Module 2- EBP, Communication, Learning, & Documentation

What is Evidence Based Practice?

A type of nursing research that integrates clinical expertise, patient values, and the best research evidence into decision-making processes.

What is nursing research?

A process that uses observable and data to describe, explain, or predict events.

Why is EBP important?

-allows for proven data to back up our care

-improves patient care

-manages and eliminates symptoms caused by illnesses

What are the 2 types/methods of nursing research?

Qualitative and Quantitative

Quantitative

-involves concepts of basic and applied research

-numbers and data

Qualitative

-conducted to gain insight by discovering meanings

-based on perceptions that differ for each person and change over time (feelings)

PICOT

-a way to ask clinical questions

-P: patient, population, problem of interest (the who and what)

-I: intervention of interest (the thing we want to study)

-C: comparison of interest

-O: outcome of interest

-T: time

Once research is complete, what is done with the newly found knowledge?

-nurses read the newly published articles containing information

-they bring this knowledge to their work

-and appropriate changes are made

Communication definition

the process of giving, receiving, and sharing information

4 ways nurses communicate

1: verbally

2: nonverbally

3: written

4: visually

Electric communication

-Social media

-Texts and emails

Why is communication important in nursing?

helps us:

-collect our assessment data

-initiate interventions

-evaluate interventions

-initiate needed changes

-prevent or lessen legal issues

-work as a team

What happens if we do not communicate?

We can:

-hurt our patients

-hurt ourselves

-hurt our team

-get sued

-death of our patient

SBAR definition

a way to speak in healthcare to get your point across quickly and efficiently while not missing key information

SBAR (what does each stand for + function)

S: situation- describes the issue/reason for contacting provider

B: background- patients background info that related to the situation

A: assessment- describes what you assessed

R: recommendation- tell the provider what you need to move forward

ISBARR (what does each stand for + function)

I: identify- identify yourself

S: situation- describes the issue/reason for contacting provider

B: background- patients background info that related to the situation

A: assessment- describes what you assessed

R: recommendation- tell the provider what you need to move forward

r: read back-read back the orders that the provider gave you

What are characteristics of caring communication?

-respect

-empathy

-honesty

-privacy

-culturally sensitive

-listen

Barriers to communication

-environment (lack of time, hostile work environment)

-personal characteristics (culture, judgement)

-Poor communication techniques (lack of listening skills, unable to focus)

What are patients rights when it comes to their health record?

patients can:

-see and have a copy their health record

-requests corrections

-access health information

SOAP(IER) (what does each letter stand for)

-S: subjective

-O: objective

-A: assessment

-P: plan

-I:interventions

-E: evaluation

-R: recommendation

Cognitive learning

storing and recalling of new knowledge in the brain

Psychomotor learning

learning a physical skill

Affective learning

changed in attitudes, values, and feelings

What are factors affecting patient learning?

-Age and developmental level

-Family/caregiver support

-Financial resources

-Culture and language

-Health literacy

What tactics should you utilize when teaching older adults?

-identify learning barriers

-Allow extra time

-Plan short teaching sessions

-Reduce environmental factors

-Relate new information to familiar activities or information

What tactics can you do to provide culturally competent patient education?

-develop an understanding of the patient’s culture

-be aware of personal assumptions, biases, and prejudices

-develop written material in patient’s preferred language

-use an interpreter

What are nursing informatics and how do they support nursing and the quality of health care?

-nursing informatics=EMR’s/EHR’s

they combine nursing science, information, and technology to communicate date, information, and knowledge

Define telehealth and how it supports patient’s and their care

-remote healthcare services

-allows for patient’s to access health care anywhere they are and at their comfort

Define telemedicine and how it supports patient’s and their care

-(a type of Telehealth)

-remote healthcare service where provider directly speaks to patient

Define tele care and how it supports patient’s and their care

-technology supports independent living (examples: fall alerts or monitoring devices)

Describe examples of effective documentation

-real time/current

-detailed

-accurate

What are considerations that the nurse should take when receiving the verbal orders?

-only in emergency situations

-write it down immediately

-read order back

-document

-ensure provider goes back to sign it within 24 hours

What are 3 basic learning principles?

-ability to learn

-motivation to learn

-learning environment

What things can affect a client’s motivation to learn?

-mutual goals

-engagement and motivation

-education to patient

-appropriate teaching strategies

What are the 3 essential elements of EBP?

-clinical expertise

-patient preferences

-best evidence

Define informed consent and why it is important in the protect of our patients

-allows patient to be knowledgeable and be in control of their health and treatments

-allows for the patient to be educated and consent to the medical care they are receiving