Evidence-Based Practice Network

Show Me The Evidence

The Blog of Lippincott's Evidence-Based Practice Network


The debate over standardization of nursing uniforms is well-documented, however, the existence of rigorous, well-designed studies is lacking. In the latest issue of JONA, Journal of Nursing Administration, an integrative review examining the professional appearance of RNs examines the evidence. While the strength of the evidence is low, it is essential for us to recognize the importance of patients being able to identify us as nurses and to understand how our attire impacts the public’s perception of our knowledge and skills.

Seven studies were included in this review and a nice table comparing each of the studies can be found in this supplemental digital content. One study found that among nurses, students, and patients, solid color scrubs reflect more skills and knowledge than print scrubs or T-shirt tops. Another study, which looked at uniform color preference among patients, found blue or white to be most preferred, while red was least preferred. Take a close look at this table to learn more about how both patients and nurses feel that uniform and general appearance impact perception. It’s pretty interesting.

Is there a standard uniform for nursing staff where you work?

Reference:
Cassidy, C., Del Guidice, M., Hatfield, L., Pearce, M., Polomano, R., Samoyan, J. (2013). The Professional Appearance of Registered Nurses: An Integrative Review of Peer-Refereed Studies. JONA, Journal of Nursing Administration, 42(2).


Posted by Lisa Morris Bonsall on 2/10/2013 7:50:36 AM
Tags: integrative review,nurses,nursing uniforms
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We know that evidence-based practice (EBP) leads to improved patient outcomes. Yet it is also known that nurses identify barriers to implementing evidence-based practice, such as lack of knowledge, support, time, and authority to change practice (O'Nan, 2011). Change can be difficult, but as nurses it is our responsibility to our patients and our profession to develop and implement activities that promote evidence-based practice. One such activity that can help us overcome barriers and incorporate research findings into practice is a journal club. A journal club can be described as “the sharing of contemporary knowledge and appraising the value of that knowledge for applications in clinical practice” (Duffy, Elpers, Hobbs, Niemeyer-Hacket, & Thompson, 2011).

What are the benefits of a journal club?
  • Sharing knowledge of current clinical research
  • Facilitating the learning process
  • Enhancing literature critique and appraisal skills
  • Encouraging interaction and dialogue with other nurses
  • Encouraging research utilization
  • Promoting team building
  • Promoting EBP in a cost-effective manner
What are the steps for starting a journal club?
  • Decide if the journal club will be unit-based or hospital-wide.
  • Gain the support of unit managers or senior nursing administration.  Be prepared to discuss the benefits, objectives, scope of work, timetable, and key stakeholders (Chabot, et al., 2011).
  • Determine meeting schedule and length.
  • Identify a leader/facilitator.
  • Identify the topic of interest.
  • Select and disseminate article(s).
  • Hold meeting and discuss the topic/appraise the evidence.
  • Determine if further research or action is needed.
You can learn more by reading the articles referenced below. There are great ideas to help you get started and also to determine the best schedule for your group, the roles and responsibilities of the facilitator and members, and how to evaluate your group’s success. Also, consider the use of an online journal club or use of the tools available from the Joanna Briggs Institute to help you appraise the evidence. Good luck!

References:

Chabot, J., Conners, S., DeNigris, J., Dunn, R., Panzera, A., & Patel, P. (2011). Evidence-Based Practice and a Nursing Journal Club: An Equation for Positive Patient Outcomes and Nursing Empowerment. Journal for Nurses in Staff Development, 227-230. 

Duffy, J., Elpers, S., Hobbs, T., Niemeyer-Hacket, N., & Thompson, D. (2011). Evidence-Based Nursing Leadership: Evaluation of a Joint Academic-Service Journal Club. JONA: Journal of Nursing Administration, 422-427.


O'Nan, C. (2011). The Effect of a Journal Club on Perceived Barriers to the Utilization of Nursing Research in a Practice Setting. Journal for Nurses in Staff Development, 160-164. 

Posted by Lisa Morris Bonsall on 11/29/2012 12:25:00 PM
Tags: evidence-based practice,journal clubs
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Recently I had the pleasure of attending Nursing2012 Symposium in Orlando, Florida. One of the sessions, titled Faculty-Guided Poster Tour: Ask the Experts, was a highlight for me. This session was exactly what the title implies; an informal tour of the posters being presented at the conference. Three experts – Frank Myers, MA, CIC; Cheryl Dumont, PhD, RN; and Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC – led the session which was held right in the exhibit hall where the posters were displayed. Frank Myers who critiqued each presentation first, initially broke the ice by sharing that he’s taken about 15 research courses throughout his career and education and asked “What does that make me?” While I thought “an expert,” “amazing,” and “impressive,” he answered for us all by saying “Boring!” It certainly was a fun and interactive session!

The leaders shared their reactions and feedback on 6 of the posters. They pointed out key features of the posters themselves as well as the research being presented. It was helpful to get tips about what a poster should look like, what the elements should be, and a little bit more of the intricacies of research and evidence. Here are some of the things that I learned and I hope that you find them useful too!

The poster should…
  • Be visually attractive.
  • Be about 1/3 pictures and/or graphs.
  • Have about 20% white space.
  • Be legible from 3-4 feet away.
  • Be organized so that the content flows in a logical manner.
  • Include your references.
Regarding the research…
  • Be clear about what you are testing.
  • Make sure you have a good reason to do the research.
  • Get approval from the Internal Review Board (IRB) if needed.
  • Understand the difference between an observation study and an intervention study.
  • When using graphs to show your data, note the intervention period on the graph.
  • When considering endpoints, pay attention to other fields or disciplines.
  • Know what the “popcorn effect” is – remember that during the first weeks of an intervention, people are more likely to like it and perform it.
  • Use rate (for example, amount/1000 patient days) rather than just a number when reporting results.
  • Understand the difference between statistical significance and clinical significance.
  • Compare mean and median to balance outliers. It’s generally okay to discard outliers when they are 2 standard deviations from median or when you disclose that you’ve done so (ask yourself if patient who is an outlier matches your patient population).
  • With regard to sample size, it should never be smaller than 30 and more than 1,500 won’t impact your findings. The more covariants you have, the bigger your sample size needs to be.
  • Anytime something “jumps” out, such as a peak or downward trend, explain it.
Other tips…
  • Spell out acronyms with first use.
  • Remember your audience; not everyone is an expert in statistical analysis.
  • Don’t cut and paste from statistical analysis programs; create new tables and graphs.
  • Supplement your poster with print copies and also copies of any tools you developed for the intervention.
  • Include information about the financial impact of your intervention to “sell” it to administration.
  • Be savvy with terminology – use “cost avoidance” rather than “cost savings.”
Poster presentations can be used as a “stepping stone” to publication. Consider turning your research into a poster and presenting it at an appropriate conference. It’s a wonderful way to get feedback from your peers which you can then incorporate into a manuscript.

Posted by Lisa Morris Bonsall on 5/7/2012 10:35:21 PM
Tags: poster presentation,research
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Studying the dying process and terminal extubation in particular, is clearly a challenge. Are the measures we choose even relevant to the person in the bed? We may never know. Nevertheless, some brave souls have attempted to offer their best effort on it. What they mostly do is retrospectively review the chart for processes of care and trends of results. This amounts to little more than consensus of expert opinion but is the best most have been able to achieve to date.

A few trends became obvious as one team reviewed this literature and offered their own local experience. Some of this is just plain common sense. For example, if you don’t need to use devices to maintain patient comfort or resting safety, then don’t. If you don’t need to start an intravenous to give medications, then don’t. Use alternate routes. We have oral morphine (Roxanol) and we can use atropine eye drops under the tongue for secretions. Never stop comfort measures already in place, such as benzodiazepines (Kompanje, 2008). Truog et al. (2008) reminded us all that the goal is to support dignity and comfort, providing quiet, comfortable spaces for the patient and family, absent the trappings of technology, full of human caring. Turn off the alarms and monitors.

Experts argue about the speed of withdrawal of the endo-tracheal tube, but are clear that there are circumstances where it is not appropriate to remove it: large volume of secretions and swollen tongue , for example (Campbell, 2007). Truog et al. (2008) cited the absence of evidence governing this subject. They further noted that rapid withdrawal may cause dyspnea and related discomfort.

Fear of causing a premature death via opioids paralyzes some. Mazer et al. (2011) found that the mean dose of morphine just before death was about 10 mg. During the last hour of life each 1 mg/hour increment of morphine infused was associated with a delay of death by 7.9 minutes. The authors encouraged practitioners to reduce their concern for premature death and act purely on the patient’s assessed needs for comfort.

Truog and colleagues (2008) did their best to summarize care recommendations in a consensus statement by the American College of Critical Care Medicine. This was published in Critical Care Medicine, in 2008. Authors included nurses and physicians knowledgeable in the field. Although many hope this will change as time goes on, around 20% of all deaths in the United States occur in ICUs. Clinicians need to apply the same vigor to dignity and comfort preservation as they do to life saving.

References
Kompanje, E.O., Van der Hoven, B., & Bakker, J. (2008) Anticipation of distress after discontinuation of mechanical ventilation in the ICU at end of life. Intensive Care Medicine, 34, 1593-1599.

Mazer, M. A. (2011). The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit. Journal of Pain and Symptom Management, 42(1), 44-51.

Truog, RD et. al. (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine. Critical Care Medicine. 36(3), 953-961.

Submitted by:
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System

www.meridianiebc.com



Posted by Lisa Morris Bonsall on 4/16/2012 9:59:00 AM
Tags: end of life care,terminal extubation
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When a patient has a peripheral line placed in an emergency, whether it is out in the field or in an acute care setting, the intravenous infusion device is discontinued and replaced as soon as possible and certainly within 48 hours (CDC, 2002). This policy from the Centers for Disease Control  and Prevention has been the mainstay of our practice for many years, but is it still best practice? The Infusion Nurses Society thinks differently and recommends that without signs of catheter-related complications, pre-hospital peripheral catheters should not be routinely replaced (Mermel, Farr, & Sheretz. 2001).

A study published in the Journal of Trauma Nursing, Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous Catheter, examined this issue.Their study was a descriptive, archival, retrospective study that reviewed 365 trauma patients, over the age of 17 years, who were admited to an urban level 1 trauma center. The results demonstrated that less than 1% of the patients had complications related to a prehospital peripheral intravenous catheter being left in place longer than 48 hours (Clemin, Heldt, & Jones, et. al., 2012).

What are the implications for practice? Although one study should not change practice, there is evidence in the literature that the current policy needs to be further investigated through research and revised. I encourage all of you to base your practice on evidence and recognize that evidence is not stationary, it evolves every day. What was evidence-based practice 10 years ago, may not be best practice today.

References:
Centers for Diseas control and Prevention, 2002.
Guidelines for the prevention of intravascular catheter-related infections. MMWR,  (5)1, 1-29.

Clemin, Heldt, & Jones, et. al., 2012.
Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous CathetersJournal of Trauma Nursing, (19)1, 46-49.

Mermel, L., Farr, B., & Sherentz, R. et. al., 2001.
Guidelines for the management of intravascular catheter-related infections
. Journal of Infusion Nursing, (24)3, 180-205.

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies

Posted by Lisa Morris Bonsall on 4/9/2012 9:56:00 AM
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