Evidence Based Nursing Practice Group Project
Evidence Based Nursing Practice Group ProjectLai Harper, Maggie Siler, Gary Webster, Jaime ZiembaFerris State UniversityNURS 350AbstractFor 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? The purpose of this Evidence-Based Nursing Practice group project is to critique the best peer-reviewed research articles and answer this significant clinical question based on the hierarchy of evidence. Literature review has shown strong evidence for collaboration between physicians and nurses at Magnet hospitals. The evidence for training programs to improve communication skills between physicians and nurses is applied to group members’ nursing practice (cardiovascular, medical/surgical, oncology, and general surgery).Evidence Based Nursing Practice Group ProjectEvery day we have conversations between nurses and doctors. What are the outcomes of those conversations, both positive and negative, for patients and nurses? Communication between doctors and nurses can also affect patient safety. If nurses cannot read orders written by the doctors, patient safety can be negatively affected. If either the doctor or the nurse is having a bad day, he/she may take it out on the patient with improper body language or communication. Finally, patients’ safety can be affected by the type of hospital they are at. Is it a larger magnet hospital that can take care of all types of illness or is it a smaller non-magnet hospital that can only stabilize and transfer the patient to a larger hospital? There are two types of professional communication: verbal and nonverbal. Verbal communication is basic conversation of words that people say to one another. These can be simple words or technical jargon. Verbal communication can be difficult if the nurse or doctor has English as a second language, or if the terms in the technical jargon are not shared by either the doctor or nurse. Nonverbal communication is body language and written communication. Both body language and written communication can be taken positively or negatively. Positive or negative nurse-physician relationships can have impacts on communication, patient outcomes, and nurse/physician job satisfaction (Schmalenberg & Kramer, 2009, p. 77).Communication between medical professionals is not a local problem. It is a problem found throughout the entire medical community. This is evident by the many articles written and studies done regarding the effect of professional communication on patient care. Literature ReviewOur group initially evaluated eleven peer-reviewed research articles from the Agency for Healthcare Research and Quality, Cochrane Library, and PubMed/CINAHL databases. The non-cohesive communication between male authoritarian physicians and female subservient nurses can result in two segmented groups at acute care hospitals (Ballou & Landreneau, 2010, p. 75). Using the qualitative ethnographic approach, Gardezi et al. (2009) analyzed at least 700 surgeries for two years and reported communication conflicts due to nurses’ gap in knowledge and surgeons’ dominant authoritative power at three Canadian hospitals. Nurses’ quiet/submissive communication had potential damaging impacts on patient safety (pp. 1394-1397). Hendel et al.’s (2007) study showed that charge nurses were more likely to reduce conflicts using the “collaborative” communication style when compared to physicians at five Israeli hospitals (p. 249). Literature review has revealed the negative effects of dysfunctional communications in acute care hospitals. Manojlovich and DeCicco’s (2007) study showed that miscommunication between physicians and nurses was statistically significant and positively associated with perceived medication mistakes among 462 intensive care nurses at eight Michigan hospitals (p. 452). Rosenstein and O'Daniel (2008) reported that physician-nurse disturbing behaviors (authoritarian communication, verbal insult, or disrespect) were likely to increase harmful consequences, such as medication errors and patients’ deaths (p. 464). Using the “Hamilton’s Anxiety Scale” and “Stamp’s Index of Work Satisfaction,” Karanikola et al. (2012) investigated the psychological and emotional health of 229 intensive care nurses at eleven hospitals in Greece; dissatisfaction in physician communication was statistically significant with increased nurses’ stress levels (p. 41).The gender model for the authoritative dominance of physicians is not applicable to advanced practice nurses/APNs which have high educational preparations (Rothstein and Hannum, 2007, p. 235). A study has shown the statistical significance for APNs’ positive attitude/communication with female physicians (less than 50 years old) and male physicians (at various ages); male and female physicians are also more likely to be respectful about APNs’ knowledge and clinical decisions (Rothstein and Hannum, p. 238). What are the evidence-based interventions for reducing authoritarian dysfunctional communications and increasing interdisciplinary collaboration? The Cochrane Database has shown no randomized controlled studies about physician-nurse collaboration at acute care hospitals (Zwarenstein, Goldman, & Reeves, 2009, p. 8). The best four articles are selected based on the hierarchy of evidence, theoretical framework, research methodology, and measurement instrument: two “Level III” quasi-experimental studies (Boone et al., 2008; McCaffrey et al., 2011) and two “Level I” meta-analysis/integrated review (Kramer, Schmalenberg, & Maguire, 2010; Schmalenberg & Kramer, 2009). Analysis of EvidenceThe first article “Conflict management training and nurse-physician collaborative behaviors” (Boone, King, Gresham, Wahl, & Suh, 2008) is a quantitative quasi-experimental study. Ethical research guidelines are firmly adhered to. This study uses a convenience sample, closely approximating the real world experience. The purpose is to examine a knowledge gap between unit specific interventions and improved communication and collaboration. The importance of improving quality of care and nurse satisfaction through respectful communication and collaboration is the basis for this study. The impact of conflict management training on nurse-physician communication and collaboration is analyzed. Theoretical framework is based on “Kilmann and Thomas conflict resolution theory” (Boone et al., p. 168). The instrument, Collaborative Behavior Scale (CBS) is valid and reliable with a Cronbach alpha score of 0.76-0.97 (Boone et al., 2008, p. 169). Unexpectedly, the null hypothesis was not rejected. The intervention was statistically insignificant with both study and control group mean CBS scores pre and post intervention p>.05 (Boone et al. pg. 172). Several limitations are identified. Continued research for interventions to promote quality communication and collaboration is a significant step toward creating a culture that supports healthy work environments. The level of evidence for this article could be identified as II ("Johns Hopkins Nursing Evidence Based Practice Research Evidence Appraisal," n.d.; C. Bongiorno, personal communication, November 26, 2012) or III (Ford, 2012). Both are credible for use in evidence based practice. There are many tools available for the evaluation of evidence in nursing research (Nieswiadomy, 2012, p. 284). A senior hospital research specialist was consulted to review our evaluation methods (C. Bongiorno, personal communication, November 26, 2012). Course modules and a tool from Johns Hopkins are applied to the appraisal of evidence in this paper. The second article “Nine structures and leadership practices essential for a magnetic (healthy) work environment” (Kramer, Schmalenberg, & Maguire, 2012) is a quantitative meta-analysis of thirty professional publications to identify structures and leadership practices necessary to support a healthy work environment. The results of over 1300 interviews (good sample size) of expert nurses, nurse managers, and physicians were compiled and compared to results from regulatory and professional organizations. The theoretical framework is based on the Donabedian model of patient safety ("Medical Teamwork and Patient Safety," n.d.) which assesses quality of care by evaluating structures, processes, and outcomes. Results of the meta-analysis revealed comparable findings from expert interviews and regulatory/professional organizations as to what structures and leadership practices yielded a healthy work environment (HWE). HWE’s are defined as places where “clinical nurses can execute the work processes and establish the relationships essential to the provision of quality patient care” (Kramer et al., 2012, p. 12). Creating a culture of interdisciplinary collaboration and teamwork through shared power and administrative support were common themes. This is a level I research study for evidence based practice (Ford, 2012; "JHNEBP Research Evidence Appraisal," n.d.; C. Bongiorno, personal communication, November 26, 2012).The third article chosen, “The effect of an educational programme [sic] on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration” (McCaffery et al., 2012), is a quasi-experimental study exploring how an educational programme [sic] could positively affect communication and collaboration between nurses and medical resident’s. A convenience sample and pre and post-test design were utilized to test the hypothesis. Ethical research guidelines are carefully adhered to. Instruments used to measure the attitudes of nurses and residents were the “Jefferson Scale of Attitudes towards Physician-Nurse Collaboration” and the “Communication, Collaboration, and Critical Thinking for Quality Patient Outcomes Survey” (McCaffery et al., 2012, p. 297). Both instruments were proven reliable utilizing the Cronbach alpha test (scores 0.87-0.92) (McCaffery,et al, p.298). The literature review is logical, sequential and thorough. A critical finding of this study is that “Effective communication is the cornerstone of interdisciplinary collaboration” (McCaffery et al., 2012, p. 294). Statistical findings revealed positive pre and post- test differences for both nurses and medical residents with p values ranging from 0.000 to 0.001, demonstrating positive results with the intervention (McCaffery, et al, pg. 298). Due to the lack of a control group the evidence level for this study is III (Ford, 2012, C. Bongiorno, personal communication, November 26, 2012). Alternatively this study is rated as evidence level II, by the Johns Hopkins scale ("JHNEBP Research Evidence Appraisal," n.d.) as it is quasi-experimental. Both levels are acceptable for application to evidence based practice.The fourth article utilized is “Nurse-physician relationships in hospitals: 20,000 nurses tell their story” (Schmalenberg & Kramer, 2009). This study is a quantitative synthesis of findings from six research studies which evaluated the problem of how nurses “perceive, assess, and develop high quality relationships with physicians in hospitals with the goal of improving patient care” (Schmalenberg & Kramer, 2009, p. 74). An excellent sample size of 20,616 staff nurses defined five types of nurse-physician interactions (collegial, collaborative, student-teacher, friendly stranger and hostile/adversarial) that occur in nearly all clinical settings. High quality nurse-physician interactions directly affect patient care and organizational outcomes (decreased costs, and improved patient, nurse, and physician satisfaction). Nurse-physician relationships were further compared at magnet and non-magnet institutions. It was consistently found that nurses practicing at magnet hospitals report higher quality nurse-physician relationships than nurses in comparison hospitals. Three structures that can improve nurse- physician relationships are to keep patient needs first, develop constructive conflict resolution techniques, and establish collaborative, interdisciplinary patient rounds. As this study is a double blinded peer review, and a synthesis of six research studies; it is clearly level I evidence by all methods (Ford, 2012, "JHNEBP Research Evidence Appraisal," n.d., C. Bongiorno, personal communication, November 26, 2012).Application of EvidenceJaimeMedical/Surgical units rely on effective communication between doctors and nurses to ensure that patients are safe and well taken care of. Doctors and nurses need to look to each other to treat the patient as a whole and make sure that their stay in the hospital is short lived and that the patients will not return within a week. Many medical/surgical nurses, where I work, are faced with working several 12 hour shifts in a row. Our patient census has exceeded 14 (which is well over our units allotted beds), and we are faced with doctors, who just don’t listen to the nursing staff. The McCaffrey et al. article is accurate for my hospital. We are starting to have monthly meetings between nursing and supervisors for follow up on nurse/doctor relationships. The doctors meet monthly with each other and our director of nursing to discuss communication/relationships. In my job as Utilization Review, I need to have very effective communication with all doctors. Each day I sit down with the doctors and we go over patient by patient. I must communicate with them when a person is meeting or is not meeting criteria to be in the hospital. I also must communicate some ways they can make the patient meet criteria if the doctor wants to keep them an extra day. At first the doctors were not too keen on a nurse telling “what to do,” but over the past several months it has gotten better, and they are even communicating with me before a patient is admitted from the ER. We are both trying to work together for the better of each and every patient in our hospital.GaryIntra-operative settings place nurses and physicians in close collaborative work settings. The typical communication style is authoritarian. The doctors choose the procedure, positioning, prep, technique, start and stop times. Schmalenberg and Kramer’s article stated that physicians felt the nurse-physician relation to be more collaborative than nurses did. I can see that being true in my work environment. Nurses may suggest something by asking a question but we do not have the freedom to make care changes or suggestions. 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 that could result in failure to increase collaboration. These can help direct any programs to support an increase in collaboration.LaiAt an oncology unit, nurses can utilize the Cochrane Database and the “John Hopkins Research Evidence Appraisal” as the tools to communicate and collaborate with oncologist about the evidence-based practice. Ongoing literature review for the most credible interventions is essential for improving oncology patients’ physical, psychological, and emotional well-being. The hospital nursing research committee is recommended to initiate a survey about possible communication barriers between nurses and physicians. The McCaffrey et al (2012) training program provides great perspectives for reducing dysfunctional communication (p. 293). The low-cost convenient computer-based training in physician-nurse communication skills can be implemented due to the challenging schedules for attending the classroom training.MaggieHigh quality communication and strong collaborative skills with physicians and peers make a great difference in the cardiac catheterization laboratory (CCL) (Boone, King, Gresham, Wahl, & Suh, 2008, p. 168). Long experience and a broad knowledge base bring a high level of confidence to my work; both are critical to collaborative relationships and clinical autonomy (Schmalenberg & Kramer, 2009, p. 82). The value of collaborative practice is vital to each patient, physician and nurse, as well as the entire healthcare system. Benefits include: decreased hospital stays, improved patient outcomes and nurse-physician job satisfaction/retention (Kramer et al., 2012, p. 7). Barriers faced in my work setting are the fast pace, occasional extreme hours, and less than optimal nurse-nurse and unit-unit communication. Improving communication through evidence based educational methods (McCaffery et al., 2012) is possible, but could be expensive. A few less expensive options may include bidirectional staff shadowing with partner units to better understand each area’s needs and processes, improved interaction of our Unit Action Councils (UAC’s) to increase unit-unit communication, and effective staff/procedure scheduling to help ensure extreme hours are the exception. SummaryThe purpose of this project was to answer this 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? The selected articles did not address every aspect of the preceding question, but were able to be combined as quality evidence for this topic.Schmalenberg and Kramer’s 2009 literature review shows collaboration as the best way for professionals to communicate. Kramer et al’s literature on healthy work environments shows the importance of supporting collaboration to develop a healthy work environment. McCaffrey et al (2011) and Boone et al (2008) address the importance of increased education for proper collaboration to occur. Unfortunately, the results were different for each study. Nevertheless, the articles show two different educational based attempts to increase interdisciplinary communication and collaboration.Collaboration is the goal for interdisciplinary communication. The current literature and studies are able to help direct further research. Development of education to increase collaboration for all disciplines is required. Creation of working environments that foster collaboration is necessary. Future studies can test methods to increase education as well as ways to incorporate those methods into current working environments.AppendixJHNEBP Research Evidence AppraisalEvidence Level:article title:number:author(s):date:journal:setting:sample (composition/size) Experimental Meta-Analysis Quasi-experimental Non-experimental Qualitative Meta- SynthesisDoes this study apply to the population targeted by my practice question? Yes NoIf the answer is No, STOP here (unless there are similar characteristics).Strength of Study Design Was sample size adequate and appropriate? Yes No Were study participants randomized? Yes No Was there an intervention? Yes No Was there a control group? Yes No If there was more than one group, were groups equally treated, except for the intervention? Yes No Was there adequate description of the data collection methods? Yes NoStudy Results Were results clearly presented? Yes No Was an interpretation/analysis provided? Yes NoStudy Conclusions Were conclusions based on clearly presented results? Yes No Were study limitations identified and discussed? Yes Nopertinent study findings and recommendationsWill the results help in caring for my patients? Yes NoEvidence Rating (scales on separate sheet)Strength of EvidenceQuality of Evidence (check one) High (A) Good (B) Low/Major flaw (C)JHNEBP Research Evidence Appraisal (continued)STRENGTH OF EVIDENCELEVEL 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; usedwhen it is felt that the knowledge of treatment is unimportant.META-ANALYSIS OF RCTS? Quantitatively synthesizes and analyzes results of multiple primary studies addressing asimilar research question? Statistically pools results from independent but combinable studies? Summary statistic (effect size) is expressed in terms of direction (positive, negative, orzero) and magnitude (high, medium, small)LEVEL 2QUASI-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 3NON-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 ofseverity 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 thatare more objective and quantifiable.META-SYNTHESIS? Research technique that critically analyzes and synthesizes findings from qualitativeresearch? 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 findingsQUALITY RATING (SCIENTIFIC EVIDENCE)A High quality: consistent results, sufficient sample size, adequate control, anddefinitive conclusions; consistent recommendations based on extensive literaturereview 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 basedon fairly comprehensive literature review that includes some reference toscientific evidence.C Low quality or major flaws: little evidence with inconsistent results, insufficientsample size, conclusions cannot be drawn."JHNEBP Research Evidence Appraisal"ReferencesBallou, K., & Landreneau, K. (2010). The authoritarian reign in American health care. Policy, Politics & Nursing Practice, 11(1), 71-79. doi:10.1177/1527154410372973 Boone, B., King, M., Gresham, L., Wahl, P., & Suh, E. (2008). Conflict management training and nurse-physician collaborative behaviors. Journal For Nurses In Staff Development, 24(4), 168-175. doi:10.1097/01.NND.0000320670.56415.91 Ford, L. (2012). Week 8 & 9 Critique of Research. Retrieved from , F., Lingard, L., Espin, S., Whyte, S., Orser, B., & Baker, G. (2009). Silence, power and communication in the operating room. Journal Of Advanced Nursing, 65(7), 1390-1399. doi:10.1111/j.1365-2648.2009.04994.xHendel, T., Fish, M., & Berger, O. (2007). Nurse/physician conflict management mode choices: implications for improved collaborative practice. Nursing Administration Quarterly, 31(3), 244-253.John Hopkins University/John Hopkins Hospital (n.d.). JHNEBP Research Evidence Appraisal. Retrieved from Karanikola, M., Papathanassoglou, E., Kalafati, M., Stathopoulou, H., Mpouzika, M., & Goutsikas, C. G. (2012). Exploration of the Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel. Dimensions Of Critical Care Nursing, 31(1), 37-45. doi:10.1097/DCC.0b013e31823a55b8 Kramer, M., Schmalenberg, C., & Maguire, P. (2010). Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nursing Administration Quarterly, 34(1), 4-17. doi:10.1097/NAQ.0b013e3181c95ef4Manojlovich, 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 on attitudes of nurses and medical residents towards the benefits of positive communication and collaboration. Journal Of Advanced Nursing, 68(2), 293-301. doi:10.1111/j.1365-2648.2011.05736.xMedical teamwork and patient safety. (n.d.). Retrieved November 2, 2012, from , R. M. (2012). Foundations of Nursing Research (6th Ed.). Upper Saddle River, New Jersey: Prentice Hall.Rosenstein, A., & O'Daniel, M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal On Quality & Patient Safety, 34(8), 464-471.Rothstein, W., & Hannum, S. (2007). Profession and gender in relationships between advanced practice nurses and physicians. Journal Of Professional Nursing, 23(4), 235-240. doi:10.1016/j.profnurs.2007.01.008 Schmalenberg, C., & Kramer, M. (2009). Nurse-physician relationships in hospitals: 20 000 nurses tell their story. Critical Care Nurse, 29(1), 74-83. doi:10.4037/ccn2009436Zwarenstein, M., Goldman, J., & Reeves, S. (2009). Interprofessional collaboration: Effects of practice-based interventions on professional practice and healthcare outcomes.?Cochrane Database Of Systematic Reviews, (3), 1-31. doi:10.1002/14651858.CD000072 ................
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