Moving Evidence into Practice Dawn Stacey RN, PhD, CON(C), - - PowerPoint PPT Presentation

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Moving Evidence into Practice Dawn Stacey RN, PhD, CON(C), - - PowerPoint PPT Presentation

Apr 05, 2024 149 likes •652 views

CANO 2010 - Research Workshop: Moving Evidence into Practice Dawn Stacey RN, PhD, CON(C), University of Ottawa Denise Bryant-Lukosius, RN, PhD,CON(C), McMaster University, Hamilton Andrea Maria Laizner, RN, PhD, McGill University Health Centre,

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CANO 2010 - Research Workshop:

Moving Evidence into Practice

Dawn Stacey RN, PhD, CON(C), University of Ottawa Denise Bryant-Lukosius, RN, PhD,CON(C), McMaster University, Hamilton Andrea Maria Laizner, RN, PhD, McGill University Health Centre, Montreal On behalf of Cancer Care Ontario’s Community of Practice Nursing Research Group and CANO Research Committee

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Workshop Outline

  • 1. Welcome & introductions (~30 min)
  • 2. Clinical Practice Guidelines – what, how to find them,

appraising their quality (~30 min)

  • 3. Strategies for implementing guidelines in clinical practice

(~20 min)

  • 4. Case study: implementation of guidelines in oncology

nursing practice (~30 min)

  • 5. Wrap-up and workshop evaluation (~10 min)
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3

Best Practices Guidelines

  • Improve patient care
  • Standardize care
  • Integrate research into practice
  • Develop knowledge base
  • Assist with clinical decision-making
  • Recognize deviations
  • Stop ineffective interventions
  • Decrease costs
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Goals of MUHC Best Practice Guideline Program

  • Improve performance

– Patient Outcomes (PU, Pain, falls with injury) – Nurse Outcomes (practice, documentation) – System Outcomes (costs, efficiency, collaboration)

  • Harmonization (decrease variation)
  • Increase knowledge transfer capacity
  • Leadership development

(Ritchie, O’Connor, Rose, Sourdif, Jan 29, 2009)

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PARIHS Framework Guided MUHC Implementation

  • Evidence

– Research, clinical and patient experiences, as well as local data

  • Context or environment (HCS, research to be

implemented, where change to occur) – Culture, leadership, evaluation – Complexity, readiness, feedback mechanisms

  • Facilitation or process of enabling (help, support,

strategies that enable reflection)

(Roycroft-Malone, 2004)

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Workshop Outline

  • 1. Welcome & introductions (~30 min)
  • 2. Clinical Practice Guidelines – what, how to find them,

appraising their quality (~30 min)

  • 3. Strategies for implementing guidelines in clinical practice

(~20 min)

  • 4. Case study: implementation of guidelines in oncology

nursing practice (~30 min)

  • 5. Wrap-up and workshop evaluation (~10 min)
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CANO 2010

Case study: Implementation of guidelines in oncology nursing practice

Andrea Maria Laizner, R.N., Ph.D.

Nursing Practice Consultant-Research, MUHC Assistant Professor, School of Nursing, McGill University

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McGill University Health Centre

  • Academic health center
  • Patient-family centered care

– clinical practice, education, research

  • Specialized care across the life span
  • Over 3,000 nurses across 6 sites
  • 7 Clinical missions, includes Oncology & Palliative Care
  • Professional Practice and Research

– Emphasis on patient safety, research & quality care – 65 Clinical Nurse Specialists – 30 Nurse Educators

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McGill University Health Centre

9

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BPG Steering Committee

MUHC

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Evaluation

  • Prevalence Survey
  • Annually with each admitted patient

(1 hospital site per day)

  • Study 1(31 units) and Study 2 (17 units)
  • 30 patients per unit
  • Categorized units:
  • Level of improvement: Low, Medium, High

Based on number of criteria met a change of > 10% from baseline

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Strategies: Task Force

  • Responsible for determining priorities and rollout plan for

indicator for which they are responsible

  • Review and select RNAO BPG recommendations
  • Co-chairs clinicians, educators or administrators
  • Interdisciplinary: RN, physio, MD, quality & risk

management, patient representative, researcher, and

  • thers
  • Select indicators, including criteria and benchmark
  • Develop implementation plan, time-line, documentation,
  • ther tools and manual
  • Provide support and coaching
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Support from Task Forces

  • Content ‘Experts’
  • Design & give learning activities
  • Resource packages
  • Pocket guides for assessment
  • Resource binders, BPG bulletin boards, Posters
  • Hold focus groups/celebrations with frontline staff
  • Provide coaching & problem solving especially

to unit-based champions re content of change

  • $ 5,000 to each Task Force
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Strategies: Unit

  • 8-12 weeks implementation
  • Stakeholder assessment
  • Facilitation

– External: TF Co-chairs, Advocate support (CNS, Educator, Other) – Internal: Unit Champions (RN, ANM, PABs)

  • Workshops on Change management and

implementation for champions and leadership team

  • Train the Trainer sessions for the champions
  • Regular audit with feedback to staff
  • Pocket tools and posters
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Strategies: Organisation

  • Workshops and Information sessions
  • Regular reporting to Council of Nurses and

Leadership groups

  • Advocates facilitate practice change
  • Communication

– Needs to be frequent and at multiple levels

  • Practice guidelines linked to patient safety

agenda and planning for equipment (business case).

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Support from Advocates

  • BPG Implementation ‘Experts ‘; General content
  • Provide external implementation guidance

– Participate in unit group or focus group meetings – Review with unit re EBP and BPG implementation – Coach unit-based champions on change model; help develop unit plan and strategies – Suggest evidence-based strategies; plan sustainability

  • Leading change workshops
  • General leadership advice!
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Coordinator Role

  • Coordinates and facilitates:

– implementation and work reorganization activities associated with implementation – Research activities associated with evaluation

  • f implementation
  • Provides support to Task Forces
  • Reports to BPG Project Leaders
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RNAO Toolkit : 6 Steps to Guide Implementation

  • 1. Stakeholder Analysis
  • 2. Preparation of Workplace
  • 3. Potential Barriers
  • 4. Implementation Plan
  • 5. Evaluation
  • 6. Required Resources
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RNAO Toolkit : Stakeholder Assessment Worksheet for Planning Implementation

  • 1. Key stakeholder
  • 2. Nature of vested interest
  • 3. Stakeholder
  • influence (high versus low)
  • Support (high versus low)
  • 1. Management strategies
  • 2. Revisions
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Environmental Readiness

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Clinical Practice Guidelines RNAO

Pain Toolkit

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RNAO Nursing Best Practice Guidelines for the Assessment and Management of Pain 78 recommendations for clinical practice, education and organization of care with goal:

  • To provide direction in the assessment

and management of pain in both institutional and community settings

  • To prevent pain wherever possible
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BPG: Based on following Principles

  • Pain is an individual experience and unique to

each person

  • Pain has important physiological and

psychological effects on the person

  • Pain influences recovery from illness, alters

physical and emotional functioning and decreases quality of life

  • Nurses need to learn to assess and manage

pain

  • There are a variety of methods to manage pain,

pharmacological and non-pharmacological

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Assessment and Management of Pain

  • Best Practice recommendations
  • Implementation strategies
  • Evaluation
  • Facilitating factors
  • Results, including Unit example
  • Lessons learned
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Tools Developed

  • Patient Information Sheet developed to

encourage patients to talk about their pain

  • Revised protocols for PCA, epidural analgesia,

and surveillance of opioids

  • Guide for prescription of opioids and other

analgesics for physicians

  • Algorithm for the assessment and management
  • f pain (poster)
  • Revision and implementation of documentation

tools (paper, electronic, etc)

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Numeric Scale Numeric Scale

0 1 2 3 4 5 6 7 8 9 10 no pain Pain as bad as you can imagine 0 1 2 3 4 5 6 7 8 9 10 Pas de La pire douleur que douleur vous pouvez imaginer

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FACES ( FACES (Revised Revised Bieri) Bieri)

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MUHC Infothèque

  • MUHC Health Education Collection
  • Includes pamphlets meeting specific

health literacy standards

  • http://infotheque.muhc.ca/Results.aspx?QY=find%28FileNumber=612%29
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DRUG Equianalgesic dose Onset of action Peak of action Duration

  • f action

Starting dose in opioid- naïve* patients WITH risk factor(s) (Adults) Starting dose in

  • pioid-naïve*

patients with NO risk factor (Adults) SC/IV PO SC/IV (PO) IV SC PO SC/IV (PO) Morphine 5 mg 10 mg 2-5 min (15 min) IV: 15 min SC: 30 min PO: 30-60 min 4 hrs (4-6 hrs) 2.5 mg SC/IV 5 mg PO 5 mg SC/IV 10 mg PO

Hydromorphone

1 mg 2 mg 6 min (15 min) IV: 15 min SC: 15 min PO: 30-60 min 4 hrs (4-6 hrs) 0.5 mg SC/IV 1 mg PO 1 mg SC/IV 2 mg PO Fentanyl 50 mcg N/A 1-2 min (N/A) IV: 5-15 min SC: 5-15 min PO: N/A 30-60 min (N/A) 25 mcg SC/IV 50 mcg SC/IV Codeine (IV not recommended) 60 mg 100 mg 30-60 min PO: 2-4 hrs 4-6 hrs (4-6 hrs) 30 mg PO 60 mg PO Oxycodone N/A 7.5 mg IV/SC: N/A (15 min) I/VSC: N/A PO: 30-60 min N/A (3-6 hrs) 5mg PO 7.5 mg PO

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MUHC PO Opioid Policy: MUHC PO Opioid Policy: Monitoring Monitoring

Time: X 24 hours & with each increase in dose Pre-administration At Peak Effect: Hydromorphone 30mins Morphine & Oxycodone 60 mins After 1st 24 hours if patient stable & dose remains the same Pain Assessment (0-10) Yes Yes Yes Level of Sedation (S, 0-3) Yes Yes According to pt’s clinical condition Respiratory Assessment (rate & amplitude) Yes Yes According to pt’s clinical condition Presence of snoring Yes Yes According to pt’s clinical condition BP, HR According to pt’s clinical condition According to pt’s clinical condition According to pt’s clinical condition

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MUHC SC Opioid Policy: Monitoring MUHC SC Opioid Policy: Monitoring

Parameters to monitor Following each dose for the duration of action during the first 24 hours AND with each dose change (increase or decrease) After 1st 24 hrs if patient stable & dose remains the same Pain Assessment (0-10) Level of sedation (S, 0-3) Respiratory assessment (rate, amplitude & presence of snoring) Pre- Administration At Peak Effect and at 60 mins: Fentanyl Monitor at 5, 15 & 60 mins. Hydromorphone Monitor at 15 & 60 mins Morphine Monitor at 30 & 60 mins. Q2H x 2 for duration of drug action: Hydromorphone & Morphine only Prior to administration and at Peak Effect: Fentanyl Monitor at 15 mins Hydromorphone Monitor at 15 mins Morphine Monitor at 30 mins BP, HR According to pt’s clinical condition According to pt’s clinical condition According to pt’s clinical condition According to pt’s clinical condition

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Strategies for Implementation

1- Train the Trainer Sessions:

  • One-day workshop: BPG Recommendations,

tools to motivate the teams, identification of facilitators and barriers among each of the teams, action plan adapted for unit context. 2- Evaluation : Chart audit before, midway, and at end of implementation, as well as other unit determined strategies . 3- Support from resource persons: experts on change and pain management.

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Strategies cont’d

4- Plan for debriefing sessions (focus groups) with nurses on the unit (midway and at end of implementation). 5- Role of other professionals or other members of health care team regarding BPG 6- Role of managers in support of the implementation such as liberating unit champions to attend workshop sessions, meetings, train colleagues, conduct audits, provide feedback to unit staff, etc. 7- Include patient representative on the Pain Task Force

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Strategies cont’d

8- Provide materials and necessary tools or equipment:

  • CD, manual with BPG guidelines and

recommendations as well as implementation plan, including timeline and strategies

  • Posters announcing implementation
  • Posters providing feedback on the assessment

and management of pain: Pain as the 5th vital sign

  • Algorithms and associated plan of care

9- Celebrations (Pizza and muffins)

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Implementation Plan

WEEK ACTIVITY RESOURCES NEEDED Before Implement BPG

  • Nurse managers who are planning to

implement BPG meet together, meet with representatives of Task Force and Advocates

  • Nurse manager introduces BPG to staff
  • Unit Champions identified
  • Team to attend Change and Pain

Workshop BPG Advocates Nurse Manager Task Force Champions Week

  • Champions, Educators, CNS, Nurse

managers and their assistants attend workshop (Train the Trainer session)

  • Provided Pain Implementation binder

(containing power point presentation slides and audit tool, implementation planned timeline etc).

  • Posters delivered to unit

Champions Educator/CNS Nurse Manager Task Force Advocate

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Week 1 & 2

  • 5. Staff receive training provided by

Champions

  • 6. Create visible reminders

e.g. Poster with principle recommendations, list of champions Champions Educators/CNS Week 3

  • 7. Implement recommendations
  • 8. Champions conduct survey of

indicator, including chart audit for feedback at unit focus group Champions and Unit staff Advocates Task Force Week 4

  • 9. Implementation continues
  • 10. Focus group on unit with nurse

manager, champions and unit staff Champions and Unit staff Advocates Task Force

Implementation Plan

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Implementation Plan

Week 5, 6 & 7s

  • 11. Implementation continues

Champions and Unit staff Week 8

  • 12. Champions repeat survey of indicator,

including chart review

  • 13. Focus group on unit with nurse manager,

champions and unit staff Champions and Unit staff Advocates Task Force Post –

Implement

  • 14. Sustainability measured at time of annual

prevalence survey and unit audits (PRN) Quality Committee, Nurse Manager, CNS, and others.

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Unit Case - Video

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Nurses Feedback

  • Improved relations with members of health

care team

  • Provided a common language
  • Increased knowledge
  • Relevance of Pain
  • Challenge to change and sustain
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Results

  • Recognize importance of pain
  • Universal screening for pain on care units

(including psychiatry) at least once a day

  • Patients are providing reports of their pain
  • Using pain scale throughout MUHC

– Numeric rating scale 0-10 – Faces Scale (Revised Bieri)

  • Increased pain documentation by nurses
  • Implementation occurred on 33 units (90%)
  • Re-evaluation and surveillance after intervention
  • Change in practice hasn’t led to consistent

change in patient outcomes

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Facilitators

  • Administrative support at all levels
  • Dedicated resource (BPG-Coordinator)
  • Degree of enthusiasm and motivation
  • Buy-in by team/total commitment
  • Some teams more sensitive about pain than
  • thers and therefore had already implemented

some of the CPG recommendations

  • Concept of leader/champion
  • Equipment
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Barriers

  • Multiple priorities
  • Change in Nurse Manager, Assistant
  • r Educator
  • Sustainability of practice guideline
  • Nursing shortage
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Challenges

  • Continue to have practices that are not evidence-

based/out-of-date

  • Patient records not electronic
  • Multi-disciplinary (not just nursing)
  • ? Effective strategies for sustainability
  • Maintain interest and motivation
  • Required resources
  • Communication, communication, communication
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Lessons Learned

  • The experience is different if a unit is

implementing for the first time, second time or third time

  • Timing is rarely perfect (nursing shortage,

renovation of unit, documentation issues, leadership on vacation, etc.)

  • We were able to realize some

changes....but are they sustainable?

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Lessons Learned

  • Issue of flexibility at time of implementation
  • Get buy-in from unit team prior to implementation

– Role of Nurse Manager – Role of Unit Champion

  • Provide team with documentation about principles and

processes (roadmap)

  • Buy-in at admin and organizational level important,

including other members of health care team

– Need resources (human, equip, tools)

  • External resources from government, grants and

foundations important facilitators (Quebec, GRIISQ, Newman and Hospital Foundations, etc)

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Conclusion

1- Patient safety agenda important

  • benchmarking and performance objectives
  • Change client and personnel behaviour

2- BPG: Perceived worth; Possibility of bringing change for patients 3- Organisational support critical

  • Advocates at multiple levels
  • Dedicated resources (people and materials) for

education and support 4- Quality Improvement monitoring

  • Up to date information
  • Audit and feedback
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Workshop Outline

  • 1. Welcome & introductions (~30 min)
  • 2. Clinical Practice Guidelines – what, how to find them,

appraising their quality (~30 min)

  • 3. Strategies for implementing guidelines in clinical practice

(~20 min)

  • 4. Case study: implementation of guidelines in oncology

nursing practice (~30 min)

  • 5. Wrap-up and workshop evaluation (~10 min)