctors. What are the outcomes of these conversations, both positive and negative, for patients and nurses? • What is patient safety? What is acute care? What is professional communication?

4. What is patient safety? • Easily defined as anything that would directly affected the patient • Examples with negative consequences on patient safety: language barriers, medication errors, miscommunication between doctors and nurses • Based on the Joint Commission, patient safety (death/injury or medical errors) can be related to segmented communication or relationship between nurses and physicians (Saxton, Hines, and Enriquez, 2009, p. 180).

5. What is acute care? • Taking care of patients who are having a “now” type of medical condition • “A pattern of health care in which a patient is treated for a brief but severe episode of illness, for the sequelae of an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials, and it may involve intensive or emergency care. This pattern of care is often necessary for only a short time, unlike chronic care” (Mosby's Medical Dictionary, 2009).

6. What is Professional Communication? Verbal communication is basic conversation of words that people say to one another. • Simple words or technical jargon. • Difficult if the nurse or doctor has English as a second language, if the terms in the technical jargon are not shared by either the doctor or nurse. Nonverbal communication is body language and written communication. • body language and written communication can be taken positively or negatively.

7. Communication between medical professionals is not just a local problem, but is a problem found throughout the entire medical community.

8. PICO Question For adult patients in an acute care setting, what does the literature reveal about the DIFFERENCE in communication styles (collaboration interdisciplinary versus segmented authoritarian) between physicians and nurses on indicators of nurse satisfaction rates and patient safety outcomes?

9. Definitions • According to the American Nurses Association, “collaboration” is “a true partnership, in which the power on both sides is valued by both, with recognition and acceptance of separate and combined practice spheres of activity and responsibility, mutual safeguarding of the legitimate interests of each party, and a commonality of goals that is recognized by both parties” (Hendel, Fish, & Berger, 2007, p. 251). • Ballou and Landreneau (2010) discuss that “authoritarian persons typify an outlook that is ethnocentric, rigid, and anti-democratic” (p. 71). • “Segmented”: “divided into or composed of segments or sections” “Authoritarian”: “of, relating to, or favoring blind submission to authority” (Merriam-Webster Dictionary, 2012).

10. A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient SafetySample size N= 4,530 From January 2004 to March 2007 How often do you think disruptive behavior results in the following at your hospital? (Sometimes, Frequent, and Constant) How often do you think that there is a link between disruptive behavior and the following clinical outcomes at your hospital? (Sometimes, Frequent, and Constant)

11. A Survey of the Impacts of Disruptive Behaviors and Communication Defects on Patient SafetySample size N= 4,530 From January 2004 to March 2007 Have your ever witnessed any disruptive behavior from a physician at your hospital? Have you ever witnessed any disruptive behavior from a nurse at your hospital?

12. Literature Review (Level One Evidence)

13. Literature Review (Level Three Evidence)

14. Literature Review (Level Four Evidence)

15. Literature Review (Level Four Evidence continued)

16. Literature Review (Level Six Evidence)

17. Analysis of Evidence The ability to critically analyze evidence presented in various research projects is necessary to evaluate the work for applicability and use in evidence based nursing practice. “To use research evidence, one must be able to evaluate this evidence” (Nieswiadomy, 2012, p. 298).

19. STRENGTH OF EVIDENCE • LEVEL 1 (HIGHEST) • EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT) • • Study participants (subjects) are randomly assigned to either a treatment (TX) or control • (non-treatment) group. • • May be: • o Blind: neither subject nor investigator knows which TX subject is receiving. • o Double-blind: neither subject nor investigator knows which TX subject is receiving. • o Non-blind: both subject and investigator know which TX subject is receiving; used • when it is felt that the knowledge of treatment is unimportant. • META-ANALYSIS OF RCTS • • Quantitatively synthesizes and analyzes results of multiple primary studies addressing a • similar research question • • Statistically pools results from independent but combinable studies • • Summary statistic (effect size) is expressed in terms of direction (positive, negative, or • zero) and magnitude (high, medium, small) • LEVEL 2 • QUASI-EXPERIMENTAL STUDY • • Always includes manipulation of an independent variable • • Lacks either random assignment or control group. • • Findings must be considered in light of threats to validity (particularly selection) • LEVEL 3 • NON-EXPERIMENTAL STUDY • • No manipulation of the independent variable. • • Can be descriptive, comparative, or relational. • • Often uses secondary data. • • Findings must be considered in light of threats to validity (particularly selection, lack of • severity or co-morbidity adjustment). • QUALITATIVE STUDY • 􀂃 Explorative in nature, such as interviews, observations, or focus groups. • 􀂃 Starting point for studies of questions for which little research currently exists. • 􀂃 Sample sizes are usually small and study results are used to design stronger studies that • are more objective and quantifiable. • META-SYNTHESIS • 􀂃 Research technique that critically analyzes and synthesizes findings from qualitative • research • 􀂃 Identifies key concepts and metaphors and determines their relationships to each other • 􀂃 Aim is not to produce a summary statistic, but rather to interpret and translate findings JHNEBP Research Evidence Appraisal The Johns Hopkins Hospital/The Johns Hopkins University QUALITY RATING (SCIENTIFIC EVIDENCE) A High quality: consistent results, sufficient sample size, adequate control, and • definitive conclusions; consistent recommendations based on extensive literature • review that includes thoughtful reference to scientific evidence. B Good quality: reasonably consistent results, sufficient sample size, some control, • and fairly definitive conclusions; reasonably consistent recommendations based • on fairly comprehensive literature review that includes some reference to • scientific evidence C Low quality or major flaws: little evidence with inconsistent results, insufficient • sample size, conclusions cannot be drawn.

20. Article #1: “Conflict management training and nurse-physician collaborative behaviors”(Boone et al., 2008) • Quantitative, quasi-experimental design. • The researchers are highly qualified and experienced. • Convenience sample which closely approximates the real world experience. • This study is ethically sound as a written explanation of the study was provided and informed consent was obtained. • The problem is clearly stated to examine a knowledge gap between a unit specific intervention (conflict management training) and improved communication and collaboration between physicians and nurses. • Theoretical framework: Kilmann and Thomas conflict resolution theory (Boone et al., 2008, p. 168). • Findings reveal that the intervention was unsuccessful. (The null hypothesis not rejected) • The importance of continued research for interventions that promote quality communication and collaboration is stressed. • Creating a culture that values quality communication and collaboration forms the basis for developing a healthy work environment. • Level of evidence varies by tool used, but is evaluated as II, or III. Both levels are credible for utilization in evidence based care. • Informed consent was obtained from all participants

21. Article #2: “Nine structures and leadership practices essential for a magnetic (healthy) work environment” (Kramer et al., 2010) • This is a quantitative meta-analysis of thirty professional publications. • The problem is clearly stated to identify what structures and leadership practices are necessary to support a healthy work environment. • The researchers are experienced, and well qualified. • The sample size was good. Over 1300 interviews of expert nurses, nurse managers, and physicians were compiled for comparison to findings from regulatory and professional organizations. • The theoretical framework is based on the Donabedian model (http://www.ahrq.gov/qual/medteam/medteamfig2.htm) of patient safety. • Healthy work environments lead to improved patient and nurse outcomes • Creating a culture of interdisciplinary collaboration and teamwork through shared power and administrative support were important themes. • This is a valid level I for evidence by all methods (course modules, interview with hospital research specialist, and Johns Hopkins Nursing Research Evidence Appraisal). Level I is the highest level of evidence for utilization in evidence based practice.

23. Article #3: “The effect of an educational programme on attitudes of nurses and medical residents towards the benefit of positive communication and collaboration”(McCaffrey et al., 2012) • This is a quasi-experimental study based on a convenience sample of nurses and medical residents . • The researchers are experienced and well qualified. • The research question is clearly stated. • Ethical research guidelines are carefully adhered to. • A pre and post-test design based on the Jefferson Scale of Attitudes towards Physician-Nurse Collaboration, and the Communication, Collaboration, and Critical Thinking for Quality Patient Outcomes tools. Both tools are proven to be reliable and valid (the Cronbach’s alpha coefficient of 0.87-0.92). • A critical finding in this study is that “Effective communication is the cornerstone of interdisciplinary collaboration” (McCaffery et al., 2012, p. 294). • Statistical findings reveal that the chosen intervention of an educational programme to improve physician-nurse communication and collaboration was beneficial. • This study is evaluated as evidence level III due to lack of a control group by two methods (Ford, 2012; C. Bongiorno, personal communication, November 26, 2012). Alternatively it is rated as level II on the Johns Hopkins scale ("JHNEBP Research Evidence Appraisal," n.d.) .

24. Article #4:“Nurse-physician relationships in hospitals: 20,000 nurses tell their story” (Schmalenberg & Kramer, 2009) • This study is a quantitative synthesis of the findings of six research studies based on the Essentials of Magnetism. • The researchers are experienced and highly qualified. • The purpose of the study is several fold: 1) To discern what constitutes quality communication and collaboration between physicians and nurses, 2) Define types of nurse-physician relationships, 3) Define organizational structures and leadership practices that help develop collaborative nurse-physician relationships, and 4) Study differences in nurse-physician relationships between magnet and comparison hospitals. • The sample size of 20,616 staff nurses is excellent. • Thorough literature review is the foundation for this study. • It was consistently reported that nurses at magnet hospitals reported higher quality relationships with physicians than the comparison hospitals. • Structures that improve relationships and are supported by magnet institutions are: keep the patient first, develop constructive conflict resolution techniques, and have collaborative, interdisciplinary patient rounds. • Nurses can play an active role in bringing about these interventions. • This is a double blinded peer review of six studies clearly making it evidence level I by all methods.

25. Percentage of staff nurses responding affirmatively to nurse-physician relationship types by magnet and comparison hospitals and by period

26. Application of Evidence for oncology nursing practice (Lai Harper) • Utilize the Cochrane Database or the “JHNEBP Research Evidence Appraisal” as the research tools; effectively communicate and collaborate with oncologists about the nursing perspective on evidence-based practice • Ongoing literature review for the most current, credible, and high-quality evidence-based practice for reducing oncology patients’ physical, psychological, and emotional issues (such as pain, nausea, anxiety, or depression).  • Recommend the hospital nursing research committee to initiate a survey to explore possible physician-nurse communication barriers at an oncology unit. • Recommend the implementation of the low-cost convenient computer-based training in physician-nurse communication skills.

27. Application of Evidence at the Cardiovascular Department (Margaret Siler) • High quality communication and collaboration make a great difference in the cardiac catheterization laboratory (Boone, King, Gresham, Wahl, & Suh, 2008, p. 168). • Experience and a broad knowledge base bring confidence to our daily work (Schmalenberg & Kramer, 2009, p. 82). • All involved parties (patient, nurse, physician, healthcare system) can reap the benefits of collaborative practice (Kramer et al., 2012, p. 7). • There are many educational opportunities available to improve interdisciplinary and interdepartmental communication. Many are quite costly. Some that may make the biggest difference are fairly inexpensive, including Unit Action Council work and interdepartmental job shadowing. (McCaffery et al., 2012).

28. Application of Evidence into the Surgical Setting (Gary Webster) Intra-operative settings place nurses and physicians in close collaborative work settings. The typical communication style is authoritarian. Schmalenberg and Kramer (2009) stated that physicians felt the nurse-physician relation to be more collaborative than nurse did. I can see that being true in my work environment. The Boone et al (2008) and McCaffrey (2011) articles combined are very valuable. Together the articles show a successful attempt to increase collaboration and some pitfalls to avoid. These can help direct any programs to support an increase in collaboration. 

29. Application of Evidence (JamieZiemba) • Poor communication between nurses and physicians related to language and cultural barriers • Physicians’ dysfunctional or authoritarian communication style (e.g. instruct nurses not to call at night unless it is a life-and-death emergency) is a major patient safety issue. • As the patient advocate, nurses have an important role of communicating with physicians to verify medication orders, clinical procedures, and improve patient outcomes. • Hospital training programs in communication skills and cultural diversities are recommended for physicians and nurses with different cultural/ethnic backgrounds

30. Summary Statements • Meta-analytical review of evidence-based research articles support the clinical significance of effective communication styles. • Authoritarian communication styles increase disruptive behaviors and negative hostile relationships at work environments. • Healthy work environments have positive effects on nurses, physicians, patients, and healthcare organizations. • Inter-disciplinary collaboration is an essential aspect of healthy work environments • Evidence-based studies have shown positive patient outcomes, nursing job satisfaction, collaborative environments at Magnet hospitals. • There is a need to address the barriers and incorporate educational programs to teach effective communication and the need for collaboration. Educational training should be re-enforced with weekly discussions. “Effective communication is the cornerstone of interdisciplinary collaboration” (McCaffery et al., 2012, p. 294). • Educate staff on the 5 types of nurse-physician relationships (collegial, collaborative, teacher-student, friendly-stranger, and hostile/adversarial relationships) • Teach staff how to utilize positive relationships and change negative ones • Training should avoid focusing on negative behaviors. • Training should focus creating cooperative behaviors.

31. References Agency for Healthcare Research and Quality (n.d.). Medical teamwork and patient safety. The Donabedian model of patient safety. Retrieved from http://www.ahrq.gov/qual/medteam/medteamfig2.htm American Nurses Association (1980). Nursing: A social policy statement. Washington, DC: American Nurses Association. Ballou, K., & Landreneau, K. (2010). The authoritarian reign in American health care. Policy, Politics & Nursing Practice, 11(1), 71-79. doi:10.1177/1527154410372973 Boone, B., King, M., Gresham, L., Wahl, P., & Suh, E. (2008). Conflict management training and nurse-physician collaborative behaviors. Journal For Nurses In Staff Development, 24(4), 168-175. doi:10.1097/01.NND.0000320670.56415.91 Burns, N., & Grove, S. (2007). Understanding Nursing Research: Building an Evidence Based Practice (4th Ed.). St. Louis, Missouri: Saunders Elsevier Publishing. Ford, L. (2012). Week 8 & 9 Critique of Research. Retrieved from https://fsulearn.ferris.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse&id%3D_2241_1&url%3D Gardezi, F., Lingard, L., Espin, S., Whyte, S., Orser, B., & Baker, G. (2009). Silence, power and communication in the operating room. Journal Of Advanced Nursing, 65(7), 1390-1399. doi:10.1111/j.1365-2648.2009.04994.x Hendel, T., Fish, M., & Berger, O. (2007). Nurse/physician conflict management mode choices: implications for improved collaborative practice. Nursing Administration Quarterly, 31(3), 244-253. John Hopkins University/John Hopkins Hospital (n.d.). JHNEBP Research Evidence Appraisal. Retrieved from http://www.nursingworld.org/DocumentVault/NursingPractice/Research-Toolkit/JHNEBP-Research-Evidence-Appraisal.pdf Karanikola, M., Papathanassoglou, E., Kalafati, M., Stathopoulou, H., Mpouzika, M., & Goutsikas, C. G. (2012). Exploration of the Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel. Dimensions Of Critical Care Nursing, 31(1), 37-45. doi:10.1097/DCC.0b013e31823a55b8

32. References Kramer, M., Schmalenberg, C., & Maguire, P. (2010). Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nursing Administration Quarterly, 34(1), 4-17. doi:10.1097/NAQ.0b013e3181c95ef4 Manojlovich, M., & DeCicco, B. (2007). Healthy work environments, nurse-physician communication, and patients' outcome. American Journal Of Critical Care, 16(6), 536-543. McCaffrey, R., Hayes, R., Cassell, A., Miller-Reyes, S., Donaldson, A., & Ferrell, C. (2012). The effect of an educational programme on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration. Journal Of Advanced Nursing, 68(2), 293-301. doi:10.1111/j.1365-2648.2011.05736.x Nieswiadomy, R. M. (2012). Foundations of Nursing Research (6th Ed.). Upper Saddle River, New Jersey: Prentice Hall. Rosenstein, A., & O'Daniel, M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal On Quality & Patient Safety, 34(8), 464-471. Rothstein, W., & Hannum, S. (2007). Profession and gender in relationships between advanced practice nurses and physicians. Journal Of Professional Nursing, 23(4), 235-240. doi:10.1016/j.profnurs.2007.01.008 Saxton, R., Hines, T., & Enriquez, M. (2009). The negative impact of nurse-physician disruptive behavior on patient safety: A review of the literature. Journal of Patient Safety, 5(3), 180-183. Stone, P. W. (2002). Popping the PICO question in research and evidence-based practice. Applied Nursing Research, 16(2), 197-198 Schmalenberg, C., & Kramer, M. (2009). Nurse-physician relationships in hospitals: 20 000 nurses tell their story. Critical Care Nurse, 29(1), 74-83. doi:10.4037/ccn2009436 Zwarenstein, M., Goldman, J., & Reeves, S. (2009). Interprofessional collaboration: Effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Of Systematic Reviews, (3), 1-31. doi:10.1002/14651858.CD000072

33. NURS 350: Evidence-Based Nursing Practice (Group paper plus Group Powerpoint presentation) Total group grade: 100% Instructor’s comments: Excellent paper. I think your group should consider submitting it for publication if you could flesh out the details on improving collaborative communication.