APNA 30th Annual Conference Session 4023: October 22, 2016 Florence - - PDF document

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 1

Florence Nightingale Meets the New Generation of Evidence Based Practice: A Tale of Collaborative Inquiry

Diane Hurd, BSN, RN-BC Keri Cross, BSN, RN-BC, CNML Heather Landon, BSN, RN The presenters have no disclosures or conflicts of interest

Objectives

• Identify the importance of nursing participation in the

larger culture of inquiry.

• Present the experience of one team’s journey from initial

inquiry to an evidence based protocol and final approval to conduct clinical research.

• Outline the organizational structures, both formal and

informal, and leadership style which promote collaborative inquiry and interdisciplinary research.

Adolescent Depression: What We Know

• 1 in 10 teens will experience depression.
• Most will go untreated.
• Suicide is the 2nd leading cause of death among

adolescents in the U.S.

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 2

What is Triple Chronotherapy?

• 5-day manipulation of sleep-wake cycles which includes

initial sleep deprivation, sleep phase advancement, and bright light therapy

• Rapid treatment of depression often achieving remission
• f symptoms in the first few days of the protocol
• Faster response to treatment than medication which
• ften take 6-8 weeks to achieve even a partial remission
• A powerful adjunct treatment which can be used with

medication

What is Triple Chronotherapy? The Protocol

• Day 0 - 36 hours of sleep deprivation
• Day 1 - Sleep at 1800, up at 0100
• Day 2 - Sleep at 2000, up at 0300
• Day 3 - Sleep at 2200, up a 0500
• Day 4 – Maintenance sleep schedule 2200 – 0600
• Bright light therapy daily from 0700 – 0730. Daily light

treatment continued after discharge.

Triple Chronotherapy Outcomes: Research in Adults

• In studies conducted in adults, 70% of patients

experienced a 50% reduction in symptoms (Benedetti et al, 2014).

• Suicidality decreased significantly after the first cycle of

sleep deprivation (Sahlem et al, 2014).

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 3

What Next . . . Front-line Research with Adolescents

• No existing studies of triple chronotherapy in the acute

treatment of depression with the adolescent population

• Currently conducting an open label pilot study of 20

adolescent subjects with moderate to severe depression

• n the youth inpatient psychiatric unit at Billings Clinic
• Front-line nurses collaborating with psychiatrists in

interdisciplinary research - a collaborative success story Evidence based practice (EBP) is the conscientious use of current best evidence in making decisions about patient care (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000)

Evidence Based Practice: An Evolving Culture of Inquiry and Collaboration

A Brief History of Evidence Based Practice

• 1992 – Gordon Guyatt, MD coins the phrase Evidence Based

Medicine and teaches a course at McMasters University.

• 1996 – David Sackett, MD publishes “Evidence based

medicine: What it is and what it isn’t.”

• 2001 – Pubmed search for Evidence Based Medicine results in

2,584 publications; 38% in developed countries had internet access, 11% in developing countries.

• 2016 – Pubmed search for Evidence Based Practice results in

120,724 publications; over 80% in developed countries have internet access, 34% in developing countries.

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 4

Linear Model of Evidence Based Practice

Research Evidence Practitioner Practice Patient

Information Hierarchy New Generation of Evidence Based Practice

Practice Patient Practitioner

• Accelerated
• Information Fluent
• Inquiry Oriented
• Patient Centered
• Systems-based
• Evolving
• Collaborative

Collaborative Inquiry =

(Interdisciplinary Collaboration)(Culture of Inquiry)

(EBP)(Transformational Leadership)(Positive

Deviance) (Action Research) (Interdisciplinary Collaboration)(Culture of Inquiry)

(EBP)(Transformational Leadership)(Positive

Deviance) (Action Research) Interdisciplinary Collaboration)(Culture of Inquiry)

(EBP)(Transformational Leadership)(Positive

Deviance) (Action Research)

rdisci rdisciplin inar

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 5

Stages of Collaborative Inquiry: Exploring as a Way of Co-Learning

Planning Stage – identifying, sorting, organizing, Action Stage – trialing, collecting, questioning Observing Stage – interpreting, sharing, making connections Reflection Stage – evaluating, analyzing, implementing The research process repeats these four stages at each cycle with deepening experience and knowledge of the initial proposition.

Collaborative Inquiry in Action: The Co-Learner’s Experience

Focus Intuitive speculation Learning Action Creative leap Re-evaluate Gathering Making connections

* * * * * * * * *

“What if . . ?” Implement

*

Keys to Collaborative Inquiry

• Partnership
• Co-Learning
• Interdisciplinary

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 6

Keys to Collaborative Inquiry: Partnership

• Among the working group, hierarchy becomes

secondary to the team itself. Expect the unexpected.

• Team members take ownership of the process. “We”

and “our” language is used.

• Partnerships achieve mutually owned goals.

Keys to Collaborative Inquiry Co-Learning

• A culture of inquiry is a culture of learning.
• Working together means learning together, even if there

are “experts” at the table.

• Authentic discovery fuels passion and momentum.

Keys to Collaborative Inquiry: Interdisciplinary Collaboration

• Seeing things clearly requires different points of view.
• Diversity helps us to ask the right questions.
• Collaboration of disciplines creates synergy of resources

and skill sets.

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 7

The Inquiry Process

Source: Ginger Group Collaborative (now disbanded), Jean Singer & Michael Keller former members, http://www.ecologyofdesigninhumansystems.com/knowledge-gateway/collaborative-inquiry-whidbey-institute/

A Tale of Collaborative Inquiry . . .

“How a Light Box and a Dream Team Changed One Hopeless Teen’s Life”

• Dr. Eric Arzubi, Child Adolescent Psychiatrist

Billings Clinic, Billings, MT. TedTalk MT , YouTube excerpt https://www.youtube.com/watch?v=99u86yh0Mns

What’s a nurse manager supposed to do with this guy? Collaborative Leadership: What is best for patient care?

• Quality versus safety?
• Invasive?
• Side effects?
• Evidence-based? What if there isn’t any?
• Cost?
• Are nurses really on board?
• What is the procedure?
• What guidelines can we put together quickly?
• Hope?

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 8

Collaborative Leadership: Believe in your team, you did hire them

• Take a leap of faith.
• Recognize individual strengths.
• Refrain from micromanaging.
• Create bonds of trust with your staff.
• You don’t have to be the face of the department, let
• thers shine.

Collaborative Leadership: Be the “yes” guy

• Find ways to say “yes.”
• Advocating for calculated risk pays off in original

innovation.

• Encourage the sharing of innovation to create

momentum.

• Magnet story – psychiatry too specialized, story not

worth publishing to an exemplar of best practice.

• We can change the world! – set the example for

international acute depression treatment.

Collaborative Leadership: Think Innovation

• Compliance and safety versus creativity and innovation
• Talk about the bigger picture.
• Be the strategist, look ahead.
• Cerner, forms, releases, assessment tools
• “Run with it” vs “let’s slow down and discuss”

APNA 30th Annual Conference Session 4023: October 22, 2016 Hurd 9

Transformational leadership – a buzz word?

• Idealized influence - Just do it! Make change possible.
• Inspirational motivation - Recognize individual
• motivators. Empower. Be a cheerleader!
• Intellectual stimulation - Create a culture of learning and

inquiry.

• Individualized consideration - Identify and tap into

individual strengths.

References

Benedetti, F., Riccaboni, R., Locatelli, C., Poletti, S., Dallaspezia, S., & Colombo, C. (2014). Rapid treatment response of suicidal symptoms to lithium, sleep deprivation, and light therapy (chronotherapeutics) in drug-resistant bipolar depression. J Clin Psychiatry, 75(2), 133-140. Gest, S., Legenbauer, T., Bogen, S., Schulz, C., Pniewski, B., & Holtmann, M. (2014). Chronotherapeutics: an alternative treatment of juvenile depression. Med Hypotheses, 82(3), 346-349. Gest, S., Legenbauer, T., Bogen, S., Schulz, C., Pniewski, B., & Holtmann, M. (2016). Chronotherapeutic treatments for depression in youth. European Child Adolescent Psychiatry 25: 151-161.. International Telecommunication Union. Information and Communication Technology: World Telecommunication/ICT Indicators database. Internet Use Per 100 Inhabitants. Retrieved on 5/16/16 at http://www.itu.int/ITU-D/ict/statistic/ict/ National Institute of Mental Health. (2015). Mental Health Information. Retrieved June 5, 2015, 2015, from http://www.nimh.nih.gov/health/topics/index.shtml Nightingale, F. (1869). Notes on Nursing. New York, New York: Dover Publications Reason, P. & Bradbury, Handbook of Action Research. London: Sage, 2001.

References (cont)

Sackett, D, Rosenberg, W, Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: what it is and what it isn’t BMJ 312 (7023): 71-2 Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based medicine: how to practice and teach EBM. Second edition. Edinburgh:Churchill Livingstone, 2000. Sahlem, G. L., Kalivas, B., Fox, J. B., Lamb, K., Roper, A., Williams, E. N., . . . Short, E. B. (2014). Adjunctive triple chronotherapy (combined total sleep deprivation, sleep phase advance, and bright light therapy) rapidly improves mood and suicidality in suicidal depressed inpatients: an open label pilot study. J Psychiatr Res, 59, 101-107 Zimmerman, A. (2013). Evidence Based Medicine: A Short History of a Modern Medical

• Movement. American Medical Association Journal of Ethics. 15 (1): 71 -76