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Jane Barnsteiner, PhD, RN, FAANProfessor Emerita, University of Pennsylvania School of Nursing

Editor, Translational Research and QI, AJNNovember 6, 2015

barnstnr@nursing.upenn.edu 

Health Professions Education

6 Core Competencies:1. Provide patient‐centered care

2. Work in interdisciplinary teams

3. Employ evidence‐based practice

4 Safety as a system property4. Safety as a system property

5. Apply quality improvement

6. Utilize informatics

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IOM Competencies

PCC

Teamwork

EBPTeamwork

&

Collaboration

Quality Improvement

Safety

Informatics

Evidence-Based Practice Old – Adhere to internal

policies and procedures. New - Integrate best

d h current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

Why the focus on EBP?• Leads to higher quality of care, improved patient outcomes, decreased costs, and greater nursing satisfaction.

• Significant gaps in care:

30 40% d t i t t t• 30 – 40% do not receive treatments  proven effective, 

Antibiotics before and after surgery

Hand hygiene 100% of the time

• 20 – 25% receive treatments that are not needed or are potentially harmful 

Indwelling catheters post‐op or in ICU

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Locating and Retrieving the Evidence

The World of Evidence

PublishedEvidence

Indexed and Indexed and Locatable

Accessible and Reviewable

Use

EBP ‐ Staff nurse use of research( Yoder, AJN, 9/14)

Where do you get your evidence?

Personal Experience – 75%

Policies and Procedures 58%

Peers 55%

Intuition – 32%

Use of journals, internet – 25%

36% avoid using research as they perceive they do not have authority to use even if useful.

Do I hear myself saying… We’ve always done it this way That’s not our way As soon as this change is over, we can do it I’m just not comfortable with change It’s just not the way it used to be I’m just not a creative person

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2015 National Survey‐ Sacred CowsPractice True False

Shock ‐

Trendelenburg

51% 49%

Scrub the hub 81% 19%

Instill NSS NTT 35% 65%

Auscultate G‐

tube

31% 69%

Ph testing G‐

tube

51 49%

Aspirate 

subglottic 

secretions to 

prevent VAP

29% 71%

Willful Blindness Conscious avoidance, not challenging the status quo

12 hour shifts lead to increased safety errors

Increased staffing leads to decreased adverse events, LOS, and is cost neutral

Faculty adding their name to junior faculty and student papers when not met criteria for authorship

Incivility and bullying

Patient/Family Centered Care Old – Listen to patient and

demonstrate compassion and respect.

American Association of Colleges of Nursing. © 2010 - All Rights Reserved.

New - Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values and needs

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New Focus “Knowledge is power.”Angelina Jolie Pitt:, Diary of a Surgery, NYT 3.24.15

Patient‐Centered Care“‐ is providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions”   (Institute of Medicine)

Orthopedist goal – uneventful hip replacement surgery

Nursing goal – discharge with no complications

Patient goal – be back on golf course

(Need to begin to measure patient goal outcomes)

“It’s all about the patient”Not true

It’s about cost

It’s about completing the checklist It s about completing the checklist 

It’s about physician schedule

It’s about us being in charge as we are the most knowledgeable

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Benefits of PFCCPerson Outcomes Patients more involved in their care are better able to

Manage complex chronic conditions

Seek appropriate assistance

Have reduced lengths of stay and avoidable readmissions and emergency department visits

Experience increased patient satisfaction and employee engagement(Jarousse, 2011)

Barriers Attitudes

When physicians and nurses perceive that family members are “policing” them, or that unrestricted visiting by family members is “not possible” it speaks to a culture ‐ but not amembers is  not possible  it speaks to a culture  but not a culture of P&FCC. 

AJCC, 2014

Knowledge – studies for past 40 years

Skill – HC professionals often novices with the new definition. Reason for push‐back on handoffs and rounds in patient rooms.

Patient Engagement and Activation – not anymore about handing out instructions and doing discharge teaching. 

Engagement

Activation

Patient Activation Measure (PAM)(Hibbard, et al, 2005)

Plan interventions based on level of activation

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Patient EngagementEvidence-based approaches that lead to patient engagement, activation and improved clinical outcomes:

Medical literacy Shared decision making Goal settingSelf-care skills Motivation/confidence Plans of care

Patient Activation Measure (Hibbard)

Lucille‐Packard Children’s Hospital 

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EB Benefits of PFCC ‐ Financial Outcomes

100 Planetree healthcare institutions 

Increased patient satisfaction

Increased staff retention

Enhanced staff recruitment Enhanced staff recruitment

Decreased length of stay

Decreased emergency department return visits

Decreased adverse events including fewer medication errors

Reduced operating costs’ and a lower cost per case

Increased market share

Improved liability claims experience 

Collaboration and Teamwork

Old – Work side by side with other HC professionals while performing nursing skills.

American Association of Colleges of Nursing. © 2010 - All Rights Reserved.

New - Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

EB Benefits of Interprofessional Teamwork and Collaboration

• Improved mortality outcomes and quality of life  after adjustment for patient severity

• Increased patient and family satisfaction with care

I d i f i fli• Improved team perception of micro‐system conflict management, collaboration, job satisfaction and quality of care

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Integrate TW&C

Team STEPPS, Crucial Conversations  – communication

Interprofessional experiences in orientation and regular discussion on work area

i b f li d lf Patient as member of team – literacy and self‐management

Incivility not tolerated

Care Coordination – integrator role

Safety

Old – focus on individual performance, vigilance to keep patients safe.

k f

American Association of Colleges of Nursing. © 2010 - All Rights Reserved.

New - Minimize risk of harm to patients and providers through both system effectiveness and individual performance

van der Schaaf‐ modified for healthcare

Technical

Organi-zational

Adequatedefenses

Return to Normal

Close Call

Dangerous Situation

Dangerous Situation

HumanFactors

defenses

DevelopingErrors

ERRORERROR(Inadequate Defenses)

PatientFactors

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Quality and Safety:Two Forms of Vigilance

Optimal Patient Care

Vigilant Individual

Care (Traditional)

Vigilant Systems of 

Care( ad t o a )

• Patient Centered Care• Teamwork & Collaboration• Evidenced Based Practice• Safety • Quality Improvement• Informatics

QSEN

Mary Dolansky2012 QSEN National Forum

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I will turn my 

ti t

I will post a note above the bed to remind 

I will ask other nurses about products to 

I will look at the ulcer rate on our 

I will compare our unit ulcer rate with 

Continuum of Systems Thinking

Moving Along the Continuum:  In Education and Practice

patientothers

pprevent ulcers unit benchmarks 

From: M. Dolansky & S.Moore. Systems Thinking Scale, available at:

http://fpb.case.edu/systemsthinking/sts.shtm

I will work with others to improve our unit’s 

ulcer rate 

End goal (Cronenwett)

Quality Improvement

Old – Update nursing policies and procedures, chart audits of documentation.

New Use data to monitor

American Association of Colleges of Nursing. © 2010 - All Rights Reserved.

New - Use data to monitor outcomes of care processes and improvement methods to design and test changes to continuously improve quality and safety of health care systems

One example:  Handwashing (TJC 2012)

Routine safety processes fail routinely

Hand hygiene

d dMedication administration

Patient identification

Communication in transitions of care

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Informatics - HIT

Old – timely and accurate documentation

American Association of Colleges of Nursing. © 2010 - All Rights Reserved.

New - Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making

Decision Support Aids "What clinicians need is decision support tools that fit into their workflow and remind them of evidence‐based practices” S. Baacken, Columbia School of Nursing

With electronic decision support aids clinicians: 

7 times more likely to diagnose obesity

5 times more likely to spot issues in tobacco use

44 times more likely to identify depression in adults 

4 times more likely to identify depression in children and adolescents 

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Headache Diary

What It Is: Tracks every  detail (including triggers and remedies) with recurring headaches.Why It's Cool: By keeping detailed notes of headache symptoms—right down to the location, duration, and foods you snacked on before the headache flared—you can help your health provider diagnose you more easily and begin treating you quickly.Cost: Free. Available for Android

Health Patch MDAbout the size of a Band‐Aid 

and tracks heart rate, heart rate variability, respiratory rate, ECG and skin temperature continuously.p y

Can be worn constantly for three days before it needs to be replaced. The stats it collects can be sent to physician in real time via the cloud.  

Nutrition ‐ ShopwellWhat It Is: With a quick scan of a barcode, this app can determine which foods meet your dietary needs.Why It's Cool: Shopwellpersonally scores each product personally scores each product just for you based on your age, gender, health goals, diet needs, and ingredient and nutrition preferences. Scores range from 0‐100; the higher the number, the better the product is for you.Cost: Free. Available for iOS

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Evidence to Action

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Institutional Barriers to EBPLack of budget for information resources

Lack of budget for training in resource use

CNO belief that EBP not achievable in “real world”

Individual Barriers to Use of Evidence  Lack of time Lack of value for research in practice Lack of knowledge about research Lack of computer skillsL k f d t di f l t i d t b Lack of understanding of electronic databases

Lack of access to computer and library Lack of search skills Lack of skills to critique or synthesize the literature Difficulty accessing research materials Difficulty understanding research articles

Funk et al, 1995; Kajermo et al, 1998; Omery et al, 1999; Parahoo, 1998; Rodgers, 2000 Provikoff, 2005

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EBP Culture change necessary among health care providers to understand that life‐long learning has an equal priority as delivering care.

Health care providers are incentivized for staying t d tup to date.

Greater efforts are needed to provide (commercial free) synthesized knowledge that is easily translated into practice briefs, guidelines and policies. These need to be regularly updated as new knowledge is generated. All too often guidelines are published but not kept current. 

Creating a Culture of EBPAccelerate uptake 

Awaken the spirit of inquiry

Patients and Families Expect CompetencePatients and Families Expect Competence

They don’t say “I prefer you care for me by the standards and guidelines, policies and procedures of 10 years ago”.

Formal Methods of Dissemination • Standards of Practice

• Practice Guidelines and Protocols

• Decision support systems

• Improved technology ‐ Smart pumps

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Informal Methods of Dissemination• Brown Bags

• Journal Clubs

• NewslettersNewsletters

• Professional Meetings/Conferences

Choosing Wisely Campaign(ABIM & AAN, 2014)Don’t

1. Automatically initiate continuous electronic FHR

2. Let oldsters lay in bed or be in chair during hospitalization

3. Use physical restraints for oldsters

4. Wake for routine care

5. Place or maintain UC without specific indication

The Choosing Wisely®, “Things Nurses and Patients Should Question,” identified by ONS include (4.23.15):

Don’t neglect to advise patients with cancer to get physical activity and exercise during and after treatment to manage fatigue and other symptoms. 

Don’t use L‐carnitine/acetyl‐L‐carnitine supplements to prevent or treat symptoms of peripheral neuropathy in to prevent or treat symptoms of peripheral neuropathy in patients receiving chemotherapy for treatment of cancer. 

Don’t use mixed medication mouthwash, commonly termed “magic mouthwash,” to prevent or manage cancer treatment‐induced oral mucositis. 

Don’t administer supplemental oxygen to relieve dyspnea in patients with cancer who do not have hypoxia. 

Don’t use aloe vera on skin to prevent or treat radiodermatitis. 

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Leadership – EB Practice

Set the vision

Secure resources

Create environment

Establishing a Culture:  Institutional Level CNO and Senior Leadership Support

Budget allocations

Technology, staff time, education 

Leverage Existing Programs

Professional Development

Practice and Quality Improvement Committees

Advanced Practice Nurses

Partner with School of Nursing

Secure the ResourcesUnlimited access to online sources of evidence at all work areas

Search engines, elearning such as MosbySearch engines, elearning such as Mosby Nursing Skills, paper and electronic journals

Staffing and scheduling for release time to participate in education and practice development activities

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Create the EnvironmentShared Governance – research, practice, education counsels/committees

Faculty mentors as nurse scientistsFaculty mentors as nurse scientists

Tie into Compensation, Benefits and Incentives

Nursing sensitive quality outcomes

Establishing a Culture: Institutional Level Research behaviors in clinical advancement levels

EBP/Research Champions

Demonstrate use of electronic databases

Journal clubs, brown bags, case reviews, poster sessions, Nursing Grand Rounds 

Research/EBP Committee

Research Fellowships

Establishing a Culture: Institutional Level EBP Toolkit

What is a clinical question

How to search – tip sheet

Resources – librarian, champions

How to do a synthesis – Table of Evidence

How to critique

How to lead a journal club

How to develop EB policies/procedures/ CPG

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Integrate EBP at the POC Resources to easily access knowledge

Position descriptions/performance appraisals –incorporate requirement of EBP use

i i Orientation 

Evaluate Guidelines, Cochrane, JBI, 

Web eval of consumer content using CARS (credible, accurate, reasonable, supported)

Annual competency for EBP

Work area – unit council discussions on practice evidence

Next Steps

P&FCC

Teamwork

EBPTeamwork

&

Collaboration

InformaticsQuality Improvement

Safety

Overcoming Barriers to Use of Evidence  Knowledge 

About research process Electronic databases  Accessing research materials Understanding research articles

Skills Computer skills Search skills Skills to critique or synthesize the literature

Attitudes Value for research in practice If this is important I will find the time

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Lesson on Leadership and Followers

http://www.youtube.com/watch?v=hO8MwBZl‐&f l dVc&feature=related

CHANGE THE WORLD OF HEALTH CARE

Start where you areUse what you haveUse what you haveDo what you can

A. Ashe

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Questions, Comments and Questions, Comments and

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