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Translating Evidence: Exemplars From an Evidence-Based Practice Nursing Fellowship
Translating Evidence: Exemplars From an Evidence-Based Practice Nursing Fellowship Patricia M. Selig, PhD, RN, FNP-BC, Natalie Drawdy, BA, RN, and Karen Waymack, ADN, RN
An evidence-based practice project begins with a nurse asking the question—what is the evidence to support this particular clinical practice? If a practice change is appropriate because there is current evidence to support it, an analysis of the clinical environment will assist with developing a plan for practice change. Keywords: Translation to practice; Evidence-based practice
Programs that are designed to educate and encourage bedside nurses on evidence-based practice (EBP) and nursing research are gaining popularity in many acute care facilities across the nation. Nurses want to be more proactive in the care of their patients. The pursuit of Magnet designation promotes nursing excellence and a shared governance model demands a level of accountability to improve patient outcomes and a responsibility to add to the body of knowledge in nursing. Nursing leadership must support initiatives and provide resources as appropriate before a fully integrative culture of inquiry is assimilated by nursing staff. Program facilitators and nurse researchers involved in program development have a reciprocal responsibility to demonstrate a return on investment to nursing leaders. Evidence-based practice fellowship programs, also called “clinical scholar programs,” can boost the confidence and skills of nurses who may not have acquired the necessary skill set in their nursing program or for whom it has been a protracted period since graduation. Assessment of skills should be done before and at completion of the program. Areas for assessment should include appraising evidence, integration and translation of evidence to current practice, and evaluate the impact of the change. For those clinical issues for which there is little evidence, a formal nursing research study should be designed and executed to enrich nursing practice. The following are examples of two of the fellowship projects in maternal-child care.
From the Bon Secours Richmond Health System, Mechanicsville, VA; Bon Secours Memorial Regional Medical Center, Mechanicsville, VA; and Neonatal Intensive Care Unit, Bon Secours Memorial Regional Medical Center, Mechanicsville, VA. Address correspondence to Patricia M. Selig, PhD, RN, FNP-BC, Bon Secours Richmond Health System, 8266 Atlee Road, MOB II Suite 218, Mechanicsville, VA 23116. Tel.: +1 804 764 6617. E-mails: [email protected], [email protected], [email protected]. © 2009 Elsevier Inc. All rights reserved. 1527-3369/09/0902-0301$36.00/0 doi:10.1053/j.nainr.2009.03.007
Overcoming Communication Barriers with Hispanic Patients after Childbirth Background and Significance The EBP research project, completed by Natalie Drawdy BA, RN, focused on overcoming language barriers in non–Englishspeaking Hispanic postpartum female patients. Healthcare systems are experiencing a sharp rise in the number of Spanish speaking patients admitted to their facilities. In some localities, the Hispanic population accounts for greater than 10% of the community. Statistics collected in a University of Virginia report on Hispanic immigrants in Virginia revealed that 69% of those who entered the US within the last 5 years do not speak English well or at all. When health care providers interact with patients where significant language and cultural barriers exist, the quality of care may be compromised. Language barriers may lead to an increased incidence of medical errors, longer hospital stays, decreased compliance with self-care or discharge instructions, and overall poorer patient outcomes. In addition, although many educational materials are available in Spanish, some of our patients are unable to read them due to low literacy levels. Patients may be reluctant to ask questions through an interpreter and verbalize understanding, but later, their action's do not reflect a true understanding of expectations for care upon discharge. The clinical question was, what discharge education strategies will lead to increased understanding and integration of postpartum and neonatal homecare instructions for non–English-speaking patients?
Evidence Synthesis This EBP project involved a literature search and a staff survey on the discharge process for Spanish speaking patients. The literature search was conducted, using the CINAHL database, for articles related to “language barriers,” “cultural
awareness,” and “non–English speakers.” The literature was limited to qualitative, descriptive studies. Legal imperatives for the establishment of language appropriate services by healthcare institutions are encompassed within Title VI of the Civil Rights Act of 1964 and through the National Standards for Culturally and Linguistically Appropriate Services. Institutional practices related to the care of non–English-speaking patients must meet the standards outlined within the US law and policy by Department of Health and Human Services, Office of Minority Health Web site. The literature supported several interventions for non–English-speaking or limited English proficiency patients. They include access to front line interpreters or telephonic interpreting services, translated documents, and health care professionals trained in cultural competency to improve patient outcomes.
Evidence Translation Before selecting and implementing interventions, baseline surveys were conducted to assess staff and patient perceptions of the effectiveness of current discharge teaching methods for Spanish-speaking patients. Based on data collected from staff and patients and the evidence regarding best practice found in the literature, the following interventions were developed: • Cultural competency of providers are evaluated using cultural assessment surveys • Discharge teaching materials are translated and formatted by the health system's Cross Cultural Services • An educational program for nursing staff that focused on cultural awareness specific to Hispanic populations • Information made available on opportunities for staff to seek Spanish language training through internal educational offerings • Staff training on the implementation and use of telephonic translation services • Dissemination of findings to nursing staff throughout the hospital as a poster presentation during Week of the Nurse • Dissemination of findings at the 10th Annual International EBP Conference “Translating Research into Best Practice for Vulnerable Populations,” Arizona State University, February 19, 2009 Although Natalie has completed the EBP fellowship, she continues to be active in the cultural diversity council and plans to resurvey the nursing staff to rate the effectiveness of interventions and recommendations for future refinements.
Neonatal Developmental Care as a Determinant of Infant Outcomes Background and Significance Neonatal intensive care is a relatively new specialty that has grown in tandem with technological advancements. Specialty care for premature infants had initially organized efforts in
NEWBORN
rescue and survival. More recently, evidence suggests our interventions have a significant impact on the degree and progress on premature infant's growth and development. Karen Waymack, ADN, RN, was passionate that the interdisciplinary teams incorporate developmental care into the clinical care guidelines for neonatal care. These interventions have an impact motor skill development for feeding and mobility delays, foster infant-family bonding, and ultimately demonstrate a shorter length of stay.
Evidence Synthesis Clinical practice guidelines are available for neonatal intensive care but do not explicitly delineate developmental care. No randomized, control studies on developmental care were found. There were 5 common areas for developmental care interventions in the literature; management of the environment, clustered care, flexed positioning, nonnutritive sucking, kangaroo care, and supporting parental involvement. Nursing staff were surveyed as to their knowledge of interventions for infants less than 36 weeks for gestational age. There was an opportunity to educate staff on evidence based developmental care and close the gap between research and practice.
Evidence Translation A 2-day skills fair was developed with the nursing staff and physical and speech therapists on developmental care interventions specific to the environment, positioning, and feeding with 88% staff participation. Specific interventions included: Management of work environment • Avoid unintended alarms • Limit traffic through unit • Musical stimulation offered above 34 weeks of corrected age • Noise levels below b55 dB • Vary lighting to 200 to 225 lux during the day and 5 to 10 lux at night • Use of task lighting and infant isolette covers to assist with light control Positioning • • • •
Gentle touch, avoid sudden movements Position infants in tucked/flexed postures Encourage kangaroo care Back to sleep, prone to play
Feeding • Monitor for feeding readiness cues, begin feeding when infant is calm and alert • Nonnutritive sucking for up to 2 minutes before feeding can increase infant alertness • Swaddle with hands to midline • Provide chin-cheek support
& INFANT NURSING REVIEWS, JUNE 2009
107
• Allow for pace feeding; deciding when to suck and when to pause • Burp by supporting head and rub back instead of patting This project is unique in the interdisciplinary team approach to developmental care. Physicians, nurses, physical, speech, and respiratory therapists must all integrate their care in the best interests of the infant. Nurses advocate and encourage parental involvement in a patient centric environment.
108
VOLUME 9, NUMBER
Summary Best practices may be disseminated through poster or podium presentations, nursing grand rounds, journal clubs, and nursing publications. A successful didactic and mentoring program for EBP should demonstrate improved and sustainable patient outcomes. This requires a team effort, often involving interdisciplinary teams, quality performance experts, and commitment to quality patient outcomes.
2, www.nainr.com
An evidence-based practice project begins with a nurse asking the question—what is the evidence to support this particular clinical practice? If a practice change is appropriate because there is current evidence to support it, an analysis of the clinical environment will assist with developing a plan for practice change. Keywords: Translation to practice; Evidence-based practice
Programs that are designed to educate and encourage bedside nurses on evidence-based practice (EBP) and nursing research are gaining popularity in many acute care facilities across the nation. Nurses want to be more proactive in the care of their patients. The pursuit of Magnet designation promotes nursing excellence and a shared governance model demands a level of accountability to improve patient outcomes and a responsibility to add to the body of knowledge in nursing. Nursing leadership must support initiatives and provide resources as appropriate before a fully integrative culture of inquiry is assimilated by nursing staff. Program facilitators and nurse researchers involved in program development have a reciprocal responsibility to demonstrate a return on investment to nursing leaders. Evidence-based practice fellowship programs, also called “clinical scholar programs,” can boost the confidence and skills of nurses who may not have acquired the necessary skill set in their nursing program or for whom it has been a protracted period since graduation. Assessment of skills should be done before and at completion of the program. Areas for assessment should include appraising evidence, integration and translation of evidence to current practice, and evaluate the impact of the change. For those clinical issues for which there is little evidence, a formal nursing research study should be designed and executed to enrich nursing practice. The following are examples of two of the fellowship projects in maternal-child care.
From the Bon Secours Richmond Health System, Mechanicsville, VA; Bon Secours Memorial Regional Medical Center, Mechanicsville, VA; and Neonatal Intensive Care Unit, Bon Secours Memorial Regional Medical Center, Mechanicsville, VA. Address correspondence to Patricia M. Selig, PhD, RN, FNP-BC, Bon Secours Richmond Health System, 8266 Atlee Road, MOB II Suite 218, Mechanicsville, VA 23116. Tel.: +1 804 764 6617. E-mails: [email protected], [email protected], [email protected]. © 2009 Elsevier Inc. All rights reserved. 1527-3369/09/0902-0301$36.00/0 doi:10.1053/j.nainr.2009.03.007
Overcoming Communication Barriers with Hispanic Patients after Childbirth Background and Significance The EBP research project, completed by Natalie Drawdy BA, RN, focused on overcoming language barriers in non–Englishspeaking Hispanic postpartum female patients. Healthcare systems are experiencing a sharp rise in the number of Spanish speaking patients admitted to their facilities. In some localities, the Hispanic population accounts for greater than 10% of the community. Statistics collected in a University of Virginia report on Hispanic immigrants in Virginia revealed that 69% of those who entered the US within the last 5 years do not speak English well or at all. When health care providers interact with patients where significant language and cultural barriers exist, the quality of care may be compromised. Language barriers may lead to an increased incidence of medical errors, longer hospital stays, decreased compliance with self-care or discharge instructions, and overall poorer patient outcomes. In addition, although many educational materials are available in Spanish, some of our patients are unable to read them due to low literacy levels. Patients may be reluctant to ask questions through an interpreter and verbalize understanding, but later, their action's do not reflect a true understanding of expectations for care upon discharge. The clinical question was, what discharge education strategies will lead to increased understanding and integration of postpartum and neonatal homecare instructions for non–English-speaking patients?
Evidence Synthesis This EBP project involved a literature search and a staff survey on the discharge process for Spanish speaking patients. The literature search was conducted, using the CINAHL database, for articles related to “language barriers,” “cultural
awareness,” and “non–English speakers.” The literature was limited to qualitative, descriptive studies. Legal imperatives for the establishment of language appropriate services by healthcare institutions are encompassed within Title VI of the Civil Rights Act of 1964 and through the National Standards for Culturally and Linguistically Appropriate Services. Institutional practices related to the care of non–English-speaking patients must meet the standards outlined within the US law and policy by Department of Health and Human Services, Office of Minority Health Web site. The literature supported several interventions for non–English-speaking or limited English proficiency patients. They include access to front line interpreters or telephonic interpreting services, translated documents, and health care professionals trained in cultural competency to improve patient outcomes.
Evidence Translation Before selecting and implementing interventions, baseline surveys were conducted to assess staff and patient perceptions of the effectiveness of current discharge teaching methods for Spanish-speaking patients. Based on data collected from staff and patients and the evidence regarding best practice found in the literature, the following interventions were developed: • Cultural competency of providers are evaluated using cultural assessment surveys • Discharge teaching materials are translated and formatted by the health system's Cross Cultural Services • An educational program for nursing staff that focused on cultural awareness specific to Hispanic populations • Information made available on opportunities for staff to seek Spanish language training through internal educational offerings • Staff training on the implementation and use of telephonic translation services • Dissemination of findings to nursing staff throughout the hospital as a poster presentation during Week of the Nurse • Dissemination of findings at the 10th Annual International EBP Conference “Translating Research into Best Practice for Vulnerable Populations,” Arizona State University, February 19, 2009 Although Natalie has completed the EBP fellowship, she continues to be active in the cultural diversity council and plans to resurvey the nursing staff to rate the effectiveness of interventions and recommendations for future refinements.
Neonatal Developmental Care as a Determinant of Infant Outcomes Background and Significance Neonatal intensive care is a relatively new specialty that has grown in tandem with technological advancements. Specialty care for premature infants had initially organized efforts in
NEWBORN
rescue and survival. More recently, evidence suggests our interventions have a significant impact on the degree and progress on premature infant's growth and development. Karen Waymack, ADN, RN, was passionate that the interdisciplinary teams incorporate developmental care into the clinical care guidelines for neonatal care. These interventions have an impact motor skill development for feeding and mobility delays, foster infant-family bonding, and ultimately demonstrate a shorter length of stay.
Evidence Synthesis Clinical practice guidelines are available for neonatal intensive care but do not explicitly delineate developmental care. No randomized, control studies on developmental care were found. There were 5 common areas for developmental care interventions in the literature; management of the environment, clustered care, flexed positioning, nonnutritive sucking, kangaroo care, and supporting parental involvement. Nursing staff were surveyed as to their knowledge of interventions for infants less than 36 weeks for gestational age. There was an opportunity to educate staff on evidence based developmental care and close the gap between research and practice.
Evidence Translation A 2-day skills fair was developed with the nursing staff and physical and speech therapists on developmental care interventions specific to the environment, positioning, and feeding with 88% staff participation. Specific interventions included: Management of work environment • Avoid unintended alarms • Limit traffic through unit • Musical stimulation offered above 34 weeks of corrected age • Noise levels below b55 dB • Vary lighting to 200 to 225 lux during the day and 5 to 10 lux at night • Use of task lighting and infant isolette covers to assist with light control Positioning • • • •
Gentle touch, avoid sudden movements Position infants in tucked/flexed postures Encourage kangaroo care Back to sleep, prone to play
Feeding • Monitor for feeding readiness cues, begin feeding when infant is calm and alert • Nonnutritive sucking for up to 2 minutes before feeding can increase infant alertness • Swaddle with hands to midline • Provide chin-cheek support
& INFANT NURSING REVIEWS, JUNE 2009
107
• Allow for pace feeding; deciding when to suck and when to pause • Burp by supporting head and rub back instead of patting This project is unique in the interdisciplinary team approach to developmental care. Physicians, nurses, physical, speech, and respiratory therapists must all integrate their care in the best interests of the infant. Nurses advocate and encourage parental involvement in a patient centric environment.
108
VOLUME 9, NUMBER
Summary Best practices may be disseminated through poster or podium presentations, nursing grand rounds, journal clubs, and nursing publications. A successful didactic and mentoring program for EBP should demonstrate improved and sustainable patient outcomes. This requires a team effort, often involving interdisciplinary teams, quality performance experts, and commitment to quality patient outcomes.
2, www.nainr.com