kim bissettt wilmer presentation · june 1, 2016 2 nursing inquiry: ... 6/1/2016 5 evidence-based...

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Nursing Inquiry

Deciding which road to take

Objectives

• Identify the differences between research, QI, and EBP.

• Describe the process for defining a problem.

• Understand how to develop a question using the PICO format.

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Nursing Inquiry:

• How do we know that we are achieving the best patient outcomes from our nursing interventions?

• How do we incorporate best

practices into our nursing

protocols?

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Which way should we go?

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QUALITY IMPROVEMENTEVIDENCE-BASED PRACTICE

RE

SE

AR

CH

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Research

• Generates new knowledge for broad application

• Uses scientific methods

Quality Improvement

• Improves systems or processes within a unit or organization

• Uses PDSA method

EBP

• Synthesizes “best” evidence

• Uses PET process

Three Forms of Inquiry

Problem

• Ventilator acquired pneumonia (VAP) in ICU causes increased morbidity and mortality in patients and may be preventable.

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Research

• Generates new knowledge for broad application (produces evidence)

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Research• Goal is to generate new knowledge or to test an intervention

• Systematic inquiry that uses scientific methods– Research hypothesis

– Research design

– Data Collection

– Analysis

– Conclusion

Research

• Conduct a study to determine:

–Is there a link between VAP and oral care frequency?

–Is there a link between VAP and suctioning?

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Quality Improvement

• Improves systems/processes within specific unit or organization (produces evidence)

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Quality Improvement

• Key feature is that it is a cyclic process designed to evaluate/measure work flow and work processes

• Plan – Do – Study ‐ Act

Quality Improvement

• Collect data on VAP rates in the ICU?– Do they show that VAP rates have increased in the

past few months?

– If so, what strategies can be implemented to further decrease VAP rates?

– Implement the strategies.

– Continue to monitor trends in VAP rates.

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Evidence-based Practice

• Synthesizes “best” evidence

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Best EvidenceResearch & non-

Research

Nurse Expertise

Clinician, Manager, Educator

PreferencesPatient, Staff,

Student

Management

Education

Clinical Practice

Evidence‐based Practice

Decision Making

EBP

• Background/PICO question to gather evidence: – What are the best practices to prevent VAP in ICU

patients?

• Formulate the foreground question after initial literature search-– Will daily suctioning or routine oral care have a better

impact on rates of VAP?

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Research, QI, or EBP?

• The labor and delivery unit at a community hospital wants to improve the discharge time of patients.

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• An interdisciplinary team in the OR wants to know how best to position patients prevent pressure ulcers

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• A team interested in cancer outcomes wants to know the quality of life outcomes in mastectomy patients from pre-surgery to one year post-surgery

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• PACU nurses want to reduce practice variation and would like to find the best practices for screening for obstructive sleep apnea

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What is the problem?

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One of the most important steps of the entire process.

The notion of 55:5

Defining The Problem

photo by itsbeach on Flickr 21

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Defining the Problem

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MANAGERIAL CLINICAL EducationalWhy do I have to change my IV bags every

24 hours?

Is it safe for nurses to work 12 hour shifts?

When is the best time to

start discharge

teaching for patients?

– Safety and/or risk

– Unsatisfactory patient outcomes

– Wide variations in practice

– Different from community

standard

– Significant financial concerns

Examples of Practice Issues

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Problem Statement

Phrase the problem statement in terms of the knowledge gap not the solution.

We need a new way to create a nurse staffing

schedule.

We need to understand how to best ensure

appropriate coverage for patient care.

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Problem Statement

State the problem rather than symptoms of the problem

Gap between current state and what isdesired

• Outward sign of problem• Variance from the norm• Evidence that problem exists

• Outward sign of problem• Variance from the norm• Evidence that problem exists

Symptom

Problem

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Describe in precise terms the possible GAP between the world as you see it and how you would like it to be.

Problem Statement

Broken: needs to be

fixed?

Risk: needs to be prevented?

New Evidence: needs to be accepted?

Missing:needs to be provided?

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Examine the problem definition critically.

Reflect Gather Information Observe

Listen Visualize Probe

Problem Statement

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Not enough nurses Add nurses!

Variable patient acuity

Revise scheduling practices

Best practices to manage

staffing

Make sure that your problem statement defines the real problem

Problem Statement

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Ask clarifying questions to further refine your problem statement

We need a better way to do CL dressing changes.

We need to use best

practice.

We need to reduce CL-BSI.

Why? Why?

Problem Statement

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Untimely management of pain in PACU

patients receiving epidural infusions.

Why?

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Why?Difficulty determining the

reliability of sensory block or dermatome level

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Variable practices for assessing sensory block

or dermatome level





Why?

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Knowledge gaps – we don’t know the best way to assess sensory

block or dermatome level

Variable practices for assessing sensory block

or dermatome level





Why?

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Do not blame the problem on an external force or focus attention on the wrong aspect of the problem

Problem Statement

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State the problem in a different way.

We need to increase

productivity.

We need to work smarter.

We need to make our job

easier.

Problem Statement

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Challenge your assumptions.Think outside the box, avoid conjecture

Question everyday things you take for granted

This problem is caused by our

electronic system. It can’t be fixed.

We’ve always done it this way, but let’s do an

EBP project to see if there’s evidence

supporting a better way.

Problem Statement

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Expand and contract the problem.

Problem Statement

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Think about the scope of the problem– Who is affected?

– Where is the problem experienced?

– When does the problem surface?

– What new information is needed?

Problem Statement

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• Assume multiple solutions

– We need to understand the best way to…?

– We need to understand the best ways to…

• Word the problem in a positive manner

– We need to understand how to prevent smoking

– We need to understand how to increase positive smoking cessation behaviors

Problem Statement

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Case Scenario

Fall Prevention Advisory Committee members notice an increase in fall-related injury over the past few quarters.

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1. The current fall risk assessment tool does not prevent falls.

2. There has been an increase in fall-related injury.

3. We need to know how to prevent fall-related injury.

4. We need to know how to identify patients at risk for fall-related injury.

Problem Statement

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1. The current fall risk assessment tool does not prevent falls. This problem statement does not directly relate to the issue presented in the scenario.

2. There has been an increase in fall-related injury.This problem statement relates to the issue of concern, but is too broad and does not help to inform an EBP question.

3. We need to know how to prevent fall-related injury.

This problem statement identifies a knowledge deficit, but does not relate to the specific issue under discussion

4. We need to know how to identify patients at risk for fall-related injury.

The statement identifies a knowledge deficit that relates to the issue and can be addressed through the EBP process.

Problem Statement

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Developing the Question

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PICO Format

P Patient, Population, Or Problem

I Intervention

C Comparison With Other Interventions

O Outcome Of Interest

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QuestionDevelopment

Tool 45

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Background vs. Foreground PICO

Background

• Answer: who, what, why, when, where, for whom, how well

• Produce a wide range of evidence

• No comparisons to other interventions

• Provide a starting point

Foreground

• Include specific comparisons between 2 or more methods

• Produce a limited body of evidence

• Build on background knowledge

• Help refine the search

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Examples of Background and Foreground Questions

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BACKGROUND QUESTION:

• What are best practices to decrease the number of monitor alarms?

FOREGROUND QUESTION:

• Does changing the electrodes daily as compared to current practice have an effect on the quantity of monitor alarms from cardiac monitors?

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Examples

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BACKGROUND QUESTION:

• What is the best method of administering SC heparin to adult patients that would decrease ecchymosis and pain at the injection site?

FOREGROUND QUESTION:

• Will a 30 second duration of heparin injection result in less bruising and site pain as compared to a 10 second injection?

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Examples

Resources

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Resources

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Summary

• Always start with the evidence. • Research- large scale, generalizable

new knowledge• QI- smaller scale, localized, • EBP- synthesis of best evidence • Spend time defining your problem• Use PICO to generate your question

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Questions? [email protected]

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kim bissettt wilmer presentation · june 1, 2016 2 nursing inquiry: ... 6/1/2016 5 evidence-based...

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