Article #1

Report
Ferris State University
NURS 350 Evidence-Based Nursing Practice
EBNP Group Project
Lai Harper
Margaret Siler
Gary Webster
Jamie Ziemba
“Communication--the human connection--is the key to personal and
career success.” Paul J. Meyer
“It’s important to make sure that we’re talking with each other in a way
that heals, not in a way that wounds.”-Barack Obama
“Communication works for those who work at it.” John Powell
“Unity is strength . . . when there is teamwork and collaboration,
wonderful things can be achieved.” Mattie Stepanek
Introduction
Every day we have conversations between nurses
and doctors. What are the outcomes of these
conversations, both positive and negative, for
patients and nurses?
What is patient safety? What is acute care? What
is professional communication?
What is patient safety?
• Easily defined as anything that would directly affected the patient
• Examples with negative consequences on patient safety: language barriers,
medication errors, miscommunication between doctors and nurses
• Based on the Joint Commission, patient safety (death/injury or medical
errors) can be related to segmented communication or relationship
between nurses and physicians (Saxton, Hines, and Enriquez, 2009, p.
180).
What is acute care?
• Taking care of patients who are having a “now” type of medical condition
• “A pattern of health care in which a patient is treated for a brief but severe
episode of illness, for the sequelae of an accident or other trauma, or during
recovery from surgery. Acute care is usually given in a hospital by specialized
personnel using complex and sophisticated technical equipment and materials,
and it may involve intensive or emergency care. This pattern of care is often
necessary for only a short time, unlike chronic care” (Mosby's Medical
Dictionary, 2009).
What is Professional Communication?
Verbal communication is basic conversation of words that people say to one
another.
 Simple words or technical jargon.
 Difficult if the nurse or doctor has English as a second language, if the terms in
the technical jargon are not shared by either the doctor or nurse.
Nonverbal communication is body language and written communication.
 body language and written communication can be taken positively or negatively.
The positive or negative nurse-physician relationships can have
impacts on communication (Schmalenberg & Kramer, 2009, p. 77).
▫
Collegial relationships-nurse and physician have equal trust, power and respect
▫
Collaborative relationships-nurse and physician have mutual trust, power, respect; cooperation is
mutual not equal
▫
Student-teacher relationship-Either nurse or physician can be the teacher as the situation dictates
▫
Friendly stranger-Formal exchanges of information with neutral tone
▫
Hostile/adversarial relationships-Marked by anger, verbal abuse, real or implied threats, or
resignation
Communication between medical professionals is
not just a local problem, but is a problem found
throughout the entire medical community.
PICO Question
For adult patients in an acute care setting, what
does the literature reveal about the
DIFFERENCE in communication styles
(collaboration interdisciplinary versus segmented
authoritarian) between physicians and nurses on
indicators of nurse satisfaction rates and patient
safety outcomes?
Definitions
• According to the American Nurses Association, “collaboration” is “a true
partnership, in which the power on both sides is valued by both, with
recognition and acceptance of separate and combined practice spheres of
activity and responsibility, mutual safeguarding of the legitimate interests
of each party, and a commonality of goals that is recognized by both
parties” (Hendel, Fish, & Berger, 2007, p. 251).
• Ballou and Landreneau (2010) discuss that “authoritarian persons typify
an outlook that is ethnocentric, rigid, and anti-democratic” (p. 71).
• “Segmented”: “divided into or composed of segments or sections”
“Authoritarian”: “of, relating to, or favoring blind submission to
authority” (Merriam-Webster Dictionary, 2012).
A Survey of the Impacts of Disruptive Behaviors and
Communication Defects on Patient Safety
Sample size N= 4,530 From January 2004 to March 2007
How often do you think disruptive behavior results
in the following at your hospital?
(Sometimes, Frequent, and Constant)
99%
94%
How often do you think that there is a link between
disruptive behavior and the following clinical outcomes
at your hospital? (Sometimes, Frequent, and Constant)
71%
71%
67%
94%
89%
91%
51%
87%
83%
27%
Adverse
Events
Errors
Patient
Safety
Quality of Patient
Care
Mortality
A Survey of the Impacts of Disruptive Behaviors and
Communication Defects on Patient Safety
Sample size N= 4,530 From January 2004 to March 2007
Have your ever witnessed any disruptive behavior
from a physician at your hospital?
Have you ever witnessed any disruptive behavior
from a nurse at your hospital?
88%
73%
78%
77%
65%
64%
66%
51%
77%
48%
Literature Review (Level One Evidence)
Research
Articles
Kramer,
Schmalenbeg, &
Maguire (2010).
Research
Methods
Metaanalysis of
multiple
published
studies
Theoretical
frameworks,
Measurement
Instruments
Donabedian’s
conceptual framework
of structure, process,
and outcome
Heberlein and
Baumgartner’s
methodology
Schmalenberg, &
Kramer (2009).
Review of
six research
studies
Essentials of
Magnetism
Concepts of nursephysician relationship
(collegial,
collaborative, studentteacher, friendly
stranger,
hostile/adversarial
Zwarenstein,
Goldman, &
Reeves (2009).
Cochrane
Systematic
Review
Not specifically
mentioned
Samples
Data Analyses/Study
Findings
12 publications from 7
professional and regulatory
organizations
positive physician-nurse communication,
collaborative leadership, and autonomy in
Magnet hospitals (Kramer et al., p. 11).
18 publications from studies
using the Essential of Magnetism
(including 1300 interviews with
nurses, physicians, and mangers)
Nurses’ autonomous role in identifying
patients’ worsening conditions (need to
rescue/NTR) for reducing the rates of
mortality or adverse patient outcomes
(Kramer et al., p. 11).
3602 staff nurses in 16 Magnet
and 10 non-Magnet hospitals in
the 2003 study
In 2003, physician-nurse relationship
scores in Magnet hospitals were statistically
significant and higher when compared to
non-Magnet hospitals (F ratio 21.279; P less
than 0.001)
10514 staff nurses in 18 Magnet
and 16 non-Magnet hospitals in
the 2007 study
Five studies about collaborative
interventions
interprofessional
rounds/meetings
externally facilitated
interprofessional audit
In 2007, the higher scores in Magnet
hospitals were also statistically significant
(F ratio: 14.446; P less than 0.001)
(Schmalenberg, pp. 78-79)
no randomized controlled studies about
the impacts of interdisciplinary
collaboration (Zwarenstein et al., p. 8).
“Problems with conceptualising and
measuring collaboration”; No “generalizable
inferences about interprofessional
collaboration” (Zwarenstein et al., p. 2).
Literature Review (Level Three Evidence)
Research
Articles
Boone,
King,
Gresham,
Wahl, &
Suh
(2008).
McCaffrey,
Hayes,
Cassell,
MillerReyes,
Donaldson,
& Ferrell
(2012).
Research
Methods
Quasiexperimental
(Pre- and PostTest for the
training in
assertiveness
and
cooperation)
Quasiexperimental
(Pre- and Posttest for training
in
communication
skills)
Theoretical
frameworks/
Measurement
Instruments
Samples
Kilmann and
Thomas’ model of
conflict
resolution
(accommodating,
avoidance,
competition,
compromise,
collaboration)
9 nurses from
the
cardiovascular
laboratory
(experimental
group) and 18
nurses from the
telemetry unit
(control group)
Collaborative
Behavior Scale
Non-probability
sampling in an
American
hospital
Jefferson Scale
of Attitudes
68 nurses and
47 medical
residents in a
Florida hospital
Non-probability
sampling
Data Analyses/Study Findings
No statistical significance for the Collaborative
Behavior Scale before/after the training between the
experimental group and the control group “p more
than 0.05” (Boone et al., p. 172).
the communication style of “avoidance” was
associated with increased nurses’ emotional stress
(Boone et al., p. 173).
Implication: explore barriers before training
programs; involve physicians’ participations
statistical significance (P=0.001) of the T-test
before and after the 6-month educational program
for enhancing physician-nurse collegiality,
communication skills, mutual decision-making
processes (McCaffrey et al., p. 298)
Literature Review (Level Four Evidence)
Research
Articles
Hendel, Fish,
& Berger
(2007).
Karanikola et
al. (2012).
Manojlovich
& DeCicco
(2007).
Research
Studies
Crosssectional
Correlational
study
Descriptive
Correlational
study
Descriptive ,
Crosssectional ,
Nonexperimental
Theoretical
Frameworks
Measurement
Instruments
Samples
Thomas-Kilman
Model of Conflict
Resolution
75 physicians 54 charge
nurses at 5 acute care
hospitals in Israel
Conflict Mode
Instrument
(MODE)
Non-probability
sampling
Hamilton’s
Anxiety Scale
2-stage random
probability sampling
Stamp’s Index of
Work Satisfaction
11 hospitals randomly
selected in Greece; then
229 nurses at intensive
care units randomly
selected
Concepts of
workplace
empowerment
ICU NursePhysician
Questionnaire;
Practice
Environment Scale
of the Nursing
Work Index
Data Analyses/Study Findings
charge nurses were more likely to use the
“collaborating” communication style when
compared to physicians (P=0.001) (Hendel et
al., p. 249).
Satisfaction in physician communication was
statistically significant and negatively associated
with intensive care nurses’ anxiety level
“correlation coefficient Kendall = -0.160,
P=0.001” and depressed mood “correlation
coefficient = -0.148, P=0.005” (p. 41).
Limitations: confounding variables of nurses’
personal psychiatric or psychological histories
462 nurses’ perceptions
in 25 intensive care units
from 8 Michigan
hospitals
statistical significance for the positive
correlation of physician-nurse
miscommunication to the perceived outcomes in
medication errors (p. 542).
Non-probability
sampling
Limitation: not generalized findings ; not
reflect cause-effect relationships
Literature Review (Level Four Evidence continued)
Research
Articles
Research
Studies
Rosenstein
& O'Daniel
(2008).
Nonexperimental
study;
quantitative
and
qualitative
approach
Rothstein
& Hannum
(2007).
Crosssectional
Theoretical
Framework,
Measurement
Instruments
Instrument:
“NursePhysician:
Impact of
disruptive
Behavior on
Patient Care”
Gender model
(male physician
dominance and
nurse deference)
 Professional
model
self-reported
close-ended
questionnaire on
nurse-physician
relationship
Samples
Data Analyses/Study Findings
Convenience
samples: 2846
nurses, 944
physicians
from 102 notfor-profit VHA
member
hospitals in
the U.S. from
2004 to 2007
physician-nurse disturbing behaviors are likely to reduce patient
safety outcomes and nurse satisfaction. Narrative data: e.g. “afraid
to call Dr..” “get yelled at,” “poor communication postop,”
(Rosenstein & O’Daniel, p. 467)
125 advanced
practice
nurses/APN at
a statewide
professional
conference
statistical significance for APN’ s positive
attitude/communication with female physicians (less than 50
years old) and male physicians (of all ages); male and female
physicians are also likely to be positive and respectful about APN’s
knowledge in patient care (2-tailed t test and one-way analysis of
variance; P value less than 0.05) (Rothstein & Hannum, p. 238).
nonprobability
sampling
The gender model for the authoritative dominance of male
physicians is not applicable to the female APNs who have at least a
master’s degree in nursing (p. 235).
67% respondents perceived that disruptive behaviors were
associated with adverse patient outcomes (medical errors and
patient mortality) (Rosenstein & O’Daniel, p. 464).
Limitation: theoretical framework not specifically described
Strength: large sample size
Limitation: confounding variables not measured “type and size of
the work organization, nurse and physician specialties, and patient
illness and social characteristics” (p. 239).
Literature Review (Level Six Evidence)
Research
Article
Gardezi,
Lingard,
Espin,
Whyte,
Orser, &
Baker
(2009).
Research
Method
Qualitative
study
Ethnographic
approach
Retrospective
study
Theoretical
Framework
Sample
Critical Theory
about silence in
communication
observed physiciannurse
communications
over 700 surgeries
at 3 acute care
hospitals from
2005 to 2007 in
Canada
Study Findings
Narrative and descriptive data about
conflicts in physician-nurse communication
styles at operating rooms due to nurses’ gap
in knowledge about surgical procedures and
surgeons’ dominant authoritative power.
Nurses’ passive/silent communication
method had negative impacts on patient
safety during surgeries (Gardezi et al., p.
1391).
Limitations: evidence-based practice cannot
be based on one qualitative study.
Strengths: explore the descriptive lived
experiences about physician-nurse
communication barriers over 2 years
Analysis of Evidence
The ability to critically analyze
evidence presented in various research
projects is necessary to evaluate the
work for applicability and use in
evidence based nursing practice.
“To use research evidence, one must be
able to evaluate this evidence”
(Nieswiadomy, 2012, p. 298).
•
STRENGTH OF EVIDENCE
•
LEVEL 1 (HIGHEST)
•
•
•
EXPERIMENTAL STUDY (RANDOMIZED CONTROLLED TRAIL OR RCT)
• Study participants (subjects) are randomly assigned to either a treatment (TX) or
control
(non-treatment) group.
• May be:
o Blind: neither subject nor investigator knows which TX subject is receiving.
o Double-blind: neither subject nor investigator knows which TX subject is receiving.
o Non-blind: both subject and investigator know which TX subject is receiving; used
when it is felt that the knowledge of treatment is unimportant.
META-ANALYSIS OF RCTS
• Quantitatively synthesizes and analyzes results of multiple primary studies
addressing a
similar research question
• Statistically pools results from independent but combinable studies
• Summary statistic (effect size) is expressed in terms of direction (positive, negative,
or
zero) and magnitude (high, medium, small)
•
LEVEL 2
•
•
•
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QUASI-EXPERIMENTAL STUDY
• Always includes manipulation of an independent variable
• Lacks either random assignment or control group.
• Findings must be considered in light of threats to validity (particularly selection)
•
LEVEL 3
•
•
•
•
•
•
NON-EXPERIMENTAL STUDY
• No manipulation of the independent variable.
• Can be descriptive, comparative, or relational.
• Often uses secondary data.
• Findings must be considered in light of threats to validity (particularly selection,
lack of
severity or co-morbidity adjustment).
•
QUALITATIVE STUDY
•
•
•
•
 Explorative in nature, such as interviews, observations, or focus groups.
 Starting point for studies of questions for which little research currently exists.
 Sample sizes are usually small and study results are used to design stronger studies
that
are more objective and quantifiable.
•
META-SYNTHESIS
•
 Research technique that critically analyzes and synthesizes findings from
qualitative
research
 Identifies key concepts and metaphors and determines their relationships to each
other
 Aim is not to produce a summary statistic, but rather to interpret and translate
findings
•
•
•
•
•
•
•
•
•
•
•
•
•
•
JHNEBP Research
Evidence Appraisal
The Johns Hopkins Hospital/The Johns Hopkins
University
QUALITY RATING (SCIENTIFIC EVIDENCE)
•
•
A High quality: consistent results, sufficient sample size,
adequate control, and
definitive conclusions; consistent recommendations based on
extensive literature
review that includes thoughtful reference to scientific
evidence.
•
B Good quality: reasonably consistent results, sufficient
sample size, some control,
and fairly definitive conclusions; reasonably consistent
recommendations based
on fairly comprehensive literature review that includes some
reference to
scientific evidence
•
C Low quality or major flaws: little evidence with
inconsistent results, insufficient
sample size, conclusions cannot be drawn.
•
•
Article #1: “Conflict management training and nurse-physician
collaborative behaviors”(Boone et al., 2008)
•
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Quantitative, quasi-experimental design.
The researchers are highly qualified and experienced.
Convenience sample which closely approximates the real world experience.
This study is ethically sound as a written explanation of the study was
provided and informed consent was obtained.
The problem is clearly stated to examine a knowledge gap between a unit
specific intervention (conflict management training) and improved
communication and collaboration between physicians and nurses.
Theoretical framework: Kilmann and Thomas conflict resolution theory
(Boone et al., 2008, p. 168).
Findings reveal that the intervention was unsuccessful. (The null hypothesis
not rejected)
The importance of continued research for interventions that promote quality
communication and collaboration is stressed.
Creating a culture that values quality communication and collaboration
forms the basis for developing a healthy work environment.
Level of evidence varies by tool used, but is evaluated as II, or III. Both
levels are credible for utilization in evidence based care.
Informed consent was obtained from all participants
Article #2: “Nine structures and leadership practices essential for a
magnetic (healthy) work environment” (Kramer et al., 2010)
• This is a quantitative meta-analysis of thirty professional publications.
• The problem is clearly stated to identify what structures and leadership
practices are necessary to support a healthy work environment.
• The researchers are experienced, and well qualified.
• The sample size was good. Over 1300 interviews of expert nurses, nurse
managers, and physicians were compiled for comparison to findings from
regulatory and professional organizations.
• The theoretical framework is based on the Donabedian model
(http://www.ahrq.gov/qual/medteam/medteamfig2.htm) of patient safety.
• Healthy work environments lead to improved patient and nurse outcomes
• Creating a culture of interdisciplinary collaboration and teamwork through
shared power and administrative support were important themes.
• This is a valid level I for evidence by all methods (course modules,
interview with hospital research specialist, and Johns Hopkins Nursing
Research Evidence Appraisal). Level I is the highest level of evidence for
utilization in evidence based practice.
Structures/best leadership practices essential for
healthy work environments
Quality leadership at all levels in the organization
Availability of and support for education, career, performance, and competence
development
Administrative sanction for autonomous and collaborative practice
Evidence-based practice education and operational supports
Culture, practice, and opportunity to learn interdisciplinary collaboration
Empowered, shared decision-making structures for control of the context of
nursing practice
Generation and nurturance of a patient-centered culture
Staffing structures that take into account RN competence, patient acuity, and
teamwork
Development and support of intradisciplinary teamwork
Article #3: “The effect of an educational programme on attitudes of
nurses and medical residents towards the benefit of positive
communication and collaboration”(McCaffrey et al., 2012)
• This is a quasi-experimental study based on a convenience sample of nurses and
medical residents .
• The researchers are experienced and well qualified.
• The research question is clearly stated.
• Ethical research guidelines are carefully adhered to.
• A pre and post-test design based on the Jefferson Scale of Attitudes towards
Physician-Nurse Collaboration, and the Communication, Collaboration, and Critical
Thinking for Quality Patient Outcomes tools. Both tools are proven to be reliable
and valid (the Cronbach’s alpha coefficient of 0.87-0.92).
• A critical finding in this study is that “Effective communication is the cornerstone of
interdisciplinary collaboration” (McCaffery et al., 2012, p. 294).
• Statistical findings reveal that the chosen intervention of an educational programme
to improve physician-nurse communication and collaboration was beneficial.
• This study is evaluated as evidence level III due to lack of a control group by two
methods (Ford, 2012; C. Bongiorno, personal communication, November 26, 2012).
Alternatively it is rated as level II on the Johns Hopkins scale ("JHNEBP Research
Evidence Appraisal," n.d.) .
Article #4: “Nurse-physician relationships in hospitals: 20,000
nurses tell their story” (Schmalenberg & Kramer, 2009)
•
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This study is a quantitative synthesis of the findings of six research studies
based on the Essentials of Magnetism.
The researchers are experienced and highly qualified.
The purpose of the study is several fold: 1) To discern what constitutes quality
communication and collaboration between physicians and nurses, 2) Define
types of nurse-physician relationships, 3) Define organizational structures and
leadership practices that help develop collaborative nurse-physician
relationships, and 4) Study differences in nurse-physician relationships between
magnet and comparison hospitals.
The sample size of 20,616 staff nurses is excellent.
Thorough literature review is the foundation for this study.
It was consistently reported that nurses at magnet hospitals reported higher
quality relationships with physicians than the comparison hospitals.
Structures that improve relationships and are supported by magnet institutions
are: keep the patient first, develop constructive conflict resolution techniques,
and have collaborative, interdisciplinary patient rounds.
Nurses can play an active role in bringing about these interventions.
This is a double blinded peer review of six studies clearly making it evidence
level I by all methods.
Percentage of staff nurses responding affirmatively to
nurse-physician relationship types by magnet and
comparison hospitals and by period
Application of Evidence for oncology nursing practice
(Lai Harper)
• Utilize the Cochrane Database or the “JHNEBP Research Evidence Appraisal” as
the research tools; effectively communicate and collaborate with oncologists about
the nursing perspective on evidence-based practice
• Ongoing literature review for the most current, credible, and high-quality evidencebased practice for reducing oncology patients’ physical, psychological, and
emotional issues (such as pain, nausea, anxiety, or depression).
• Recommend the hospital nursing research committee to initiate a survey to explore
possible physician-nurse communication barriers at an oncology unit.
• Recommend the implementation of the low-cost convenient computer-based
training in physician-nurse communication skills.
Application of Evidence at the Cardiovascular Department
(Margaret Siler)
• High quality communication and collaboration make a great difference in
the cardiac catheterization laboratory (Boone, King, Gresham, Wahl, &
Suh, 2008, p. 168).
• Experience and a broad knowledge base bring confidence to our daily work
(Schmalenberg & Kramer, 2009, p. 82).
• All involved parties (patient, nurse, physician, healthcare system) can reap
the benefits of collaborative practice (Kramer et al., 2012, p. 7).
• There are many educational opportunities available to improve
interdisciplinary and interdepartmental communication. Many are quite
costly. Some that may make the biggest difference are fairly inexpensive,
including Unit Action Council work and interdepartmental job shadowing.
(McCaffery et al., 2012).
Application of Evidence into the Surgical Setting
(Gary Webster)
Intra-operative settings place nurses and physicians in close collaborative work
settings. The typical communication style is authoritarian. Schmalenberg and
Kramer (2009) stated that physicians felt the nurse-physician relation to be more
collaborative than nurse did. I can see that being true in my work environment. The
Boone et al (2008) and McCaffrey (2011) articles combined are very valuable.
Together the articles show a successful attempt to increase collaboration and some
pitfalls to avoid. These can help direct any programs to support an increase in
collaboration.
Application of Evidence
(Jamie Ziemba)
• Poor communication between nurses and physicians related to language and
cultural barriers
• Physicians’ dysfunctional or authoritarian communication style (e.g. instruct nurses
not to call at night unless it is a life-and-death emergency) is a major patient safety
issue.
• As the patient advocate, nurses have an important role of communicating with
physicians to verify medication orders, clinical procedures, and improve patient
outcomes.
• Hospital training programs in communication skills and cultural diversities are
recommended for physicians and nurses with different cultural/ethnic backgrounds
Summary Statements
• Meta-analytical review of evidence-based research articles support the clinical
significance of effective communication styles.
• Authoritarian communication styles increase disruptive behaviors and negative
hostile relationships at work environments.
• Healthy work environments have positive effects on nurses, physicians, patients,
and healthcare organizations.
• Inter-disciplinary collaboration is an essential aspect of healthy work environments
• Evidence-based studies have shown positive patient outcomes, nursing job
satisfaction, collaborative environments at Magnet hospitals.
• There is a need to address the barriers and incorporate educational programs to
teach effective communication and the need for collaboration. Educational training
should be re-enforced with weekly discussions. “Effective communication is the
cornerstone of interdisciplinary collaboration” (McCaffery et al., 2012, p. 294).
• Educate staff on the 5 types of nurse-physician relationships (collegial,
collaborative, teacher-student, friendly-stranger, and hostile/adversarial
relationships)
• Teach staff how to utilize positive relationships and change negative ones
• Training should avoid focusing on negative behaviors.
• Training should focus creating cooperative behaviors.
References
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Manojlovich, M., & DeCicco, B. (2007). Healthy work environments, nurse-physician communication, and patients'
outcome. American Journal Of Critical Care, 16(6), 536-543.
McCaffrey, R., Hayes, R., Cassell, A., Miller-Reyes, S., Donaldson, A., & Ferrell, C. (2012). The effect of an educational programme
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