Chapter 1-9 Nursing Fundamentals: Evidence-Based Practice, Informatics, Communication, SBAR, and Rapid Response
Evidence-Based Practice in Nursing
Evidence-based practice (EBP) in nursing
- Defined as a problem-solving approach to clinical decisions using the best evidence available.
- Central goal: improve patient outcomes through research and systematic use of evidence.
- Nursing relies on evidence-based research to inform practice and policies.
- Relevance to advanced degrees: in Westchester University pathway and beyond (bachelor’s, master’s, doctorate), EBP and research are foundational.
Clark model (acronym for areas of nursing research and impact)
- Clinical care
- Long-term care
- Across the lifespan
- Rehabilitation
- Community health
Role of nursing education and policy
- Education is a core nursing function: teaching patients about disease processes, medications, exercises, and follow-up with PCPs.
- Policy development: facilities have committees (e.g., policy committees) to address infection control and other safety policies.
- Ethics: ethics committees participate in research planning and ethical oversight.
- Nursing history: foundational importance; connects past practices to current research and policy.
Research utilization and its purpose
- Process that helps nurses improve patient care by supporting interventions, including assessing which interventions are appropriate for individual patients.
- Interventions proven beneficial in some patients may not help others; EBP guides selection for best outcomes.
EBP as a framework for clinical decision-making
- A problem-solving approach to clinical decisions using the best evidence available.
- Path to advanced study: doctoral projects and research contribute to better practices (e.g., improving Foley catheter insertion to reduce infections).
- Emphasis on safety and patient outcomes: safety is a core component of EBP and nursing practice.
The application of evidence in nursing practice
- EBP supports or challenges the effectiveness of treatments and diagnostic tools; policies can be revised based on new evidence.
- Nurses must practice and refine skills to build confidence and improve patient care through repeated skill mastery.
- Policies and practices may be retested; evidence may confirm or overturn traditional approaches.
Nursing informatics (NIC)
- Definition: a combination of nursing science, information science, and computer science to optimize communication among nurses, patients, and other stakeholders.
- Acronym NIC stands for: Nursing science, Information science, and Computer science.
- Examples of informatics in practice
- Electronic health records (EHRs)
- Telehealth/teladoc and telemedicine
- Patient portals (e.g., MyChart) for patient access to test results and messaging with providers
- Telehealth usage increased during COVID-19 and in ongoing care delivery
- HIPAA and confidentiality
- Do not leave patient information visible on screens; log out when stepping away; protect patient information from unauthorized access.
- Social media discussions about patients are strictly prohibited and can lead to expulsion from programs.
- Confidentiality and professional practice
- EHRs create a legal record; ensure information is complete, current, and accurate in documentation.
- Night/day shift communication (SBAR) relies on accurate electronic and verbal handoffs.
- Communication as a primary informatics function
- EHRs support documentation, reporting, and handoffs; ensure proper use to maintain continuity of care.
Key examples of informatics tools
- Electronic Health Records (EHRs)
- Telehealth and Teladoc
- Patient portals for ongoing patient–provider communication
- Data security, access control, and privacy protections under HIPAA
Patient communication and safety through informatics
- SBAR as a structured handoff and escalation tool
- Confidentiality: avoid discussing patient information in public spaces or on social media
- Report quality: communication must be accurate, complete, and current
- Guarding patient privacy when using chart access in clinical settings
Therapeutic communication and safety in practice
- Therapeutic communication: intentional, patient-centered interactions to support healing
- Speaking with clarity and empathy; avoid talking over patients; maintain patient dignity
- Nonverbal communication is as important as verbal communication
- Tone of voice and body language influence patient perception and trust
- When patients cannot communicate verbally (e.g., stroke, dementia), tailor communication to their abilities and involve caregivers
- Invasive procedures require explicit patient consent and explanation in terms the patient (and family) can understand
Intrapersonal vs interpersonal communication
- Intrapersonal: the inner self and internal responses when faced with difficult patients/families
- Interpersonal: communication between people (nurse–patient, nurse–physician, nurse–family, team huddles)
- Importance of asking the patient for preferences and involving families when appropriate
Cultural, sociocultural, and language considerations
- Sociocultural differences influence care preferences, timing, and daily routines
- Cultural humility: ask about cultural practices, food preferences, decision-making roles, and family dynamics
- Language barriers: use translators (phone or in-person) when needed; avoid assumptions; avoid over-simplified attempts to communicate by shouting or shouting over the patient
- Language acquisition is linked to necessity; ensure access to translators for non-English speakers and their families
- Awareness of dialects and potential ambiguities in terms (e.g., “pop” meaning different things across cultures)
- Respect personal space and consent for touching; explain before touching or performing procedures
Special considerations for cognitive impairment and dementia
- Alzheimer’s and dementia require tailored approaches; break instructions into simple steps; one task at a time
- Use meaningful tasks (e.g., folding towels) to reduce agitation and engage patients
- Changes in routine can increase agitation; frequent rounding and familiarization help
- Recognize that aggressive or resistant behavior may be linked to pain, incontinence, or other discomfort
- Family involvement matters; gather cultural and personal history from family to inform care
The nursing process and documentation as communication tools
- Nursing process: Assessment → Diagnosis → Planning → Implementing interventions → Evaluation
- Documentation is critical for legal and clinical purposes; ensure timely, accurate, complete notes
- Late documentation is better than no documentation; use late entries with timestamps to maintain accuracy
- Documentation supports patient safety, continuity of care, and legal accountability
- When turning and performing other interventions, document every action and its outcomes
Rapid response and codes: recognizing deterioration and escalation
- Rapid response is for significant, rapid deterioration or new critical findings between shifts
- Trigger examples include sudden changes in vital signs, worsening dyspnea, new chest pain, altered mental status, or patient becoming unstable
- The SBAR framework is used to escalate care quickly to the appropriate team
- If doctors are unavailable, escalate to rapid response or nursing supervisor to obtain timely orders and support
SBAR: structure and example
- S (Situation): A brief statement of the problem or reason for the call
- B (Background): Quick history relevant to the current situation
- A (Assessment): What you think is happening based on objective data
- R (Recommendation): What you request or propose (e.g., come to the bedside, order meds, or obtain rapid assessment)
- Example notes from clinical scenarios
- Miss Rose Golden: 84-year-old with new hip fracture after a fall, DNR, diabetes, mild dementia; pain 8/10, morphine given; X-ray shows hip fracture; plan to monitor vitals, continue analgesia per orders, consult for surgical intervention, assess fall risk and implement safety measures (bed alarms, close rounding, etc.)
- Mr. Peter North: 53-year-old post shoulder surgery (24 hours ago); hyperlipidemia on atorvastatin; baseline vitals at 15:30: HR 74, BP $120/60$, RR 18, SpO2 99%; at 17:00: dyspnea and chest pain; vitals show RR 28, SpO2 90%, HR 96, BP $102/54$; assessment includes possible cardiopulmonary complication or pulmonary embolism; recommendation: physician to assess ASAP, rapid response if deteriorating
Scenarios as practice for SBAR and clinical reasoning
Scenario 1: Missus Rose Golden (84, hip fracture, DNR, diabetes, mild dementia)
Situation: Elderly female admitted via ER from SNF after a fall attempting to use the bathroom; hip fracture suspected; DNR; family POA (daughter) involved
Background: Diabetes; mild dementia; DNR order with documentation; left hip bruise; leg length discrepancy (left hip elevated and bruised)
Assessment: X-ray confirms hip fracture; pain 8/10 prior to morphine; pain reduced to 3/10 post-morphine; ongoing need for analgesia; fall risk and cognitive status influence care planning; consider OR involvement
Recommendation: Monitor vitals; continue morphine within orders; ensure surgical consult for hip fracture; implement fall precautions (bed alarm, close rounding); label as fall risk; ensure family involvement and POA contact; consider environment adjustments for safe mobility
Scenario 2: Mister Peter North (53, shoulder surgery 24 hours ago)
Situation: Postoperative patient with acute dyspnea and chest pain; baseline vitals provided; current deterioration documented
Background: Shoulder surgery 24 hours ago; hyperlipidemia; on atorvastatin
Assessment: Acute dyspnea, chest pain; RR increased to 28, SpO2 dropped to 90%, HR 96, BP 102/54; differential includes pulmonary embolism vs postoperative cardiac strain; needs urgent evaluation
Recommendation: Urgent physician assessment; consider rapid response if condition worsens; prepare for potential diagnostic workup (ECG, imaging, labs) and possible interventions
The importance of debriefing and CSL (clinical simulations lab)
- Debriefing: post-scenario review to identify what went well, what could be improved, and how to adjust practice
- CSL: ongoing hands-on simulations to practice handoffs, safety procedures, and clinical skills
Practical takeaways for clinical practice
- The central role of EBP and informatics in everyday nursing practice
- The critical nature of patient safety, including infection prevention, privacy, and accurate documentation
- The necessity of effective, clear, and compassionate communication (SBAR) across shifts and disciplines
- The need to tailor communication to patients with cognitive impairment or language barriers
- The importance of cultural sensitivity and respecting patient autonomy and family roles
- The reality that falls and adverse events can happen; prevention requires vigilance, environmental adjustments, and proactive planning
- The ongoing need for continuous learning, skill practice, and application of evidence in clinical decisions
Quick reminders and logistics mentioned
- CSL and handwashing demonstrations scheduled (healthcare hygiene and safety basics)
- Emphasis on ethical use of patient information and professional behavior
- Awareness that some patients require additional support (e.g., translators, family involvement, cultural considerations)