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What do you do when...

clock November 9, 2011 04:01 by author Lisa Bonsall, MSN, RN, CRNP

I’ve been reading a lot of articles about ethics lately as I prepare to update our Focus On: Nursing Ethics collection. Of course, so many dilemmas that I’ve faced in my practice are coming to mind and I’ve been giving a lot of thought lately to these ethical issues and the decisions that I/the team made. Here are some of the issues that have been on my mind:

What do you do when…

…a patient wants to sign out AMA? Do you try to convince him to stay?

…you suspect someone you know personally has an eating disorder? Do you speak up?

…a patient is having pain and the prescriber refuses to order a pain medication? Do you go up the chain of command?

…you feel that your patient assignment is unsafe? Do you demand a change?

…you are sick but you know that the unit is already short-staffed for your shift? Do you go in to work?

What ethical dilemmas have you faced in your practice? How did you and your colleagues handle it?



What is your question?

clock October 29, 2011 04:56 by author Lisa Bonsall, MSN, RN, CRNP

Along the lines of my recent posts on evidence-based practice, I have one more thing I’d like to share. It’s something I wish I had known back in nursing school and especially in graduate school while working on my final research paper before graduation. It’s called a PICOT question.

PICOT is an acronym to help you formulate a clinical question and guide your search for evidence. Using this format can help you find the best evidence available in a quicker, more efficient manner. Take a look:

P = patient population

I = intervention or issue of interest

C = comparison intervention or issue of interest

O = outcome

T = time frame

Try using the PICOT format to help you formulate your next clinical question and search for relevant studies and publications. For example, if you wanted to know the effect of flu vaccination on the development of pneumonia in older adults, you could fill in the blanks like this:

In _________(P), how does __________ (I) compared to _________ (C) influence _________ (O) over ________ (T)?

In patients ages 65 and older,  how does the use of an influenza vaccine  compared to not receiving the vaccine  influence their risk of developing pneumonia during the flu season?

What’s your question? Try using the PICOT format and see how it affects your search results! You can find more information, including other templates to help you formulate your question in Asking the Clinical Question: A Key Step in Evidence-Based Practice

References

Stillwell, S., Fineout-Overholt, E.,  Melnyk, B., & Williamson, K. (2010). Evidence-Based Practice, Step by Step: Asking the Clinical Question A Key Step in Evidence-Based Practice. American Journal of Nursing, 110(3), 58-61.

Woods, A. (2011). Implementing Evidence Into Practice. Webinar. Philadelphia: Lippincott Williams & Wilkins.



Systematic review

clock October 10, 2011 05:24 by author Lisa Bonsall, MSN, RN, CRNP

During my days of nursing school and research classes, we did literature reviews to determine relevant research surrounding a topic of interest. While we did learn about ensuring that studies in our literature reviews were solid, with appropriate sample, design, methods, etc., we didn’t actually compare the findings from the studies with the same intensity that we do today. 

A recent webinar about evidence-based practice (EBP) really cleared up some concepts and terms for me, including the importance of using systematic reviews when examining evidence. A systematic review is an essential component for basing change in practice on current evidence. So how does a systematic review differ from a literature review?

  • Peer review is a critical part of the process. A systematic review looks at evidence reported in peer-reviewed journals and the systematic review itself is peer-reviewed.
  • The evidence is rigorously reviewed, using the same manner and standards that were used to produce the evidence.

We know that changing practice based on one research study is not enough. It’s not even enough to change nursing practice based on several studies. Available evidence must be investigated and interpreted using scientific review methods. A well-conducted systematic review summarizes existing research, defines the boundaries of what is known and what is not known, and helps resolve inconsistencies among diverse pieces of research evidence (Duffy, 2005).

Here’s a good example of a systematic review from the October issue of American Journal of Nursing. As you read Deactivation of ICDs at the End of Life: A Systematic Review of Clinical Practices and Provider and Patient Attitudes, pay particular attention to Table 1 where the sample, methods, and findings of each study are summarized. 

References

Duffy, M. (2005). Using Research to Advance Nursing Practice: Systematic Reviews: Their Role and Contribution to Evidence-based Practice. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 15-17.

Woods, A. (2011). Implementing Evidence Into Practice. Webinar. Philadelphia: Lippincott Williams & Wilkins.



An equation for EBP

clock October 2, 2011 01:37 by author Lisa Bonsall, MSN, RN, CRNP

I recently had the pleasure of attending a webinar on evidence-based practice (EBP) hosted by our own Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC. Anne brought the concept of evidence-based practice into a whole new light for me with this simple equation:

Research + Clinical Expertise + Patient Preference = EBP

One research study is not sufficient to support change in practice. Nor are three research studies, or 10, or 100… Solid research is only one piece of the puzzle. Three components are essential to true EBP and are critical to improve outcomes and quality of life:

1. External evidence includes systematic reviews, randomized control trials, best practice, and clinical practice guidelines that support a change in clinical practice. 
2. Internal evidence includes health care institution based quality improvement projects, outcome management initiatives, and clinical expertise. 
3. Accounting for patient preferences and values is the third component of this critical equation.

Another approach to understanding EBP is to compare what EBP isn't with what EBP is: 

  • EBP is NOT a research project. EBP is examination of completed research studies.
  • EBP is NOT simply supporting national evidence-based practice projects. EBP is a complete review and recommendation process.
  • EBP is NOT having research articles as references for policies. EBP is critical analysis of research, in the context of your organization, and with perspectives and judgment of clinicians and patients.

How familiar are you with systematic reviews and PICOT questions? Look for upcoming posts on these topics this week. Also, coming soon is Lippincott’s Evidence-Based Practice Network! We are very excited to be close to sharing this new resource with you!

References

Russell-Babin, K.  (2009). Seeing through the clouds of evidence-based practice. Nursing Management, 40(11), 26-32.

Woods, A. (2011) Implementing Evidence into Practice. [Webinar] Philadelphia: Lippincott Williams and Wilkins.



Effective mentoring

clock September 14, 2011 06:49 by author Lisa Bonsall, MSN, RN, CRNP

I just finished reading Professional Growth: Taking a novice nurse under your wing from the September issue of Nursing2011. In this article, the author, Pamela Woodfine MSN, RN, emphasizes the importance of mentoring and making a new nurse’s first experiences in the “real world” of nursing positive ones. She also stresses the importance of recruitment and retention to the future of our profession. Below, the phases of the mentoring process are listed as presented in this article. Regardless of where you are in your nursing career, whether the new nurse or a new or experienced preceptor, I think you’ll find them interesting and helpful in planning and implementing a successful transition into nursing. 

  • Phase 1: introductions, discuss one another’s personal and professional goals 
  • Phase 2: set goals and objectives together, establish a time frame
  • Phase 3: determine guidelines for implementing plan of action and working relationship (for example, open communication, availability, and constructive criticism) 
  • Phase 4: reflection and feedback  (most important phase; fosters critical thinking and increases clinical skills)

I hope you enjoy this article. You can read it free online while it is on our Recommended Reading list.  Also, you can read about A memorable mentor in my career and my thoughts on The makings of a good mentor.



From MICU nurse to NICU parent

clock September 8, 2011 13:49 by author Lisa Bonsall, MSN, RN, CRNP

In my last post, I wrote about a challenging case where a patient’s sister, who was a nurse, tried to limit the amount of pain medication we were administering. Now I’d like to share my feelings about being a nurse turned patient/family member. 

Many of you who are members of NursingCenter or who follow this blog already know the story about when my sons were born. It was a surreal time in my life when they were born prematurely and spent several months in the Neonatal Intensive Care Unit (NICU). In minutes, I had switched roles from critical care nurse to new mother of two critically ill babies.  Before this, I had seen family members through illness and surgery and even sat by the bedside of my grandmother when she died in the unit where I worked. However, I think it was my time as a NICU parent that really exposed me to what it was like to be on the “other side.”

As anyone who has ever been there can tell you, it is scary! Sure my knowledge and clinical experience were helpful in understanding what was happening, but I remember quickly (even immediately) reaching the point of being completely overwhelmed. While I understood terminology and the pathophysiology, I was used to caring for adults - premature babies were a whole different world. “What about his tachycardia?” I would think. Then, the nurse, without even knowing my question would tell me, “He’s not tachycardic, a heart rate of 140 bpm is normal!” I guess she could just see the panic on my face!

It was very stressful for me to be aware of all the potential complications that could come upon my sons. Sure, I knew that dopamine was necessary to perfuse “Baby A’s” kidneys. I also knew that when the nurses increased the dose, that the goal had changed and now maintaining his blood pressure was necessary. I didn’t want to know the possible consequences if it extravasated or that his high ventilator settings could cause a pneumothorax. 

I know that my knowledge and experience helped me advocate for my sons, be involved with their physical care, and explain what was happening to the rest of our family. I am so grateful for the staff that, while they knew about my background, they also saw me as a new mother who was scared.  So what did I learn from this? Yes, patients and family members, whether they are health care professionals are not, are more informed and educated about their health care than ever. That is a good thing, but it is important to remember that we are all human beings first and in times of crisis, we all need compassionate care and a kind ear. 



When a patient or family member is a nurse

clock August 23, 2011 16:40 by author Lisa Bonsall, MSN, RN, CRNP

 

We’ve all been there...getting report when the oncoming shift finishes up and whispers to you that the patient’s family member is a nurse. How do you feel? What is your initial reaction? Do you change your approach to the patient? To the family?

It always made me a little nervous when a patient himself or a member of his family was a health care professional, especially when I was a new nurse. Would he be watching my every move, ready to pounce if I hesitated or didn’t have an answer to a question? Or would he be helpful, offering information and advocating for himself or his loved one?

There was one particular patient* that I cared for when the dynamic of a family member who was a nurse was particularly challenging. I don’t recall the specifics about the patient, only that he’d been transferred several times to different hospitals as a “challenge to wean” patient, meaning he was having difficulty weaning from the ventilator. His sister, a nurse, was his power of attorney and very involved with his care. The issue was that the patient appeared to be in severe pain from contractures and pressure ulcers. He was noncommunicative when he arrived at our hospital, but would have significant changes in vital signs and become diaphoretic and tense his muscles with nursing care. His sister requested that no analgesia or sedation be administered so as not to interfere with his ventilator weaning. 

The team caring for this patient was perplexed. We didn’t feel comfortable not treating his pain, but also were being influenced by the wishes of the patient’s sister. Our hospital’s ethics committee was consulted and a careful balancing act was employed to treat his pain adequately while allowing him to be awake enough to wean from the ventilator.

It was challenging to care for him. His sister would check medication doses and keep track of dosing intervals. It was a stressful time for the staff as we all worked together to provide the best care for the patient while being so closely observed. 

Of course this is only one example. More often, health care professionals who happen to “cross over” into the patient or family member role leave their scrubs or lab coat outside the door. In my next post, I’ll share my own experience being on the other end of the stethoscope. 

*Any identifying characteristics are purely coincidental. 

 



What is shared governance?

clock August 11, 2011 10:27 by author Lisa Bonsall, MSN, RN, CRNP

There are certain words and phrases that are used frequently in nursing and medicine – sometimes so frequently that we lose our understanding of their true meaning. Or sometimes, we may not have really understood them at all.

For me, “shared governance” was one such phrase. In the past, if someone had asked me what shared governance meant, I would have had some difficulty explaining it in great detail. Sure, I would have answered that it’s a model for nurses to work together and manage themselves, but beyond that, I’d have been at a loss.

That is, until, I did some reading. Now I feel better prepared to discuss shared governance and its role in nursing. Here’s what I’d say now:

Shared governance is collaboration, whether in scheduling staff, educating new staff, or implementing evidence-based practice. It involves teamwork, problem-solving, and accountability, with the goals of improved staff satisfaction, productivity, and patient outcomes. It is working together to make decisions that affect nursing practice and patient care. It is working with other disciplines for the good of the patient. It is collaborating to improve nursing practice. 

Allow me to share the following excerpt which I found very enlightening:

The structure is shared governance; the process is professional nursing practice; the outcomes are positive productivity data.1

Is a shared governance structure in place where you work? Have you been involved with implementing shared governance? I'd love to learn more; it sounds like the ideal working environment, but I'm wondering - does it truly exist?

1. Church, J.A., Baker, P., Berry, D.M. (2008). Shared governance: A journey with continual mile markers. Nursing Management, 39 (8).



Once a nurse, always a nurse

clock July 31, 2011 04:00 by author Lisa Bonsall, MSN, RN, CRNP

Have you ever heard someone say “I used to be a nurse” when asked what they do? Me neither! In fact, when someone asks me what I do, the first thing I say is “I am a nurse.” This is usually followed by questions about where I work, what type of patients I care for, and the like. If the person I’m talking with is truly interested, I’ll explain my background in critical care, my role as a nurse practitioner in women’s health, and now my career in the world of publishing. I am proud of what I’ve done in the past and what I do now, but the biggest sense of pride comes with being able to say “I’m a nurse.”

A recent conversation with my mom went something like this: 

Mom: “Have you heard from your cousin?”

Me: “Yes, he’s been great.” I then went on to fill her in on recent events in his life, as well as what his family and friends have been up to.

Mom: “Wow, why is it that everyone calls you with their latest news?” She then answered her own question with “I think it’s because you are a nurse.” 

That warmed my heart! You can probably relate similar stories, especially when it comes to others, sometimes complete strangers, sharing their healthcare stories and questions.

Nurses – we truly are a special group!



A question about social media and nursing

clock July 28, 2011 07:32 by author Lisa Bonsall, MSN, RN, CRNP

Since you are here reading this on our blog, chances are you are pretty familiar with the world of social media. You may even have navigated your way here from Facebook, twitter, or another social media “avenue.”

It’s amazing how social media is infiltrating our lives and changing the world in which we live. We have  several blog posts already about social media (see here, here, and here), but now I’m interested in hearing a little bit about how you are using social media in your job. It is clear that social media is here to stay and will begin to play a more prominent role in health care and nursing. In just the past 3 months, we’ve had several articles in our journals dedicated to social media. For nurses, the use of social media gives us another way to communicate with patients, educate the public, and keep our own knowledge up-to-date. We must be mindful of course, to use social media in a professional manner and without violating privacy.

So here’s my question: What role does social media play where you work?

…and here are those recent articles I mentioned:

How Private Is Your Facebook?
Nurse Educator, May/June 2011

Career Scope: Using a blog to improve communication
Nursing Management, June 2011

Using Social Media as an Institutional Resource: Implications for the Clinical Nurse Specialist
Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, May/June 2011

Practice Points: Social Media Collaboration Checklist
Advances in Skin & Wound Care: The Journal for Prevention and Healing, July 2011



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