Evidence-Based Practice and Patient-Centered Care Study Guide, Exams of Nursing

Download Evidence-Based Practice and Patient-Centered Care Study Guide and more Exams Nursing in PDF only on Docsity! Role & Scope Exam 2 Study Guide (NUR 2868) EVIDENCE BASED PRACTICE: What is it? EBP: the integration of individual clinical expertise, built from practice, with the best available clinical evidence from systematic research applied to practice How does research improve practice guidelines? Research: A systematic investigation to determine the truth or falsity of a hypothesis, or to validate and refine existing knowledge and generate new knowledge What sources can help nurses use EBP?  Agency for Healthcare Research and Quality (AHRQ) evidence-based practice: www.ahrq.gov/  Centre for Evidence-Based Medicine (CEBM): www.cebm.net  The Cochrane Collaboration: www.cochrane.org  Cochrane Database of Systematic Reviews (CDSR):  www.cochrane.org/cochrane-reviews/cochrane-database-systematic-reviews-numbers  Centre for Evidence-Based Medicine Toronto: www.cebm.utoronto.ca  Centre for Reviews and Dissemination (CRD): www.york.ac.uk/inst/crd  Database of Abstracts of Reviews of Effects (DARE)  Health Technology Assessment (HTA) Database  NHS Economic Evaluation Database (EED)  Guidelines International Network: www.g-i-n.net/  International Council of Nurses: Closing the gap: From evidence to action: www.icn.ch/images/stories/documents/publications/ind/indkit2012.pdf  National Guideline Clearinghouse: www.guideline.gov  National Institute for Health and Clinical Excellence: www.nice.org.uk  National Institute of Clinical Studies: www.nhmrc.gov.au/nics/  Primary Care Practice-Based Research Networks: pbrn.ahrq.gov  Scottish Intercollegiate Guidelines Network (SIGN): www.sign.ac.uk/ Domain Intended use .com Mainly for commercial entities, but unrestricted .org Originally for organizations not clearly falling within the other gTLDs, now unrestricted .net Originally for network infrastructures, now unrestricted .edu Educational use, but now primarily for US third level colleges and universities .gov Governmental use, but now primarily for US governmental entities and agencies .mil Military use, but now primarily for US military only What role does technology play in promoting EBP? Who should use EBP? How can nurses get others involved in using it? What is the function of the ANA? How can nurses utilize its web and literature contents? Concerned with the quality of nursing practice in the daily health-care setting. Develops standards for the profession. The major purposes for the existence of the ANA, as stated in its bylaws, include improving the standards of health and access to health-care services for everyone; improving and maintaining high standards for nursing practice; and promoting the professional growth and development of all nurses, including economic issues, working conditions, and independence of practice. Why do some nurses resist using research or EBP? Late Majority: skeptics who do not adopt something unless there is pressure. Feel safe when there is limited uncertainty. Laggards: most secure in holding on to the past. Most comfortable when an idea cannot fail. How does the aging of the American population impact health care delivery? PATIENT CENTERED CARE: What is the significance of the report Crossing the Quality Chasm? Identified 6 major aims in providing healthcare:  Safe  Effective  Paitent-centered  Timely  Efficient  Equitable Moved care from discipline-centric foci to patient-centered foci Reinforced the disparities that occur within health care, which, in turn, led to a focus on best practices (and reinforced the need to be patient centered) Addressed issues such as healing environments, evidence-based care and transparency, which led to a more holistic environment that was built on evidence and that was transparent What is patient centered care? How can nurses be sure patients’ needs are met? How can the nurse assure that multidisciplinary needs are met for the patient? Understand the effects of culture and language on the provision of patient centered care. ADVOCACY: Understand the premises of Patient Centered Care and the RN’s role in providing it. How do nurses advocate for their patients? Foley insertion: To test the balloon or not? How about NG tube placement? Why are we still using the stethoscope to test placement when the research has proven that the pH method is best? The Institute of Medicine (IOM) has called for nurses to be educated in EBP. The IOM's recommendation is that all health care professionals be able to do the following:  Know where and how to find the best possible sources of evidence  Formulate clear clinical questions  Search for relevant answers to those questions from the best possible sources  Determine when and how to integrate those findings into practice (Yoder-Wise, 2011) Research in Evidence-Based Practice For research to be translated into practice, it needs to reach not just the nurse, but also nurse leaders, managers, and administrators in an institution, as well as policymakers who can provide the support necessary for the implementation of research results (Yoder-Wise, 2011). Clinical nurse specialists are a valuable asset to provide connections from research to practice. Nurses need to be aware of several critical steps in evidence reports when attempting to integrate EBP into their care. The first part of the report should include a structured summary statement of the problem, practice, or disease that describes what is in the evidence report. The second part should comprise a lengthy and detailed analysis of the published and unpublished data, including reviews of articles and reports, the populations included in the studies, and the nature of the nursing actions investigated. The third, and important, is the ranking of such evidence. After gathering that information, the nurse must now ask the following: 1. Is this the best available evidence? Look for sources that are peer-reviewed and no more than 5 years old. 2. Will the recommendations work for my practice given the client population and problems? If the study population is of the elderly and the nurse's primary work is with children, the information may not be applicable. 3. Do the recommendations fit well with the preferences, needs, and values of the clients I serve? If the values of the nurse's primary group vary greatly from those of the study group, it is likely the recommendations may not work well (Catalano, 2012). How Can You Conduct and Use Research to Improve Nursing Care? Several strategies can help nurses conduct and use research for the improvement of nursing care. Attending conferences and poster presentations in which clinical research findings and ideas for practice are presented is an excellent way to quickly view the findings and network with the researchers. Other strategies proposed include conducting research via textbooks and procedure manuals, connecting research use to a facility's goals, developing committees between colleges and hospitals, and inviting nurses to present during routine meetings and conferences. Technology makes the location of and the dissemination of the research possible and necessary. The goals of EBP include cost-effective practice based on the data produced by research, the dissemination of data, and the implementation of best practice interventions into the nurse's practice. EBP is problem based and within the scope of the practitioner's experience, and it is concerned with quality of service and care. It requires the utilization of collaboration and teamwork across the professional spectrum, and clinical recommendations evolving from this process present the nurse with sound decisions based on best evidence (Catalano, 2012). Associate Degree nurses (A.D.N.s) are expected to be able to demonstrate an awareness of the value of research by becoming knowledgeable consumers of current information and by helping identify problems within their scope of nursing practice that may warrant exploration. Are you ready to be that nurse? If not, why not start today by researching a nursing topic of interest to you? MODULE 5: Module 05 - C l in ica l Judgment and Pat ient -Centered Care Nurses use examples of clinical judgment in everyday activities. How did you know which size IV catheter to insert in your patient last night? How, when you assessed that Stage IV pressure ulcer, did you determine that it was improving? You used knowledge of past experiences, remembered your lab and clinical instructor's lessons, assessed the current patients' situations; you used clinical judgment in both situations! What Is Clinical Judgment? The concept of clinical judgment basically refers to interpretations and inferences that influence actions in the clinical setting (Nielsen & Lasater, 2013). To use judgment, one needs to form an opinion (an inference, interpretation or discernment) and apply it to the current clinical picture. A lot of experience helps but even in first time situations, nurses can judge the scene and apply the correct decisions. How? A related term, clinical reasoning, is the thinking process by which a nurse reaches a clinical judgment. It is defined as a way of noticing, interpreting, and responding to the patient and how the patient responds to treatments and interactions (Nielsen & Lasater, 2013). The complexity of nursing judgment requires that the nurse recognize the unique status of the patient, including a deep understanding both of the clinical situation and of the nurse's contribution to the patient care situation. Every patient and each nurse are different, and will respond differently to given situations. Two Approaches to Clinical Judgment in Nursing There are two approaches to clinical judgment in nursing. Standards-based Approach A Standards-based approach puts the nurse and the needs of the patient outside the caregiving situation, rather than situating the specific patient issue in a context of care. Decision making from this perspective involves selection from options of mutually exclusive possibilities, implying that there is one right decision. This approach often involves use of maps, decision trees, and policy and procedure manuals. These guides provide clear-cut direction that may standardize approaches to patient care within an institution and may be important to general patient care quality. Interpretivist Approach The Interpretivist approach originates from the belief that life experiences are culturally bound, that individual patients will interpret these experiences on the basis of their culture, and that one set approach is often not right for all patients. Because nursing care is not linear, and in many situations there are many uncertainties, approaches that consider multiple factors in clinical reasoning are often more appropriate. There are often no clear-cut answers about what to do in nursing. The influence of an individual patient changes circumstances of care, so clinical judgments by nurses become very specific to a given patient care situation. Interpretivist approaches bring the nurse to the sphere of the patient centered care, and account for what the nurse personally contributes to the caring encounter, including previous experiences, values, and emotions (Nielsen & Lasater, 2013). Nurses also need to determine how to establish priorities for solving problems. The problem-solving process is a dynamic one. Nurses can certainly follow the above steps for solving some problems, but a team based and patient centered approach is more likely to be successful. Three Attributes of Clinical Judgment There are, according to Nielsen & Lasater, three attributes used to understand the concept of Clinical Judgment. They are: 1. Holistic view of the patient situation: This is a willingness to consider all factors involved in patient care, including certain characteristics of the patient (as well as the nurse). 2. Process orientation: This requires an understanding of the individual patient situation and a nurse's own personal background, experience, and values. Each is unique and brings different backgrounds to the caregiving situation. The nurse notices features of a situation based on these factors and intervenes. The nurse observes the patient response and comes to understand what the next steps should be. 3. Reasoning and interpretation: At least 3 types of reasoning are required, and they are analytic, intuitive, and narrative. In unfamiliar situations, the nurse tends to rely on analytic reasoning processes, consider the options, and come to a solution. The expert nurse may recognize a situation immediately and act intuitively and tacitly, but the novice nurse typically relies on analytic reasoning. Some nurses formulate their reasoning in narrative form, that is, they use tales of the patient's prior experience with illness to engage in interventions based on understanding of the patient's needs. Problem Solving Several models of problem solving exist. A traditional approach is outlined by Yoder Wise (2011) and requires the nurse to (1) know the facts, (2) separate the facts from interpretation, (3) be objective and descriptive, and (4) determine the scope of the problem. Does some of this look familiar? Perhaps the problem solving process and the nursing process have more in common than first believed! Look more closely:  Assess the problem: Collect and record data to provide the information needed.  Diagnose and Identify Outcomes: Clarify realistic outcomes and identify problems, risks, or issues.  Plan: Make certain that there is a realistic, attainable, measurable patient-centered goal.  Implementation (Interventions): Put the plan into action.  Evaluation: Where does the patient stand? Has the goal been achieved? Does it need revision? Another way to look at it is through critical thinking. If you add your critical thinking skills (reasoning gained outside of the clinical setting) and add it to your critical reasoning skills (gained inside the clinical setting), you'll have a complex thought process of problem solving and patient centered care (Alfaro- Levre, 2013). Add your past experiences, your intuition, your culture, your morals and ethics, and combine them with your patient's situation; you'll soon be thinking like a nurse! Clinical judgment, or thinking like a nurse, does require a lot of clinical knowledge and some layers of thinking (Nielsen & Lasater, 2013). As you may have guessed, clinical knowledge and experience provides the nurse with the background needed to recognize patterns and therefore differences when they occur in patients. As you, the nurse, become more experienced, clinical judgments will become more intuitive, and soon you'll be recognizing those patterns and grabbing on to the meaning of clinical situations as they present themselves. Module 05 - C l in ica l Judgment and Pat ient -Centered Care What Exactly Is Patient-Centered Care? You've heard, and possibly have used, the phrase "patient-centered care" many times over the past year. But what is it, really? If care is truly patient-centered, shouldn't it be what the patient wants, whenever he wants it? One can define patient centered care as a focus on the patient and the individual's particular health care needs. That makes is sound simple, doesn't it? But the goal of patient centered care is not quite so simplistic; it requires the empowerment of patients to become more active in their plans of care. This means that providers must develop great communication skills and help the patient understand and advocate for himself. Care which was once directed by the physician must now be rendered with the patient rather than to the patient, with the emphasis of said care being on what is provided - not who controls the decision about the care (Yoder-Wise, 2011). According to the Agency for Healthcare Research and Quality (AHRQ), Health care has been evolving away from a "disease-centered model" and toward a patient-centered model (Stanton, 2002). In the past, the disease-centered model had doctors making almost all treatment decisions. Now, in a patient- centered model, patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals. When the Institute of Medicine (IOM) published Crossing the Quality Chasm in 2001, it established six aims for health care improvement, three of which was that patient care must be safe, effective, and patient-centered. That report went on to acknowledge things that nurses commonly value, such as the idea of a healing environment (think Florence Nightingale), individualized care, autonomy of the patient in making decisions, evidence-based decision making, and the need for transparency (Yoder-Wise, 2011). It also stated that all health care professionals should be educated to deliver patient centered care and provided the impetus for payment methods being based on quality outcomes. What better way to measure quality outcomes than by patient satisfaction? By establishing a connection with the patient and his or her family, we can help foster patient centered care. Understanding the culture and diversity of each individual client can help us develop plans of care which are truly client-focused. These plans of care should be based on sound use of the Nursing Process and utilize therapeutic communication skills, respect, and realization of patient preferences. Keeping an  A requirement that Americans buy health insurance or pay a penalty starting in 2014. The penalty will start out at 1 percent of income in 2014 and rise to 2.5 percent by 2016; however, the total amount will not exceed $2085 per year (Catalano, 2013). What does all of this mean for nurses? How will it make us better advocates for our patients? As stated above, 32 million more Americans will now be insured and able to access care. Nurses should be looking to expand their scope of practice and look to their own future employment. For the first time, all Americans can receive screening procedures such as prostate examinations, mammograms, annual physical examinations, and preventive care such as immunizations at no out-of-pocket costs. Advanced practice nurses need to be developing ways in which they can practice in a preventive, wellness model, rather than in our previous medical, disease-focused model. Consider this as well…if the changes being brought about by the Affordable Care Act are confusing to you, how then will our less educated clients feel about it? How will they maneuver through the process of enrollment and access care they now have? As advocates, nurses must ensure that clients are informed of their rights and have the correct information on which to base health care decisions. Nurses must be careful to assist clients with making health care decisions and not direct or control their decisions, especially if they're relying on their own personal feelings or opinions. Nurses continue to be the face of American health care. We need to recognize our authority and powerful influence in managing the changing health care system. We need to understand the healthcare systems and how our patients are affected by them. We need to be able to advocate for changes which will benefit all of our clients. Module 06 - Advocacy Suppose you are working as a Registered Nurse in a major hospital which provides you with great health insurance coverage. Your daughter, however, is a 22-year-old full time college student who works part time. She makes less than $12,000 per year and cannot find health insurance coverage because she has asthma. The Affordable Care Act has helped thousands of families in just that situation; students are now able to stay on their parent's health insurance plans until age 25. Nurses were at the table while developing that stipulation! The Nurse Practice Act When thinking about nursing and the law, you probably (and rightly) recall the Nurse Practice Act. Each state has its own Nurse Practice Act, and it is every nurse's responsibility to become familiar with it. The State Board of Nursing will have links to the Practice Act; these Boards have the authority to issue and revoke a nursing license based upon compliance or violation of the Nurse Practice Acts. Standards of care are developed by the ANA and other professional organizations, and they direct the level of care given by nurses. Nurses should refuse to practice beyond the scope of their practice or outside of their area of competence. How Laws Come into Being But how did the Nurse Practice Act come into existence? How does any law become a law? The three branches of the United States government are the judicial, legislative, and executive branches. These 3 branches exist at the local, state, and federal levels.  Judicial branch: This is our court system, whose primary role is to interpret laws.  Legislative branch: This consists of our House of Representatives and Senate, whose roles are to represent the people in the forming of laws.  Executive branch: This is where we find the President, vice president, cabinet, and various executive administrative bodies (Governors, County Commissioners, Mayors). Their role is to enforce the laws. Laws may begin with any elected official, lobbyist, consumer group, advocate, public interest group, or governmental agency. Once a need is identified, any individual may contact a legislator to discuss concerns and possible solutions. If and when that legislator takes up the cause, he or she becomes a sponsor to a Bill. The bill is assigned a number (with the prefix HB for House Bill or SB for Senate Bill) and referred to a committee. The committee holds hearings (which are public and open for nurses to attend!) and a debate may be scheduled before a final vote of Yes, for passage of the bill, or No, for rejection or veto of the bill. Driving influences include funding (who will pay for the service?), public demand (does it benefit everyone or a select few?) and program issues (does it interfere with or change any existing laws?) Most nurses avoid becoming involved in politics, or government issues, but they need to realize that their professional survival may depend upon it! Why? Because politics and health care laws are related to almost every aspect of life. Politics Influence:  Where (and when) children go to school  Quality of food and water  Medications, prescriptions, over the counter drugs  Where nurses work  What nurses do  Ability to organize professionally  Professional status through licensure and certification (Catalano, 2013). How You Can Become Involved How can you, a novice nurse, become more involved? Become Active in a Professional Organization The easiest way is to join and be active in a professional organization, such as the ANA, the NLN, or any other nursing organization. The ANA and most state chapters have legislative tool kits which offer suggestions for nurses to become politically involved. They maintain that the numbers of Registered Nurses in our country make us a powerful force. Our respect and ethics make us valuable assets to any elected official. They want us on their side! Develop a Political Relationship with a Local Legislator If you're interested in becoming more involved on a personal level, try to develop a political relationship with a legislator in your area. Letter writing, letters to the Editor of your local newspaper, emails, and telephone calls to the office are very successful methods of communicating with your elected official. For best results, schedule a meeting. They often have open office hours and, believe it or not, are always very willing to speak with their constituents. Do your research and find some common ground with him. They live in your legislative district. Do his children go to the same school as yours? Is anyone in his family a nurse? Getting to know your legislator is simple if you just relax and be yourself, and then you can discuss the important matter for which you came. First, identify specific goals that affect you, as a nurse. With what are you most concerned? Is it the level of responsibility in delegating that you have? Is it poor or unsafe staffing? Is it shorter hospital stays which send patients home too sick to care for themselves? Secondly, realize that your success in bringing about needed change depends on in-depth knowledge of the situation, as well as an understanding of the political process. You also need to be able to verbalize what is needed to solve the problem. Thirdly, you'll need to have something of value to offer the elected official, which fortunately, is easy. Your vote! That's what keeps him or her employed. And if you're speaking on behalf of a group of nurses, family members, or special interest group, that means even more votes. Make certain to tell him or her how many people will be positively affected by the change you seek. Politically involved nurses have the following credentials: They have self-confidence, motivation, creativity, a capacity to change, and persistence. In short, all nurses have the ability and skills to be more involved! Nurses are skilled patient advocates and are well qualified to advocate or lobby for health care legislation. It just takes a little time and motivation and any nurse can become a powerful change agent. Nurses in all areas of the country are saying, "Somebody's should do something about this problem." The reality of the situation is that the "somebody" is nurses themselves (Catalano, 2013, p. 403).