Increasing Confidence and Referrals to Social Work of Adolescents - - PowerPoint PPT Presentation

Use of Simulation With Pediatric Nurses: Increasing Confidence and Referrals to Social Work of Adolescents Engaging in Risky Behaviors

Doctor of Nursing Practice Scholarly Project Committee Members

• Chair

– Dr. – Dr. – Dr. Jacqueline Saleeby Karen Balakas Angela Lowery

Background

Throughout the past several decades, the leading cause of death

• r injury for adolescents has been accidents and often those

accidents involve alcohol or drugs According to the SubstanceAbuse and Mental Health Services Administration (SAMHSA) (2014), approximately 23% of Americans aged 12-20 years reported they drank alcohol in the previous month

– 14.2% of respondents reported binge drinking – 3.7% reported heavy drinking

Background– cont..

• The American College of Surgeons (ACS)(2014) recognizes

“many injuries have alcohol and drug use as an important contributing factor. Screening and brief intervention for alcohol use are required of all trauma centers”(p.140) “Screening for alcohol use must be performed for all injured patients and must be documented. At Level I and II trauma centers, all patients who have screened positive must receive an intervention by appropriately trained staff, and this intervention must be documented” (p.141)

– Required compliance with this metric is 100%

Significance

• In 2014, only 51% of eligible adolescent patients at Saint

Louis Children’s Hospital (SLCH) with traumatic injuries were screened. In 2015, in order to increase in compliance with this metric a taskforce was convened

– Goals:

• The realization that all adolescents ages 12 and over who were admitted

should be screened for drug and alcohol abuse – this screening should not be service or injury dependent The person who spent the most time with the patient would be the best choice for completing the screening The bedside nurse would do the screening during the initial assessment to the nursing unit

The St. Louis Children’s Hospital Study

10th

• The

floor was chosen to complete the pilot study as they were the floor where the bulk of trauma patients were admitted 10th

• Since the bedside nurses on the

floor lacked experience administering the Cars, Relax, Alone, Family , Friends, & Trouble (CRAFFT) T

• ol

– A simulation experience was developed to

• Increase their confidence in using the CRAFFT assessment tool
• Complete the requirement of an intervention referral to

treatment for all who screen positive

Study Question

For nurses working with patients from 12-17 years, does the use of simulation to teach administration and interpretation of the Cars, Relax, Alone, Forget, Friends, and Trouble (CRAFFT) Screening T

• ol using specific communication skills

result in increased identification of appropriate referrals and an increase in nurse confidence in screening for high risk behaviors?

Study Aims

Determine whether administration of the CRAFFT by bedside nurses for all hospitalized adolescents results in improved screening rates among trauma patients. Determine whether administration of the CRAFFT by bedside nurses for all hospitalized adolescents results in identification

• f at-risk patients among the general patient population on the

unit. Determine whether appropriate referrals for brief intervention are completed by the bedside nurse. Determine whether bedside nurses demonstrate improved confidence in their ability to provide screening for high risk behaviors in adolescents

Study Design and Methods

Maryville University Institutional Review Board (IRB) approval received in February 2017

• Instruments:

– – Demographic Data Form 15 Question Pre & Post T est on identifying risky behaviors, use of the CRAFFT T

• ol, and making social work referrals

The Confidence Scale to measure confidence in skill performance –

• ▪

▪ On-site 4 hour training session following consent process: N=44 Demographic data collected, Pre-test and Confidence Scale administered Presentation on identification of risky behaviors, how to ask the questions on the CRAFFT T

• ol, referral to social work – Round T

able Discussion Participation in Simulation Scenarios Debriefing after each scenario with parents and adolescents present. ▪ ▪

Certain for only Fairly certain for Certain for Not at all certain certain for all

Agree Unsure Disagree

Item

The Confidence Scale

5 4 3 2 1

performance of Absolutely a few steps a # of steps almost all steps steps I am certain that my performance 1 2 3 4 5 is correct

Strongly Strongly Agree Disagree

I feel that I perform the skills 5 4 3 2 1 without hesitation My performance would convince the observer(s) 5 4 3 2 1 that I am competent I feel sure of myself as I 5 4 3 2 1 perform the skills I feel satisfied with my skills

CRAFFT T

• ol Questions

Have you ever ridden in CAR driven by someone (including yourself) who 1. was “high” or had been using alcohol or drugs?

• 2. Do you

fit in? ever use alcohol or drugs to RELAX, feel better about yourself, or 3. 4. 5. Do Do Do you you ever ever use alcohol or drugs FORGET things you while you are by yourself, or ALONE? did while using alcohol or drugs? your FAMIL Y or FRIENDS ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into TROUBLE while you were using alcohol or drugs? 6.

• Note: Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children’s Hospital

Boston

Sample T est Questions

• In 1965 what was the average age of initiating drinking for U.S.

adolescents? In 2015 what was the average age of initiating drinking for U.S. adolescents? The CRAFFT (Car, Relax, Alone, Forget, Friends, & Trouble) T

• ol is

considered positive if: True or False: Patient’s answers to the CRAFFT can be shared with parents/caregivers regardless of the patient situation being life threatening or not, because the patient was admitted to the hospital? What is the leading cause of mortality and morbidity among American youth?

6 Simulation Scenarios

All Scenarios used the CRAFFT T

• ol
• 1. 15 year-old female admitted from the ED for an appendectomy

. Parent agrees to leave after explanation of CRAFFT T

• ol and need to ask questions

without parents present

Goal: Introducing sensitive questions, asking parents to leave, explaining why

• 2. 12 year-old male admitted from the ED after a motor vehicle accident

(MCV). Parents refuse to leave.

Goal: Introducing sensitive questions, asking parents to leave, secondary line of explanation, determination to NOT ask questions in front of parent

6 Simulation Scenarios Cont.

3. 17 year-old admitted for wrist fracture after an all terrain vehicle (ATV) accident. Parents okay with leaving room, but patient refuses to answer, says “I don’t want my parents to know.” A secondary explanation is given to patient, and patients answers questions after the secondary explanation.

Goal: Introducing sensitive questions, asking parents to leave, secondary explanation to patient, patient agrees to answer after secondary explanation

4. 14 year-old transferred from the PICU after having a spinal fusion. CRAFFT T

• ol not administered in the PICU due to the patient’s sedation status.

Goal: Introduce sensitive questions, nurse understanding how to document for a transfer patient

6 Simulation Scenarios Cont.

5. 13 year-old admitted from PACU following a cholecystectomy , still sedated, nurse is unable to ask questions during admission profile.

Goal: Introducing sensitive questions, nurse knowing how to document CRAFFT wasn’t done and how to make sure it gets done by subsequent bedside nurse

6. 16 year-old male admitted following a gunshot wound to the leg. Parents refuse to leave and indignant that you would even ask them to leave.

Goal: Introduce sensitive questions, asking parent to leave, secondary explanation to parents, politely ending questions and documenting that parents refused to leave.

Video of Simulation Scenario

Post-Session Data Collection

• 2 months post-training session n=22

– Post-test and confidence scale placed in CRAFFT T

• ol

10th box in the Floor Staff Lounge and nurses asked to complete and place in envelope with personal identifier and seal.

Statistical Analysis

Univariate Summary Statistics for demographic and instrument scores McNemar T ests to determine changes in binary Knowledge and Confidence instrument item binary variables. Non-parametric Wilcoxon signed rank sum tests for changes in the confidence scale items Wilcox-Mann-Whitney tests to compare composite scores

Characteristics of the Staff Nurses (n=22)

No statistical differences between those who were excluded due to missing follow-up testing

RN Degree – Majority had a BSN 72.7% Age – Majority 21-35 years 36.4% Y ears of Experience – Majority 0-5 years 59.1% Previous Simulation Experience 100% Previous CRAFFT T

• ol Experience 9.1%

Average T est Scores

69.4 % - 81.5% (p<0.001)

Change in Confidence Level

Each of the confidence items was statistically significant over time (p <0.05)

Screening, Brief Intervention, and to Treatment (SBIRT)

% SBIRT Pilot March 27, 2017- June 26, 2017

Referral

80% 75% 70% 60% 50% 40% 37% 30% 20% 10% 0% March April May June Not Completed Completed Reminder Provided Completed with Reminder 71% 63% 50% 50% 29% 25% 20% 10% 16% 0% 0% 6% 6% 2%

Discussion

▪ Up to 80% of adolescents report they have used drugs or alcohol before graduating from high school. However, adolescents are overall healthy , leading to infrequent contacts with the medical community . Therefore, admission to the hospital is an opportune time to screen adolescents for risky behaviors. Pediatric nurses are in need of resources for improving their skills in communicating sensitive questions to the adolescent population. ▪ ▪ ▪

Implications for Future Research

▪ The study is somewhat limited due to the small sample size and the high percentage of attrition with almost 50% of the participants not completing the post-test. ▪ Further improve improve research in this area should focus on strategies to the attrition rate and be repeated with a larger sample to generalizability . ▪ Future research should be replicated for all adolescents in both inpatient and outpatient settings.

Relationship of this Scholarly Project to a Doctor Of Nursing Practice Degree

According to Moran, Burson & Conrad (2014) a project’s worth is defined by answering the following questions:

• –

– – Is there a contribution to comprehensive quality health care? Are there specific benefits for a group, population, community or policy? Does the project advance practice at the local, (p.74) state and national level?

• The answer to all these questions is YES.

disseminate this study through manuscript replicate the study in different settings. The next steps are to submission and to

References

American College of Surgeons (2014). Resources for optimal care of the injured patient, Chicago, Il, Committee on Trauma,American College of Surgeons Grundy , S. E. (1993). Confidence scale. Nurse Educator, 18 (1), 6-9. Leonard, E.A., Buckley , T ., & Curtis, K. (2016). Impact of alcohol on outcomes in hospitalized major trauma patients. Journal of Trauma Nursing, 23(2), 103-114. doi.org/10.1097/JTN.0000000000000194 McKenna, C., Gaines, B., Hatfield, C., Helman, S., Meyer, L., Rennick, C., …Zaremski,

• J. (2013). Implementation of a screening, brief intervention, and referral to treatment

program using the electronic medical in a pediatric trauma center. Journal of Trauma Nursing, 20 (1), 16-23. doi.org/10.109/JTN0b013e318

References

Moran, K., Burson, R., & Conrad, D. (Eds.). (2014). The doctor of nursing practice scholarly project: A framework for success. Burlington, MA: Jones & Bartlett Learning. Shafii, T ., Rivara, F . P ., Wang, J., & Jurkovich, G. J. (2009). Screening adolescent patients admitted to the trauma service for high-risk behaviors: Who is responsible? The Journal of Trauma Injury, Infection, and Critical Care, 67(6), 1288-1292. http://dx.doi.org/10.1097/TA.0b013e3181847e8e U.S Department of Health and Human Services, SubstanceAbuse and Mental Health and Health: Summary of National Findings (NSDUH Series H-48, HHS Publication No. (SMA) 14-4863)

AV ery Special T eam

FamilyAdvisory Group Parents and their Children T eresa CostleyADN, RN Michele Herndon MSN, RN Carrie Quante BSN, RN, CPN Moe Schmid MA, MSN, RN Mary Lucido MSW, LCSW Bobbi Williams MSW, LCWS Sarah Weyhrich MSN, RN, CPN Karen Balakas PhD, RN, CNE Lisa Steurer PhD, RN Deirdre Schweiss MSN, RN, CPNP