Integrated Learning - Exam 2 Blueprint

Evidence-Based Practice (EBP)

integrating individual clinical expertise with the best available external clinical evidence from research
- used to form a bridge between research and nursing practice

Research

a formal, systematic way of answering a question or approaching a problem; obtaining info and objective facts to advance knowledge about a specific topic

Three Components of EBP

1. the best evidence from the most current research available
2. the nurse's clinical expertise
3. the patient's preferences which reflect values, needs, interests, and choices

Evidence-Based Nursing

seeks, considers, and synthesizes the combination of the best available research evidence, the nurse's own clinical experience, and each patient's cultural values and personal preferences to provide individualized, optimal nursing care appropriate for the patient

Translational Research

systematic approach of converting research knowledge into applications of healthcare for improved patient outcomes
- allows for enhanced human health and further investigation of diseases and their effects on humans
- may speed the process from discovery to application

What continues to be one of the most powerful tools in nursing?

observation

Concepts Related to EBP

Accountability
Clinical decision making
Health, wellness, and illness
Legal issues
Professional behaviors
Quality improvement

Nursing Research

the use of a systematic and strict scientific process to analyze phenomena of interest to all areas of nursing, including practice, education, and administration
- tests hypothesis about health-related conditions
- tests the processes of nursing care

Nursing Clinical Research

seeks answers to questions that will ultimately improve client care and outcomes

Quantitative Research

uses precise measurement to collect data and analyze it statistically for a summary and a description of the resulting findings or to test relationships among variables

Qualitative Research

investigates a question through narrative data that explores the subjective experiences of human beings and can provide nursing with a better understanding of the patient's perspective
- goal: identification of patterns and themes

Benefits of EBP

- the best patient care and outcomes
- maintaining the aspect of caring
- supports the criteria for nursing to be recognized as a profession

Components that Affect Research

Funding
Participants
Ethical and Legal Issues (vulnerable populations)

Research Participants

volunteers for a specific study project that meet all the inclusion criteria, have been informed of all aspects of the study, and have signed informed consent

Institutional Review Boards (IRBs)

review research protocols and ensure that such protocols adhere to ethical standards

3 Main Ethical Principles Research must Adhere to

1. Respect for persons - protecting autonomy
2. Beneficence - no harm
3. Justice - fairness

Informed Consent

the right of researchers to receive participant information as well as the right of participants to withdraw from the study at any time
- usually given in written form

Who defines the standards of nursing care?

the ANA, NLN, and The Joint Commission

Steps in Developing EBP

1. develop a clinical question
2. retrieve the evidence
3. evaluate the evidence
4. apply the evidence

Background Question

general questions that seek more information about a topic
- knowledge-based
- fill in gaps of knowledge
EX: Who is at risk for hypoglycemia?
- answers can be found in textbooks, medical dictionaries, drug handbooks, etc

Foreground Question

narrower in focus and are about a specific clinical issue
- practice-based
- includes PICOT
- identify useful information about direct patient care
EX: How does using an incentive spirometer affect the length of stay for a surgical patient?
- answers can be found in studies conducted to elicit evidence

Types of Studies

- Meta-Analysis
- Case Study
- Cohort Study
- Case-control Study
- Randomized Controlled Trial (RCT)

PICOT

the elements of a clinical question; develops foreground questions that apply EBP to clinical situations and problems
Population (of patients) or Problem of interest
Issue of interest or Intervention
Comparison of interventions
Outcome (desired effect)
Time frame

Retrieving the Evidence

Step 2
- reviewing pertinent literature
- judging the credibility of a site or source
- using local reference libraries and resource links (PubMed, EBSCO, AHRQ, CINAHL)

How do you evaluate evidence?

By checking the
1. Validity (the degree to which the study measured what it was intended to measure)
2. Reliability (consistent results)
3. The strength of the evidence (hierarchy)

Hierarchy of Research

Gold Standard: large randomized controlled studies/meta-analyses
- Meta-analysis of controlled studies (not large)
- Individual experimental studies
- Quasi-experimental studies
- Non-experimental studies
- Opinions of well-known experts/respected authorities
Lowest level: opinions of reviewers

Categories of Evidence Strength

Green Light, Yellow Light, Red Light

Green Light

strong evidence supports interventions that are likely to be effective and helpful

Yellow Light

not enough evidence is available to determine the effectiveness of the interventions as harmful or helpful

Red Light

strong evidence indicates that interventions are likely to be ineffective or possibly harmful

Applying the Evidence

Step 4
- integrate the best evidence, clinical expertise, and patient preferences
- implement change
- evaluate the impact of the change on patient outcomes
- share the findings with other colleagues (informally or formally)

communication

any means of exchanging information or feelings between two or more individuals
- intent: to elicit a response
- can be positive or negative
- Process includes: a sender (encodes), a message (sent through a channel), receiver (decodes), and a response (feedback)

Verbal Communication

communication using the spoken or written word

Considerations for Verbal Communication

- Pace and Intonation: the manner of speech; affects the feeling and impact of the message
- Simplicity: the use of commonly understood words
- Clarity and Brevity: saying precisely what is meant using the fewest words possible
- Timing and Relevance: timing needs to be appropriate and words need to be relevant to the receiver
- Adaptability: altering spoken messages in response to behavioral cues from the patient
- Credibility: quality of being truthful and reliable
- Humor: can be used to help patients adjust to difficult and painful situations

congruent communication

the nurse's behavior or nonverbal communication is congruent (consistent) with the words spoken

Nonverbal Communication

AKA body language; includes gestures, body movements, use of touch, and physical appearance to convey a message
- majority of communication
- tells you more about how someone feels
- controlled less consciously than verbal behavior
- can reinforce or contradict what is said verbally
- personal appearance = clothing/accessories
- facial expression (most expressive part of the body; eye contact)

Barriers to Communication (What NOT to do)

- Stereotyping
- Agreeing and Disagreeing
- Passing Judgment
- Giving common advice
- using reassuring clichés
- requesting an explanation
- being defensive
- changing the subject
- challenging, testing, or rejecting the patient

Agressive Communicators

those who tend to focus on their own needs and become impatient when these needs are not met
- often perceived as a personal attack by the recipient
- humiliates, dominates, controls, or embarrasses someone
EX: screaming, sarcasm, rudeness, belittling jokes, and direct insults

Passive Communicators

those who focus on the needs of others; they often deny themselves any sort of power, which causes them to become frustrated
- disregard their own feelings
- are insecure and try to maintain their self-esteem by avoiding conflict

Assertive Communicators

those who declare and affirm their opinions while respecting the rights of others
- strikes a balance between the aggressive communicator and passive communicator
- most productive communication
- advocate for their patients
- body language is relaxed and open to conversation
- THE BEST NURSES

Benefits of Assertive Communication

- increases the likelihood of creating a win-win result
- improves communication
- reduces stress by deescalating conflict
- improves outcomes
- reduces the likelihood of angry encounters

Techniques for Assertive Communication

- "I" statements (encourages discussion)
- Fogging (compromise)
- Negative assertion (agreeing w/ criticism)
- Repetition
- Confidence
- Managing nonverbal communication
- Thinking before speaking
- Avoiding apologizing whenever possible (puts communicator in a submissive position)
- Performing a post conversation evaluation

What do you do when posed with a language deficit?

ALWAYS ASSESS FOR THE NEED OF AN INTERPRETER
- do not use family members

What word do we NOT use when talking to patients?

WHY

Communicating with Infants

communicate nonverbally
- perceptions related to sensory stimuli
- engagement: smiling, babbling, and opening hands
- disengagement: crawling away, crying, or lip compression

Communicating with Toddlers and Preschoolers

gain skills in expressive and receptive language
- short answers due to short attention spans
- drawing pictures or using pictures and photos

Communicating with School-Age Children

give the child opportunities to be expressive, listen openly, and respond honestly
- speak at an EYE LEVEL
- include the child in conversations

Communicating with Older Adults

- always ensure patients have their assistive devices (glasses/hearing aids) is applicable
- use communicative devices (pictures/communication boards)
- speak in short, simple sentences
- always face the client
- keep environmental distractions to a minimum
- avoid elderspeak!!
- believe the nonverbal cues!
- reminisce to maintain memory
- follow a normal routine (bedtime rituals)

Techniques of Therapeutic Communication

- empathy (putting yourself in someone else's situation)
- open-ended questions (tell me more about...)
- offering self (we can sit here quietly if you'd like)
- using broad opening statements
- using general leads
- reflecting
- sharing observations
- acknowledging the patient's feelings
- using silence
- giving information
- clarifying
- verbalizing implied thoughts and feelings
- validating
- suggesting collaboration
- exploring

Communication Assessment

- the patient's communication style
- language deficits
- sensory deficits
- cognitive impairments
- verbal communication

Documentation

- date and time with every entry
- legible
- use acceptable terminology
- correct spelling
- appropriateness
if you do not document your actions you did not do it

Reporting

- always READ-BACK an order
- Hand-off includes: significant changes in client's condition, exact information, concise

Telephone Orders

- Write the complete order down and read it back to ensure accuracy
- Question the PCP is anything is ambiguous/contradicting
- Transcribe the order onto the physician's order sheet, indicating it as a verbal order or telephone order
- Follow agency protocol to have the prescriber sign the telephone order (within 24 hrs)

Groups

exist to help individuals achieve goals that might be unattainable through individual effort alone

Primary Groups

small, intimate groups in which the relationships among members are personal, spontaneous, sentimental, cooperative, and inclusive
- face 2 face; strong sense of unity
- set standards of behavior for members
- support and sustain each member

Secondary Groups

generally larger, more impersonal, and less sentimental than a primary group
- just a means of gettin stuff down
- not always face 2 face, don't need to know each other personally
- interaction discontinued after goal is achieved

Characteristics of an Effective Group

1. Accomplish its goals
2. Maintain its cohesion
3. Develop and modify its structure to improve its effectiveness

Group Dynamics

AKA group processes; related to how the group functions, communicates, sets goals, and achieves objectives

5 Aspects of Group Dynamics

Commitment, decision making ability, member behavior, cohesiveness, and power

What does TeamSTEPPS stand for?

Team Strategies and Tools to Enhance Performance and Patient Safety

TeamSTEPPS Core Skills

- Communication
- Leadership
- Situation monitoring
- Mutual Support

5 Key Principles of TeamSTEPPS

1. team structure
2. communication
3. leadership
4. situation monitoring
5. mutual support

Multi-Team System (MTS) for Patient Care

- patient
- core team (contingency teams - emergency)
- coordinating team / ancillary & support services
- administration

The 2 Types of Leaders

1. Designated leaders (EX: charge nurse)
2. Situational leaders

Responsibilities of Effective Team Leaders

- Organize the team
- Identify and articulate clear goals (i.e., the plan)
- Assign tasks and responsibilities
- Monitor and modify the plan; communicate changes
- Review the team's performance; provide feedback when needed
- Manage and allocate resources
- Facilitate information sharing
- Encourage team members to assist one another
- Facilitate conflict resolution in a learning environment
- Model effective teamwork

Barriers to TeamSTEPPS

-inconsistency in team membership
-lack of time
-hierarchy
-defensiveness
-varying communication styles
-fatigue
-misinterpretation of cues
-workload
-lack of coordination and follow-up
- distractions

TeamSTEPPS Communication Tools

- SBAR (discusses facts)
- Call Out
- Check Back
- Handoff (I PASS THE BATON)

TeamSTEPPS Leading Teams Strategies

- Brief
- Huddle
- Debrief

TeamSTEPPS Situation Monitoring Tools

- STEP
- I'M SAFE

TeamSTEPPS Mutual Support Tools

- Task Assistance
- Feedback
- Assertive Statement
- Two-Challenge Rule
- CUS
- DESC Script

TeamSTEPPS Outcomes

- Shared mental model
- Adaptability
- Team orientation
- Mutual trust
- Team performance
- Patient safety

Team Structure

identification of the components of a multi-team system that must work together effectively to ensure patient safety

Communication (TeamSTEPPS)

structured process by which information is clearly and accurately exchanged among team members

Leadership

ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources

Situation Monitoring

process of actively scanning and assessing situational elements to gain information, understanding, or to maintain awareness to support team functioning

Mutual Support

ability to anticipate and support team members' needs through accurate knowledge about their responsibilities and workload

Ergonomic Considerations

- maintain neutral body position (shoulders/upper arms perpendicular to floor; upper arms and elbows close to body; forearms, wrist, hand straight and in line)
- repetitive strain injury (limbs are subjected to repetitive use, awkward positions, or forces positions; can affect nerves/tendons/muscles)
- computer vision syndrome (eye fatigue, headaches, blurred vision, dry eyes; risk increases if computer use exceeds 3hrs/day)

How to prevent computer vision syndrome

put the monitor in the correct position, use antiglare screen covers, have correct lighting, and proper document placing

Telehealth

uses telecommunications technologies to allow patients access to care that they might not otherwise be able to obtain
- not meant to replace all provider face-to-face visits
- most helpful for those who live in rural areas where access to specialists is limited or requires travel
- an attractive and cost-effective option for both patients and providers

Benefits to Telehealth

- Access to healthcare is increased
- Health outcomes are improved
- Healthcare costs can be reduced
- Telehealth may help with shortages of healthcare providers

Drawbacks to Telehealth

- number of visits paid by insurance may be limited
- reimbursement varies by state
- obtaining a telehealth license varies from state to state
- patients may be reluctant to use services
- lack of understanding or experience with technology
- lack of access to interest
- necessary electronic equipment can be expensive

Patient Education and E-Health

when patients have access to their EHRs, they feel more knowledgeable about their health and disease processes, are more engaged during visits with their primary care provider, and feel more empowered to participate in disease management and wellness activities
- smartphone technology
- fitness training applications
- fitness bands
Nurses need to understand a patient's level of e-health literacy

Patient Portals

using the internet to give patients access to and control over their own health records
- online registration is required, and a user identification and password are needed for each visit
- patients can schedule routine appointments, request prescription refills from the office, and communicate electronically with their health provider
- use of these services leads to higher patient satisfaction and retention within the health system
- data security is a concern

Computerized Medical Records

mainly used in clinical settings; combines patient's entire health history into one single source and makes the information portable (available across multiple settings)
- Functions: patient support, health information and data, reporting, secure electronic communication, CPOE, clinical decision support systems, and administrative uses
- CANNOT TAKE THE PLACE OF SOUND NURSING JUDGEMENT

HITECH Act

Health Information Technology for Economic and Clinical Health Act
- enacted in 2009
- getting the EHRs and technology in place
- financial incentives to healthcare orgs and healthcare providers

TIGER Initiative

Technology Informatics Guiding Educational Reform
- additional training to make sure nurses can use the technology
- integrating technology and informatics competencies into nursing education as well as practice

IV Smart Pumps

designed to reduce errors
- unit specific

Point of Care Testing

Interventions or testing that takes place using transportable, hand-held devices near the client
- provides on-the-spot information about the patient rather than having to wait for the results from blood or urine samples sent to the laboratory

Information Security

- log off the computer before leaving your workstation
- position the computer to ensure others cannot view PHI on the monitor
- access computer in a private area when possible
- NEVER share your password, not even with IT
- do not log onto the computer for someone else to use
- you can't access your family members' charts if you're working on the same unit

AIDET

Acknowledge (eye contact, smile, friendly)
Introduce yourself
Duration (time frame)
Explain (what are you going to do?)
Thank you