Wednesday, January 30, 2008

Abstract with Commentary

Author’s Abstract

OBJECTIVE: The impact of interventions designed to improve the nursing work environment on patient and nurse outcomes was examined. BACKGROUND: Nursing work environments have been characterized as contributing to patient outcomes as a result of organizational management practices, workforce deployment, work design, and organizational culture. METHODS: This quasi-experimental study involved 16 unit managers, 1,137 patients, and 296 observations from registered nurses over time. RESULTS: After participation in the intervention, study nurses reported higher perceptions of their work and work environment. Demographic nurse, unit, and hospital characteristics also had an impact on the work environment and outcomes. CONCLUSIONS: Findings in this study highlight the importance of understanding factors in the work environment that influence patient and nurse outcomes.
Hall, L.M., Doran, D., & Pink, L. (2008). Outcomes of interventions to improve hospital nursing work environments. Journal of Nursing Administration, 38, 40-46.

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

The intervention in this study was fairly complex in that individual units determined a workplace change to implement. For 6 months, change development and implementation was facilitated by a trained bachelor’s prepared nurse who devoted efforts solely to this project. Changes included things like enhancing documentation activities, increasing medication supplies, and implementation of a communication tool related to patient transfers. Changes before and 6 months after the workplace change were determined for system data (unit/hospital characteristics), nurse outcome data (surveys on satisfaction, work quality, etc.), and patient outcomes (ADLs, satisfaction, etc.). Analysis involved “nesting” outcomes for nurses within units. Patient outcomes were not nested since different patients were used at data collection points.

Hospitals studied all were in Ontario Canada. Nurses were mostly females (95%) prepared at diploma or certificate level (76%). Experience levels varied with 29% of nurses having less than 5 years and 20% having > 25 years. Most units (60%) used “total patient care delivery model,” which was not defined. Patients were 46% medical, 54% surgical.

Six-month findings indicated positive changes in nurse perceptions of the work and work environment. This is one of few studies that measure change over time with a work environment change (probably due to the complexity of such research designs). Researchers discussed the significant contributions of nurse and unit characteristics on outcomes. For example, RNs with baccalaureate degrees reported higher levels of job stress than those with diplomas… could the “added knowledge and understanding that comes with degree education and the greater sense of accountability” be active in these findings? Unit characteristics such as proportion of part-time nurses also impacted outcomes with units having more part-time nurses having higher average nurse ratings of job satisfaction. Finally, hospital and unit characteristics impacted patient outcomes… patients in teaching hospitals reported better perceptions of quality and increased independence than did community hospital patients.

Implications from this Canadian study are that fairly simple workplace changes can quickly (within 6 months) alter nurse and patient outcomes. Authors described issues with nurse generations, nurse experience, and patient-to-nurse ratios that deserve further study.

Friday, January 11, 2008

Evidence-Based Policy and Procedures

Authors at the University of Colorado Hospital in Aurora have recently authored an article titled Evidence-Based Policy and Procedures: an algorithm for success which appeared in JONA : Journal of Nursing Administration 38(1): 47- 51, January 2008. Library users at St. Joseph Hospital, Orange and CHOC can read the full text of this article online via Burlew Medical Library's website. The authors identified nothing in the literature speaking to evidence-based policy and procedure development. Their EBP Council then identified the steps involved in evidence-based policy development and created a 10-step algorithm with very practical detail. The authors describe their process for systematically critiquing and rating the evidence identified. Another interesting innovation at this Magnet hospital is their requirement for a yearly EBP competency that is required for all clinical nurses. Does anyone out there in the blogosphere know of any other institution that has such a requirement?

Kudos to the authors: Kathleen S. Oman, RN, PhD, CEN, FAEN; Christine Duran, APRN-BC, DNP, CNS, CCTN; Regina Fink, RN, PhD, AOCN, FAAN.

Nursing Grand Rounds at St. Joseph Hospital (written by Sharon Kleinheinz, RN, MSN)

On November 19, 2007, St. Joseph Hospital held the second annual Nursing Grand Rounds dedicated to Nursing Research and Evidence Based Practice projects being conducted at the hospital.

St. Joseph Hospital’s Nurse Research Facilitator, Dana Rutledge, RN, PhD, led the seminar on the use of evidence-based practice in guiding health care decisions and improving patient outcomes.

This 4-hour program featured 10 St. Joseph Registered Nurses providing updates on nursing research studies and evidence-based practice projects that are currently underway at St. Joseph. Projects included the following outcomes and learnings:
· Outcomes of a hospital based MET team (Medical Emergency Team) in terms of decreased codes and decreased transfers of patients from med/surg units to ICUs.
· How adding a sedation protocol and vacation to a ventilator bundle has impacted the intubated patient.
· How preoperative preparation and education for the outpatient surgical patient can decrease cancellation of surgery.
· Reasons for and realities of implementing a study comparing the use of a temporal artery thermometer with oral/ axillary or rectal thermometers in the Emergency Department pediatric patient population.

Also featured were the results of a survey on the nurse’s knowledge and attitudes on breastfeeding, the implementation of education for nursing staff providing smoking cessation information to patients, and an overview of the progress of existing end of life programs for patients.

Dr. Rutledge presented the Iowa model and principles of evidence-based practice that is utilized at St. Joseph. Julie Smith, the manager of the St. Joseph Burlew Medical library provided an update on the EBP Blog and the numerous resources available to assist staff in nursing research and evidence-based projects.

Wednesday, January 09, 2008

Libraries as "Information Commons"

I came across this really cool blog entry written by the Director of Medical Inforamtics at University of Colorado Hospital. In this entry, libraries are "information commons" and librarians are "knowledge navigators". A nice read on the new directions that medical libraries ahve pursued-- even the ones still called "libraries"

Thursday, January 03, 2008


Welcome to Vickie’s Research Corner. I hope everyone had a wonderful holiday season. Well, here we are in 2008 and we are back to evidence-based practice (EBP) and research projects. This year should be really interesting so watch out for all the new projects coming your way.
For the first project of the year, I would like to introduce you to Amy Waunch. She is the Advanced Practice Nurse (APN) in the Emergency Department.

What is the name of your project?
Emergency Department Pediatric Temperature Study

What is your study about?
The purpose of my study is to compare temporal artery thermometer readings in emergency department patients 17 years and younger with oral, rectal, and axillary temperatures. A study sub-aim is in patients who have received antipyretics, to evaluate the presence of a “lag” in any measure compared to others due to physiologic responses to the antipyretic.

Is it EBP/Research study?
Research- a correlational comparative study.

What made you interested in this project?
Fever is the most common complaint of children seen in a pediatric emergency department (Poiriert et al. 2000). Temperature measurements reflect changes in physiologic status that may require clinical interventions. Accuracy of temperature readings and an understanding of different routes of temperature taking can affect health providers decisions concerning critically ill children and infants. In a busy ED, taking temperatures can be problematic and we were looking at the best method for taking temperatures in children.
A new thermometer, for temporal artery readings has been developed. The temporal thermometer (Exergen Corp., Walterton MA) computes temporal artery temperature by using a heat balance method. This method is noninvasive and more comfortable than rectal temperatures in infants. A representative from the company approached our ED about using this thermometer stating their studies demonstrated this is more or at least as accurate as rectal thermometry.
After looking into the research, I realized there has been no study found comparing temporal artery readings with oral, rectal, and axillary readings among children 17 years or younger admitted to emergency departments. I wanted to insure using the best method possible in our ED instead of taking a sales representatives word. I wanted to actually have research versus opinion. Therefore, I created a study.

How did you go about your research?
I started with a literature review and couldn’t find a clear-cut conclusion on the accuracy of temporal artery thermometry use on pediatric patients presenting to an emergency department. I then investigated the community standard of care for pediatric temperature attainment and learned that practice varies greatly form one hospital to another. I looked to expert opinion from professional organizations such as the American Association of Pediatrics and the American College of Emergency Physicians, again with no consensus.
So I decided to talk to Dana Rutledge to help me do a more extensive literature search. We found there is no gold standard or clear evidence for taking temperatures in pediatric patients. At this point we decided to create a research study. For the study I asked Beth Winokur, the Clinical Educator for the ED, and John Senteno, the Director of ED to help. Dana wrote the proposal and gave input. I formulated a team of interested persons: Christine Marshall, Clinical Nurse IV in the ED; Mike Vicioso, Pediatric Manager in ED; and Beth Winokur. We then applied for the IRB. For the last year we have been trying to accrue patients for the study.

What are your expected outcomes?
I believe we may find that the temporal artery thermometer is inconsistent. I also think we may find that axillary temperatures are inconsistent as well. Data from research states that rectal temperatures are the closest to the core temperature but unfortunately they are the most invasive. I hope to find that the temporal artery thermometer is a reliable and accurate means of obtaining temperatures in pediatric patients in the ED. This method is non-invasive and will cause less anxiety among parents compared to rectal thermometry.

Have you done research before? If so what did you learn?
I have co-investigated randomized clinical trials for asthma when I worked at an allergy office as a Nurse Practitioner. I learned that acquiring data is very detailed oriented. I also learned that the IRB is really designed to keep the best interest of the patients. I actually was pleasantly surprised going through the IRB that our study was approved for an expedited review due to the fact we worked with a vulnerable population.
Research can be very challenging, especially this study! We have had problems with data collection due to time of the RNs acquiring patients, making sure all the coinvestigators were compliant with the CITI training that CHOC’s IRB makes you complete prior to research, and the challenges of the administrative end of paperwork.

Will you do research/project again?
Yes, but next time I will get more help from the beginning and more people involved who are dedicated to the time issue.

Poirier, M.P., Davis. P.H., Gonzalez-del Ray, J.A., & Monroe, K.W. (2000). Pediatric emergency department nurses’ perspectives on fever in children [Abstract]. Pediatric Emergency Care, 16, 9-12.