Wednesday, November 22, 2006

Resarch Study and Commentary by Dana Rutledge, Phd, RN, Nursing Research Facilitator


Schulman-Green, D. et al. (2005). Unlicensed staff members’ experiences with patients’ pain on an inpatient oncology unit. Implications for redesigning the care delivery system. Cancer Nursing, 28, 340-347. Staff at SJO/CHOC can access the full text of this article through the library's web site.

Authors’ Abstract

Although unlicensed staff have routine contact with patients in pain, little research relates to their role with these patients. The purpose of this study was to describe the experiences of unlicensed inpatient hospital staff caring for cancer patients in pain. We sought to understand pain identification and communication practices, describe common practice sitaut9on, and identify training needs. We conducted 4 focus groups with unit secretaries, nurses’ aides, and housekeepers (n = 24) on 2 inpatient oncology units at an urban, northeastern teaching hospital. Group processes were tape-recorded, transcribed, and analyzed using Atlas/ti software and content analysis. Analysis generated 5 issues related to pain in the daily practice of unlicensed staff: perceived function with pain, building relationship with patients, interpreting patients’ pain, system issues, and job challenges and coping strategies. Unlicensed staff reported performing important functions related to pain, including alerting nursing staff to patients’ pain, and providing psychosocial support. Participants shared difficulties of working with patients in pain an expressed interest in education on pain identification and course of illness. Findings provide insight into the role of unlicensed staff, and have implications for the educational preparation of this group as well as the nature of their participation in the care delivery system.

Commentary by Dana Rutledge, PhD, RN, Nursing Research Facilitator

In this qualitative study, researchers described results of focus groups of unlicensed hospital staff who were asked about experiences with patient and pain. Nurses might be surprised at some of the important ways these staff perceive that they impact pain and its management. Patient care assistants (14, the largest group of staff) noted that they were assessing pain using the 0 – 10 score at the time they did vital signs. They reported having difficulty identifying the nature of pain when patients found the 0-10 scale confusing or difficult to respond to. Is this a problem that could occur at St. Joseph?

Those interviewed mentioned their roles in assisting in patient comfort by giving emotional and physical care. Some use nonpharmacologic pain management techniques such as distraction or listening. These staff members consider comfort care important to their roles. Most unlicensed staff reported communicating patient pain to nursing staff, and consider this one of their most important roles.

As with nurses, unlicensed staff identified challenges to dealing with patients’ pain. One was their overall heavy workloads, which interfered when they wanted to spend time with patients in pain. They emphasized the importance of teamwork, individualizing care, and empathy in caring for their patients.

In the discussion of their results, Schulman-Green and colleagues suggest that care redesign that enhances PCA-nurse relationships, expands training for unlicensed staff, and debriefing at intervals would improve pain management for patients in pain. What do you think?

Wednesday, November 08, 2006

St. Joseph Hospital PACU Nurses Win Poster Presentation Award

Tracy Dickman, RN, BSN, Clinical Nurse II, Pavilion PACU, Darlene Soriano, BS, MHA, Surgery Support Specialist, Pavilion, OR, and Dana Rutledge, RN, PhD, Nursing Research Facilitator, won first prize among 14 other presentations for a nursing research poster at the recent Joint Southern California STTI Chapters Odyssey 2006 Conference.

This prestigious honor was bestowed along with a plaque at the Ontario conference October 26-27. The poster presentation described an action research project carried out in the Pavilion PACU.

During Fall 2005, Alicia Leal, BSN, RN, CPAN and other PACU staff initially designed the research study that examined patient flow within the Surgery Center. Tracy analyzed the statistical data collected and noticed a potential clinical problem. Tracy then met with Kathy Dureault, RN, MSN, Clinical Educator. Many patients were arriving unprepared to ambulatory surgery (e.g., did not have transportation home or a responsible adult to be with them upon discharge, etc.). Kathy connected Tracy with Dr. Rutledge, who discussed how to evaluate the nature and intensity of the problem using survey methodology.

PACU nurses implemented an action research project. They found that in over 600 patients admitted for surgery, 75% had received the Personal Recovery Plan Pamphlet (PRPP) developed by SJO nurses and disseminated through surgeon’s offices. In all patients who received it, the Plan was perceived as helpful. Of the patients, 78% received a preoperative call from SJO staff. Despite not all patients receiving the pamphlet or call, 99% of patients thought that their preparation for surgery was adequate.

During fall 2006, Darlene called surgeon’s offices, making sure staff understood how the PRP was to be used. She updated and converted them into electronic files available of the English, Vietnamese, and Spanish versions to enable staff to keep copies readily available in offices. The PRP is also now available on the SJO Intranet/website at under the Patients and Families link. You can also view the Personal Recovery Plan Pamphlet here. Between Thanksgiving and Christmas, Tracy and PACU nurses will be surveying patients again to determine proportions of patients who have been adequately prepared for their surgeries. They hope to see a change.

Implementing a Sedation Protocol for Ventilated Patients

One of the presentations at St. Joseph Hospital's recent Grand Rounds on Evidence Based Practice and Nursing Research was "Implementing a Sedation Protocol for Ventilated Patients" by Victoria Randazzo, RN, BSN, CCRN, Clinical Nurse IV, Intensive Care.

Victoria discussed the practice change in progress in the Intensive Care Unit. You can review her complete PowerPoint here.

Group Visits for Diabetes Management

One of the presentations at St. Joseph Hospital's (Orange, California) recent Grand Rounds on Evidence Based Practice and Nursing Research was "Group visits for Diabetes Management: an evidence based approach to chronic disease management" by Teresa Ulrich, RN, FNP, Family Nurse Practitioner, La Amistad Health Center.

Teresa educated the audience on “Shared Medical Appointments” and specifically a group at La Amistad focused on diabetes management that started November 2005. An added bonus to her group was the inclusion of family members who could also reinforce the education presented at these group visits. You can view her PowerPoint here.

Five-Minute e-mail Nursing Journal Club

One of the presentations at St. Joseph Hospital's (Orange, California) recent Grand Rounds on Evidence Based Practice and Nursing Research was "Five-Minute e-mail Nursing Journal Club" by Judy Rousch, RN, Clinical II, Critical Care. Judy presented a project she began in 2003. Inspired by the public library’s on-line book club, she began sending small excerpts from scholarly nursing journals to a selected nursing e-mail readership. She highlighted how she dealt with format, copyright protection, etc. You can view her complete PowerPoint here

Monday, November 06, 2006

SJH Action Research: Decreasing Incidence of Bleeding and Hematoma Formation in New Fistulas

Action Research Summary Outline

Carmeleene Baguio MSN, RN Vascular Access Coordinator Renal Center, Dr. Amer Jabara, Renal Center Medical Director, Dialysis Staff in the Outpatient chronic hemodialysis unit

Problem identified:
Bleeding and subsequent hematoma on new fistulas when initially used for hemodialysis. When this occurs the fistula is allowed to rest for 2 weeks. This allows the hematoma and bruising to resolve. Sometimes it takes longer than 2 weeks or the hematoma needs surgical evacuation. This delays the use of the fistula and increases the risk of the fistula failure.

Purpose of the project:
To investigate the factors or reasons that cause excessive bleeding when new fistulas are initially used.

The arteriovenous fistula (AVF) is the “gold standard) for vascular access. Fistulas have the longest longevity (75% working at 3 years, least likely to be infected (35x less than central venous catheters, 10x less than grafts), and lowest mortality (3x less than central venous catheters).

The Kidney Disease Outcomes Quality Initiative (National Kidney foundation, 2001) and the American Nurses Nephrology Association (ANNA) Standards and Guidelines of Clinical Practice for Nephrology Nursing recommend the AVF as the first choice of access.
The Fistula First Initiative recommends that 66% of patients on chronic hemodialysis use fistula as their primary access by year 2009.
Evidence shows that skill is required in creating and cannulating new fistulas.
28-53% of fistulas never mature to support dialysis ( Beathard, 2006 American Society of Nephrology)

According to Brouwer, 2003 a new fistula must be treated with great care to prevent damage. The goal is to help the access to mature into a long-term lifeline for the patient. She has recommended some guidelines in the care of this new fistula.
Several factors impact effectiveness of fistula placement and function. A multidisciplinary approach to evaluating and managing fistula maturation increases the chance of success.

Action Plan:
I discussed this problem with St. Joseph Hospital research council chair, Dana Rutledge, Dr. Jabara, Medical director of the Renal Center, the experienced dialysis nurses and technicians to get input on how what they thought was causing this problem. Based on current guidelines in the successful use of new fistulas a data collection tool was created to collect retrospective and prospective data on patients with new fistulas. This information consisted of possible factors that could affect bleeding and subsequent hematoma when new fistulas are initially used.
Retrospective and prospective data was collected on patients that had new fistulas that were being used for the first time. I informed the staff of what the plan was to address this problem.
During the data prospective data collection the staff was aware to check patient’s heparin dose based on the ACT’s, coumadin and other oral blood thinners that patient might be taking, patient education on holding needle sites post dialysis. As Vascular Access coordinator, I collected the data and facilitated patient referral to Interventional Radiology or vascular surgeon. I also did staff and patient education in the clinical area while data was being collected.

Data was collected on six retrospective and six prospective patients that had new fistulas. Data included: Age of fistula when initially used, needle size used, heparinization during dialysis, other anticoagulants that patient was on, activated clotting times (ACTs), other bleeding issues, patient medical history associated with hematologic disorders, prescribed and/or complementary or alternative medications used by the patient and physical examination of the fistula.
Chart review was done using the data collection tool. Retrospective data showed that four of these patient’s ACTs were prolonged. Two were on coumadin, and two patients had narrowing of the fistula. Heparin dose was adjusted according to the ACT result.
For the prospective patients, heparin dose was evaluated and adjusted based on the ACT’s. This was done prior to using the fistula for the first time. Four of the patients did not have any bruising after the fistula was initially used. Two had minor bruising. This was related to needle manipulation since the fistula was not mature to support dialysis.
How is this significant?

There was a significant decrease in the incidence of bleeding after new fistulas were used for the first time.

There will be an increase of new fistulas as a result of the Fistula First Initiative.
Systematic assessment of the new fistula before first use is imperative. Using the data collection tool created for this research will be useful in assessment of new fistula.
Patient and staff education on care of fistula and graft infiltrations to promote longevity in the use of these accesses.

Knowledge and Attitudes of SJH Nurses on Pain and Management

On Friday, November 3, 2006, St. Joseph Hospital (SJH), Orange California held the second annual session of Nursing Grand Rounds focused on Evidence Based Practice and Nursing Research. The four hour presentation was developed by Dana Rutledge, RN, PhD, Nursing Research Facilitator and Sharon Kleinheinz, RN, MS, Clinical Educator. One of the presentations was by Maureen Mikuleky RN, BA, MA, Director of Cancer Services and dealt with the findings of a recent questionaire Knowledge and Attitudes of SJH Nurses on Pain Management. You can view the PowerPoint presentation here.