Posts Tagged ‘evidence-based practice’

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AJN’s June Issue: Fracking, Assessing Sleep in Teens, Preventing CAUTI, More

May 24, 2013

AJN0613.Cover.3rd.inddAJN’s June issue is now available on our Web site. Here’s a selection of what not to miss.

Fracking hazards. Though we’re moving into summer, our cover does not depict a jar of fresh, local honey. It is a photograph of Washington County, Pennsylvania, resident Jenny Smitzer, holding a jar of contaminated tap water that turned that color af­ter natural gas drilling began in 2005 above her farm. Eleven U.S. states currently engage in natural gas hydrofracking (“fracking”), and eight more are either considering or preparing for this method of gas drilling.

For an in-depth look at the potential health hazards caused by fracking, such as air pollution, working hazards, and water pollution, see our Environments and Health article, “Fracking, the Environment, and Health.” If you’re reading AJN on your iPad, you can listen to a podcast interview with the authors by clicking on the podcast icon on the first page of the article. The podcast is also available on our Web site.

Most teens get far less than the nine hours of sleep a night they require, which could affect their mental and physical health. An understanding of sleep physiology is essential to helping nurses better assess and manage sleep deprivation in teens. “Assessing Sleep in Adolescents Through a Better Understanding of Sleep Physiology” provides an overview of sleep physiology, describes sleep changes that occur during adolescence, and discusses the influence of these changes on adolescent health. This article can earn you 2.1 continuing education (CE) credits. A podcast interview with the author is also available on our Web site.

Seven steps to evidence-based practice (EBP) were described in AJN’s popular 12-part series, Evidence-Based Practice, Step by Step. In “Using Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections,” a novice EBP mentor applied these steps in a quality improvement project aimed at reducing the incidence of catheter-associated urinary tract infection among adult patients. This article can earn you 2.4 CE credits.

Still haven’t taken the plunge into the world of social media? This month’s iNurse article, “Microblogging: Tumblr and Pinterest,” gives nurses some ideas about how they can express themselves and share information on two popular social media platforms.

There is plenty more in this issue, including strategies nurses can use to address patients with low health literacy and evidence-based interventions that may reduce risky sexual behavior in adolescents. Stop by and have a look, and tell us what you think on Facebook, or here on our blog.

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Nurse Staffing Matters at the Shift Level—Evidence-Based Scenarios Illustrate How to Apply What We Know

December 10, 2012

We know that staffing matters. Studies have shown that hospitals with lower proportions of RNs have higher rates of death overall, death following compli­cations (that is, failure to rescue), and other adverse events. But how do such data on staffing translate into what the average hospital nurse experiences on a shift?

That’s the question posed by Gordon West and colleagues, the authors of this month’s CE, “Staffing Matters—Every Shift.” To address it, they reviewed findings from the Military Nursing Outcomes Database (MilNOD). MilNOD, a quality improve­ment and research project conducted in four phases between 1996 and 2009, encompassed data from 111,500 shifts on 56 inpatient units in 13 U.S. military hospitals. The project explored “the effects of staffing levels and skill mix on the probability of patient falls, medication errors, and needlestick injuries to nursing staff.”

As the authors explain, the MilNOD data showed that the number, mix, and experience of nurses on a shift—not just on a unit—were associated with adverse events for patients and needlestick injuries to nurses. West and colleagues offer several realistic, descriptive scenarios to illustrate the potential effects of staffing changes and to show how such knowledge can be applied to daily decision making.

To learn more, read the article, which is free online.—Sylvia Foley, AJN senior editor


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Posted in continuing education, nurses, nursing research, patient safety | Tagged , | 2 Comments »

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Nursing Research: Alive and Well

September 17, 2012

By Shawn Kennedy, MA, RN, AJN editor-in-chief

Last week I spent two-and-a-half days in Washington, DC, where there are LOTS of campaign collectibles. My favorite: coffee mugs proclaiming “Friends Don’t Let Friends Vote [insert Democratic or Republican).” Also noteworthy: “Hot for Mitt” and “Hot for Barack” hot sauce (see photos). I was there attending the meeting of the Council for the Advancement of Nursing Science (CANS), where close to 1,000 nursing researchers met to share their work. It wasn’t too long ago that one would have been hard-pressed to find that many nurses doing research. The National Institute of Nursing Research (NINR) only celebrated its 25th anniversary in 2010 (see our 2010 article about their many accomplishments).

Creativity and innovation. Kathi Mooney, PhD, RN, FAAN, from the University of Utah College of Nursing, gave the keynote—and it was perfectly suited to this group, many of whose members are immersed in analytical thought and scientific methodology. Mooney talked about the importance of creativity and innovation in moving research forward—yes, applying scientific rigor to identifying knowledge gaps and building on known research is critical, but she urged attendees to step back occasionally and be open to other ways of thinking.

To do that, she said, one must create time for reflection and thinking. She also encouraged deans and faculty to foster environments that support creativity, where there’s freedom to explore non-mainstream thinking, risk taking is encouraged, and there’s time for social interaction and informal encounters.

Posters and symposiums and podium presentations filled the rest of the schedule. The presentations were akin to speed dating—researchers had less than 15 minutes to present the highlights of their work. I’m sure for those presenting and those involved in the particular area of research, it might have been frustrating, but for someone like me seeking what’s new and compelling across many areas, it was an ideal format. As one presenter said, “It’s like being a detective on Dragnet, that old TV show, where the lead detective would say, ‘Just give me the facts, please.’”

Some takeaways for me:

Creative thinking involves reframing problems and tasks (one example from Mooney: does the stone cutter see his job as cutting large chunks of stone, or as being part of a team that’s building a cathedral).

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Emergency Contraception: Why It Matters and How Nurses Can Improve Access

April 16, 2012

By Sylvia Foley, AJN senior editor

Family planning counseling, by Dick Schmidt / Sacramento Bee / Zuma Press

Unintended pregnancy can, in some circumstances, be detrimental to the health of both the women who become pregnant and the children born as a result. And such pregnancies happen far more often than you might think, accounting for nearly half of all pregnancies in this country, with even higher rates among women ages 18 to 24 and low-income women. Yet we have had the means to safely prevent such pregnancies for decades, through emergency contraception. Why isn’t emergency contraception used more often?

That’s a question author Kit Devine explores in “The Underutilization of Emergency Contraception,” one of April’s CE features. First, Devine describes the four methods currently available: conventional oral contraceptives and the copper intrauterine device (IUD)—both are used for birth control and can also be used to prevent pregnancy after intercourse has occurred—and the agents levonorgestrel and ulipristal acetate, which are FDA-approved for emergency contraception. Effectiveness ranges from 51% to 62% (for conventional oral contraceptives) to as high as 99% (for IUDs).

Known and likely barriers to their use include Read the rest of this entry ?

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Critical Care: Where’s the Evidence for Central Venous Pressure Monitoring?

January 13, 2012

Editor’s note: This post is by Anne Dabrow Woods, MSN, RN, CRNP, who is AJN‘s publisher and chief nurse and publisher of Wolters Kluwer Health Medical Research. It was originally published on the blog of Lippincott’s Evidence-Based Practice Network.

I read with interest the article “Central Venous Pressure Monitoring: Where’s the Evidence?” (purchase required for nonsubscribers) in the January issue of AJN. It’s part of a series called Critical Analysis, Critical Care, which will appraise the evidence regarding common critical care practices. So much of what we do in nursing is not based on evidence but on how we have always done things in practice—or on research that was not credible.

This article looks at the evidence supporting the use of central venous pressure (CVP) monitoring alone to guide treatment decisions for patients. According to the article, a 2008 systematic review by Marik and colleagues concluded that CVP is not an accurate indicator of intravascular volume, nor is it an accurate predictor of fluid responsiveness (whether a patient will respond to a fluid bolus with an increase in stroke volume). The authors of the AJN article critically appraised the evidence and determined the following:

  • The relationship between intravascular volume and CVP is a weak relationship and clinicians should not use CVP to estimate a patient’s intravascular volume.
  • The absolute CVP value or a change in CVP should not be used to predict a change in the stroke volume or cardiac index.
  • There is not an absolute CVP value that can be used to determine what the next step of treatment should be, be it a fluid bolus or the use of a vasoactive medication.

In brief, the evidence tells us that we can’t base treatment decisions on just one hemodynamic indice. The clinician needs to look at the entire hemodynamic picture, including, for example, heart rate, blood pressure, mean arterial pressure, and urine output, when determining the best treatment option for the patient.

References
Kupchik, N. & Bridges, E., 2012. Central venous pressure monitoring: what’s the evidence? American Journal of Nursing. 112 (1).

Marik, P. et al. 2008. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 134(1).

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From the Blogs: Negotiating Medicare, Nurses Doing Research, Reader Comments

November 29, 2011


Medicare is confusing for providers who aren’t yet familiar with it. Here’s a Nursetopia post that draws attention to its complexity and notes the useful video above (it’s one of a series of videos on different aspects of Medicare). Those of you who know all about it already: Drop by her thoughtful (and consistently updated!) blog and let her know your own tips on handling the ins and outs of Medicare and Medicaid.

EBP matters. Terri Schmitt at Nurse Story has a frank and engaging post on evidence-based practice (EBP): “Translation of EBP: Why Creating Nurse Scientists is the Way to Improve Patient Outcomes.” Here’s what she promises to cover in it:

  • Research is sometimes far removed from bedside nurses
  • Research is COOL!
  • Research is about PATIENTS and not fame/fortune of researcher
  • Research is critical to practice and there are big gaps that nurses need to fill
  • Bedside nurses may be the most crucial link in research ideas, translation, and practice.

(Shameless plug for related AJN content: See our recent, amazingly useful step-by-step CE series on how nurses can get involved in evidence-based practice.)

Plus a brief note on reader comments: we’ve been getting a lot of great comments lately on this blog, and we’re grateful for that. So thank you. A fair number of the comments were on posts from previous months, such as this post comparing U.S. and Australian health care systems. Is somebody by chance teaching a nursing course that requires students to leave thoughtful, respectful, engaged comments in the blogosphere? If so, bless you!—JM, senior editor/blog editor

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On Protocols, Shortcuts, and the Unforgettable Smell of Ether

November 9, 2011

By Linda Johanson, EdD, RN, associate professor of nursing at Appalachian State University, Boone, NC

In nursing school my professors warned us of the dangers of taking shortcuts when performing procedures. They cautioned that deviations from protocols could lead to serious error. I had to learn this lesson the hard way, and although it’s been about 30 years since I made this mistake, I still remember the occasion like it happened yesterday.

The patient was in ICU bed #10, a glassed-in isolation room across from the nursing station. He was in his mid-60s, but he was mentally handicapped, so he appeared and acted younger. He was in the unit recovering from a respiratory arrest, and on the day I was caring for him he was still intubated, but breathing spontaneously.

by james bowe, via flickr

I was completing an assessment on him when the charge nurse called to me from the nursing station, and I stuck my head out the door to see what she wanted. She told me there was a new order to remove the patient’s indwelling urinary catheter. I checked my pockets for a 10 mL syringe to perform the procedure but didn’t find one.

When I complained about having to go all the way to the supply room to collect one, the charge nurse queried, “Well, you have scissors, don’t you? You can just cut the catheter with them. The balloon will deflate, and it will pull right out. I’ve done it a hundred times.”

Cut the catheter? I had never heard of that before, but I was a relatively new nurse, so I hadn’t been exposed to a lot of things yet. Of course I had scissors right in my pocket, and I got them out. Was this an example of one of those unacceptable shortcuts we’d been warned about in nursing school? It would sure be quicker and easier than running all the way to the supply room.

I approached the patient, who although unable to comprehend what was happening, seemed to regard me with a trusting expression. I exposed the catheter and opened my scissors to a spot about one inch from its point of entry. I hesitated for one brief second, then snipped the tube. I gave the catheter a little tug, and the patient winced. The tube stayed firmly in place, the balloon obviously fully inflated. Read the rest of this entry ?

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One Take on the Top 10 Issues Facing Nursing

October 31, 2011

By Shawn Kennedy, MA, RN, AJN editor-in-chief

So I’ve been in Dallas at the Sigma Theta Tau International (STTI) biennial meeting. The venue is the Gaylord Texan, a large, climate-controlled resort under a glass dome—as you leave your building and walk “outside,” you’re really not. Don’t believe the flowing stream or flowers or gardens (all real) along the walkways, or the Longhorn steer (fake) behind a fence that stands outside my building—you’re still inside. And to make it even more surreal, there are Christmas holiday decorations everywhere, including a gingerbread house the size of a small hotel room. It will be strange to step back in time to Halloween when I get back home.

A daunting list. There are a few thousand people here for the meeting, way too many sessions to choose from (20 different topics for each concurrent session period), plus rows of posters and exhibit booths. And of course, great networking. One lively session I attended was standing room only—and that’s after any floor space had been occupied by people sitting cross-legged. It was a discussion of the top 10 issues facing nursing, led by STTI’s publications director Renee Wilmeth (she’s not a nurse, which probably makes her less biased). The issues were compiled from responses provided by 30 nursing leaders, and were presented in question form:

  1. Is evidence-based practice (EBP) helpful or harmful? (Amazing how many interpretations there were of EBP, some of them—as I know from our EBP series—quite incorrect.)
  2. What is the long-term impact of technology on nursing?
  3. Can we all agree that a bachelor’s degree should be the minimum level for entry into practice? (General agreement here, despite concerns regarding the adequacy of financial support for achieving this goal.)
  4. DNP vs PhD: separate but equal? (Not much discussion—I think no one wanted to really get into this.)
  5. How do nurses get a seat at the policy table?
  6. How do nurses cope with the growing ethical demands of practice? (This generated the most discussion, especially around whether society should provide unlimited costly care to those whose personal choices contribute to their health problems.)
  7. How do we fix the workplace culture of nursing?
  8. What role do nurse leaders play in the profession?
  9. What are we doing about the widening workforce age gap?
  10. How do we make the profession as diverse as the population for whom it cares?

Your turn: would you agree that these are the ‘top 10’ issues? What’s missing? What’s here that shouldn’t be?

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Posted in ethical issues, nursing students, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , , , | 11 Comments »

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Killing Traditional Nursing Duties #2

September 6, 2011
This 2006 image depicted an adolescent female ...

Image courtesy of CDC

Editor’s note: In early August, on our Facebook page, we asked if there were “old nursing habits” that should be killed off. We received a lot of feedback, which we described in a blog post, “Killing Traditional Nursing Duties #1.” We’re back now with feedback from our second question: “When you give IM injections, what site do you most often use—dorsogluteal (upper outer quadrant of
buttocks), ventrogluteal (lateral hip), or deltoid (upper arm)? Why?”

Hands down, the deltoid injection site was preferred for intramuscular (IM) injections, especially for immunizations and if the patient was an adult. (“People don’t have to drop their drawers” was my favorite reason cited.) A few of those who favored that site noted that, if they didn’t use the deltoid (because of the volume of the injection), they would then go to the ventrogluteal site. One person preferred the vastas lateralis (the outer middle third of the thigh), which wasn’t listed as a choice, but is certainly a site that’s used, especially in infants. And several respondents said they prefer the dorsogluteal site. Reasons given were “more comfort” and “more muscle.”

This is actually contrary to current evidence and teaching, which is that the preferred site is the ventrogluteal site. As noted in an article we did in February 2010, evidence indicates we should avoid the dorsogluteal site because “it poses unnecessary and unacceptable risks of injury to the superior gluteal artery and sciatic nerve.” Also, the traditional dorsogluteal site, especially in obese
individuals, may have excess subcutaneous fat that can reduce the chances of having the medication injected into the muscle.

And it’s not just a few nurses who continue using the traditional dorsogluteal site—a recent Canadian study (see our report on the results) showed that only 14% of hospital nurses use the recommended ventrogluteal site. So, for those of you who still prefer the dorsogluteal site, think again.

Our new question is this: “Does your institution routinely follow ‘NPO after midnight’ for preoperative patients?” Give your feedback here or on our Facebook page.—Shawn Kennedy, editor-in-chief

Posted in nursing perspective, nursing research, practice tips, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , | 6 Comments »

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Killing Traditional Nursing Duties #1

August 24, 2011

By Shawn Kennedy, MA, RN, AJN editor-in-chief

We recently had a lot of feedback to a question we posted on our Facebook page: “We know old habits die hard and nursing has a lot of them. What old habits do you think we should kill? NPO after midnight? Routine temps on every patient?”

We got several good responses:

- Waking patients up at 4am for blood drawing, routine vital signs

- Measuring intake and output on every patient

- Taking routine temps

- Giving dorsogluteal IM injections

- Doing a skin prep for an IV by swabbing the site in a circular motion, inside to out (some manufacturers of products are instructing that skin prep be done by a scrubbing motion)

- Enemas before childbirth

- Double documenting

- Rushing to give medications right on time (which makes one prone to error)

- NPO after midnight

Choosing from the above, we then asked this: “Survey question #1: Do you routinely wake patients up at night to check their vital signs? If not, when would you?”

This question received many comments, from “Of course not” and “only when necessary” to “If a doc orders q 4 vs and you don’t do it and something happens to the patient, that would not be good for you AT ALL.” Also this: “Orders are orders which we must follow.”

Commenters cited several stories of recent postoperative patients (who, I agree, should have vital signs frequently monitored) who could have suffered grave consequences had the nurse not woken them to check their vital signs or level of consciousness. I do like what one response noted—“critical thinking.” This is key, regardless of what the physician order may be—if the physician order is “q4h” but a patient’s condition may warrant more frequent checks, we would all hope the nurse wouldn’t stick to q4h.

Of course, for those working in ICUs or in postanesthesia units, the answer is simple: the patients are there precisely because they need close monitoring. As one responder indicated, “If you don’t check, you don’t know. I don’t want to be that nurse!”

Our next question was this: “When you give IM injections, what site do you most often use: dorsogluteal (upper outer quadrant of buttocks), ventrogluteal (lateral hip), or deltoid (upper arm)? Why?” Weigh in here or on our Facebook page.

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Posted in nursing perspective, practice tips, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , | 8 Comments »

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