Promoting Professional Nursing Practice through Clinical Inquiry

Cheryl Rodgers, PhD, RN, CPNP, CPONAssistant Professor, Duke University School of Nursing

cheryl.rodgers@duke.edu

Objectives

• Differentiate characteristics of quality improvement, EBP, and research

• Identify suitability of quality improvement, EBP, and research work within clinical examples

• Examine nursing roles within quality improvement, EBP, and research projects

Getting Started: A Spirit of Inquiry

All healthcare providers should be encouraged to question current practices

Next Step: The Evidence

• Locating evidence to answer the clinical questions– External evidence

• Research, evidence-based theories

– Internal evidence• Clinical expertise, quality improvement projects

Balance of Evidence

• A world guided by only external evidence– Practice may be dominated by evidence that is not appropriate

for all patients

• A world guided by only internal evidence– Practice can become outdated, to the detriment of patients

• Both influences– Evidence-based clinical guidelines

EBP

ResearchQI

A Clinical Problem

Adolescents recovering from a bone marrow transplantation experience multiple side effects. These patients have expressed a desire to participate in self-care activities to manage these side effects but had limited knowledge and few resources available.

Nurses wanted to help these patients by developing resources for patients but were unsure of the best methods.

Getting Started

• Identifying the focus– What is the problem?

• No resources to self-manage side effects

– Who is the focus for the issue?• Adolescents recovering from a bone marrow transplant

– What is the outcome of interest?• Relief of distressing side effects

• Identifying evidence on the topic

Lack of Evidence: Research

• A scientific process that generates new knowledge or validates existing knowledge

• Scientific process is systematic and methodical

Shirey MR, Hauck SL, Embree JL, et al: Showcasing difference between quality improvement, evidence-based practice, and research. The Journal of Continuing Education in Nursing 42(2):57-68, 2011.

Research Steps• Acknowledge what is known and what gaps exist

in the current literature• Create hypotheses or research questions

specific to your issue of interest • Identify appropriate research design

Research Designs

• Quantitative– Experimental – Quasi-experimental– Non-experimental

• Qualitative– Phenomenology– Grounded theory– Ethnography

• Mixed-methods

Clinical Problem Research Example

• What is known– Effective self-care symptom management interventions are not available to

adolescents recovering from BMT – Self-care management strategies have been developed as cell phone

applications to assist patients with asthma, diabetes, and sickle cell anemia

• What is unknown– No evidence to support the use of a cell phone application for adolescent

BMT patients

• Research aim– A mixed-methods design was used to evaluate the feasibility of a phone

application and to describe their symptom experiences during BMT recovery

Research Characteristics

• Internal review board (IRB) oversight is required

• Involves strict adherence to protocols that control extraneous variables so that a link can be established from the issue of interest and the outcome

• Usually time-consuming process that may involve delayed patient benefits

Shirey MR, Hauck SL, Embree JL, et al: Showcasing difference between quality improvement, evidence-based practice, and research. The Journal of Continuing Education in Nursing 42(2):57-68, 2011.

Bryant R, Rodgers C, Stone S: Enhancing pediatric oncology nursing care through research, quality improvement, and evidence-based practice. Journal of Pediatric Oncology Nursing 30(3):123-128, 2013.

Clinical Problem Example: Findings

• Feasibility– High acceptability: mean score 28.7 out of 30

• “It is a really helpful app” and would recommend it to other patients

– Good use: initial use high that decreased over time• “It’s good information, just not enough to keep coming back”

– Good competency: average orientation time 3.3 minutes

• Symptom experiences– No significant change in symptom distress over time

Rodgers C., Krance R., Street R.L., & Hockenberry M.J. (2013). Feasibility of a symptom management intervention for adolescents recovering from a hematopoietic stem cell transplant. Cancer Nursing, 36(5), 394-399.

Another Clinical Problem

Nurses working in a busy primary care clinic were frustrated with the lack of teamwork due to communication issues (they were spread over a large clinic area) and lack of knowledge about the patient’s needs.

Nurses were interested in trying huddles to improve daily communication.

Getting Started

• Identifying the focus– What is the problem?

• Lack of teamwork

– Who is the focus for the issue?• Nurses in busy primary care clinic

– What is the outcome of interest?• Improved teamwork and communication

• Identifying evidence on the topic– Huddles are an established method of promoting

teamwork and communication

Adequate External Evidence, Lack of Internal Evidence

• Quality Improvement– Process by which individuals work together to

improve local systems and processes– Process involves systematic activities that are

planned, implemented, and evaluated for a targeted outcome

QI Characteristics

• Internal review board (IRB) is usually not needed• Protocol for implementation of change is usually

flexible• Outcome results are specific to the institution

and usually not generalizable

Methods of Quality Improvement

FADE PDSA DMAIC DMADV

Focus    Define Define

Analyze    Measure, Analyze Measure, Analyze

Develop Plan    Design

Execute Do Improve   

Evaluate Study Control Verify

   Act      

PDSA Cycle

Clinical Problem QI Example• Plan: Nurses met to plan the appropriate time and

location for the daily huddle along with pertinent information to be shared

• Do: Huddles were started

• Study: Communication and teamwork were measured two months after implementation of huddle and compared to pre-huddle findings

• Act: Nurses agreed huddles were imperative to improve communication in the clinic and minor changes to the time and pertinent information were made

Another Clinical Problem• Many healthcare providers instruct children with a single

kidney to avoid contact sports in order to protect and preserve the remaining kidney. This is in contrast to the American Academy of Pediatrics policy statement that suggests clinical judgment be used for contact sports in patients with a single kidney.

• Nurses wanted to provide the best advice regarding physical activity for children with a single kidney.

Getting Started

• Identifying the focus– What is the problem?

• Potential unnecessary avoidance of contact sports

– Who is the focus for the issue?• Children with a single kidney

– What is the outcome of interest?• Promoting physical activity

• Identifying evidence on the topic– Multiple sources of evidence available

Evidence-Based Practice

Patient Outcomes

Melynk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice, 2nd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins

EBP Process

• Ask the question

• Search for evidence

• Review, summarize, and analyze the evidence

• Synthesize evidence

• Create practice recommendations that include external evidence, internal evidence, and patient values

• Apply recommendations to practice

• Evaluate the change

Benefits of EBP• Provide the highest quality of care • Minimize variations in the delivery of care• Produce the best patient outcomes• Reduce healthcare costs• Allow clinicians to feel empowered and satisfied in their

role

Melynk, B.M. & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice, 3 rd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.

Clinical Problem EBP Example• External Evidence

– Literature review of 31 studies showed that kidney injury from trauma is rare, kidney

injury from contact sports is rarer, and kidney loss is even more infrequent

• Clinical Expertise

– All forms of physical activity should be encouraged without restriction in children with a

single kidney since exercise benefits outweigh unlikely risks associated with sports

• Patient Preferences

– Vary

• Recommendation

– Information should be presented to patients and families to reinforce that contact

sports poses little or no risk to the kidney and physical activity is strongly encouraged

to maintain overall general health. Okada, M., Hockenberry, M., Koh, C., Meeske, K., Rangan, K., Rodgers, C., Rosenthal, Y., Ruccione, K., and Freyer, D.R. Recommendations for physical activity in childhood cancer survivors with a single kidney. Journal of Pediatric Oncology Nursing, in review.

Comparison

• Research– Generates knowledge

• EBP– Translates knowledge

• QI– Incorporates knowledge

Challenges and Facilitators• Challenges

– Lack of knowledge of research, QI, and/or EBP– Lack of time – Lack of resources

• Facilitators – Mentors– Working in a group to lessen individual’s time– Support from administration– Support from other resources (i.e., medical librarian)

Your Role on the Team

• Novice– Brainstorm ideas– Assist with planning, collecting, analyzing, and disseminating

• Experienced– Work with others to develop projects– Lead teams from project development through dissemination

• Expert– Advocate for change– Provide mentorship

Everyone’s Role

• Cultivate a spirit of inquiry• Empower others• Embrace change

Embracing Change

• Motivate others – Question current practice and create discomfort with the status quo– Provide examples of current practice that is not providing optimal

results– Share evidence for new practice

• Create a vision for change– Build assurance that change can occur– Develop a team of key stakeholders, change experts, staff,

administrators– Create specific and measureable goals– Enlist the use of tools or resources to support change

Celebrate Outcomes

• Provide feedback about the outcome of the practice change

• Acknowledge that all staff were instrumental in the process

• Ensure recognition of people who promoted the change• Maintain momentum to continue with the practice

change

Sustain the Spirit of Inquiry

• Never settle for less than excellence• Always hold your colleagues accountable• Be ready to spark fires where inquiry is needed• Use passion to sustain you

Questions?