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VOLUME 8 | NUMBER 4 | SEPTEMBER 2015
Evidence-Based Practice: Why Does It Matter? This independent study was developed by: Pamela S. Dickerson, PhD, RN-BC, FAAN. Updates and revisions were made by Terry Pope, MS, BSN, RN This independent study has been designed to empower nurses to engage in evidence-based practice to strengthen their own professional roles. 1.6 contact hours will be awarded for successful completion of this independent study. The authors and planning committee members have declared no conflict of interest. This information is provided for educational purposes only. For legal questions, please consult appropriate legal counsel. For medical questions or personal health questions, please consult an appropriate health care professional. The Ohio Nurses Association (OBN-001-91) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Expires 6/2017. Copyright © 2011, 2013, 2015 Ohio Nurses Association OBJECTIVES Upon completion of this independent study, the learner will be able to: 1. Define evidence-based practice. 2. Describe ways to use evidence-based practice to ensure safe patient care. STUDY Evidence-based practice has become a commonly used term in health care in the past few years. It is important for nurses to know what it means, how to use it, and how important it is in protecting patient safety. This study will define evidence-based practice and provide examples of how evidence based practice questions can be used to guide delivery of safe patient care. The purpose of the study is to empower nurses to engage in evidence-based practice to strengthen their own professional roles. Significance In 2002, Sigma Theta Tau International, the honor society of nursing, developed a position statement on evidence-based practice. This paper describes how important it is for nurses to be able to access, evaluate, integrate, and use “best practices” to promote patient safety. The document was revised in 2005 and is available at http://www.nursingsociety.org/aboutus/PositionPapers/ Pages/EBN_positionpaper.aspx (STTI, 2005). In this document, the society defines evidence-based practice as “integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.”
current resident or
The National Council of State Boards of Nursing (NCSBN) has stated that evidence-based practice is not just another buzz-word or fad, but that it is an expected standard of ensuring safe patient care that is “here to stay” (Spector, 2007). Regulatory boards in each state exist for the purpose of protecting the public. One way to do that is to be sure that nurses are practicing in a safe and competent manner. For example, the Ohio Board of Nursing has rules in the Ohio Administrative Code (OAC) that relate to competent practice for registered and licensed practical nurses (47234-03 OAC and 4723-4-04 OAC, respectively). One aspect of competence is that “a registered nurse shall maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice.” (4723-4-03(B) OAC). Similar language exists in rule 4723-4-04 OAC for the licensed practical nurse. The term current means that the nurse is expected to keep abreast of new knowledge, research, and evidence that supports nursing interventions, keeps patients safe, and contributes to quality patient care. The purpose of the Ohio Board of Nursing, and boards of nursing in all other states as well, is to protect the public. Implementation of evidence-based practice is one strategy for the nurse to use to make sure that the public is protected when nursing care is provided. Over the past several years, the Institute of Medicine (IOM) has published a series of reports related to patient safety in the United States health care system. Their 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, states that the attributes of quality care are safety, effectiveness and efficiency, patientcenteredness, timeliness, and equity. Evidence-based practice provides the foundation for safe care, leading to increased effectiveness and efficiency, timeliness, and more appropriate focus of research-based data within the framework of the patient’s current situation and needs. This in turn leads to equity in utilization of resources and assurance that each patient receives the most appropriate individualized care, according to his/her presenting needs. In 2004, the IOM published a seminal work focused on improving the work environment for nurses as a significant strategy to keep patients safe. Key components of improving the work environment for nurses are stimulating nurses to seek evidence to support practice, providing the resources and tools nurses need to collect and evaluate that evidence, challenging them to assess the evidence in relation to a specific patient’s need, and empowering them to take the initiative to implement best practices. It is clearly understood that nurses do not work in a vacuum; they must work effectively as members of the healthcare team. The Joint Commission has emphasized the need for all healthcare providers to work together more effectively in the best interests of quality patient care. Their Sentinel Event Alert issued in July of 2008, for example, states that “safety and quality of patient care is dependent
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on teamwork, communication, and a collaborative work environment.” Use of evidence-based practice tools provides a common framework for discussion, shared involvement, and decision making. The SBAR example for interprofessional communication included later in this study is one example of an evidence-based practice that has contributed to more effective team interaction. The 2010 IOM report, Redesigning Continuing Education in the Health Professions, supports the requirements of The Joint Commission in advocating for ongoing learning across professions that supports integration of evidence-based practice to improve patient outcomes. This report recommends, among other things, that “continuing education efforts should bring health professionals from various disciplines together” (p. 3) in learning environments that focus on evidence-based practice and practice-based evidence to close gaps in practice that impact patient care. In 2011, the IOM published an extremely important report, The Future of Nursing: Leading Change; Advancing Health. This report has been the stimulus for development of action coalitions in states around the U.S. to implement the recommendations for nursing to be more visible, more active, and more committed to making a difference in the U.S. healthcare system. There are a number of recommendations in this report that focus on nurses practicing to the full scope of their knowledge and skills, nurses as leaders in the transformation of the healthcare system, and nurses achieving higher levels of education that provide them with the ability to critically analyze data and make effective decisions to provide quality care for patients. In an era where cost effectiveness and efficiency in healthcare operations are key, it is also important to consider the economic benefit of using evidence-based practice. Schifalacqua, Soukup, Kelley, and Mason (2012) describe a cost-of-care metric used to calculate cost savings that accrue when healthcare-acquired conditions are prevented through use of evidence-based practice standards. In their example, one healthcare system was able to document cost-avoidance (money that didn’t have to be spent to care for patients with these conditions) of $8 million in one year! This is clear evidence that evidencebased practice makes a difference – both in terms of preventing avoidable clinical complications and in terms of saving money for the organization. Definition Evidence-based practice, in its simplest form, means using evidence to guide practice. This is an alternative to “flying by the seat of your pants,” doing things “because we’ve always done them that way,” or doing things “because I don’t know what else to do, so I’ll try this and see how it
Evidence-Based Practice continued on page 4
Inside This Issue Evidence-Based Practice: Why Does it Matter? . . . . . . . . . . . . . . . . . 1 CE4Nurses.org . . . . . . . . . . . . . . . . . . . . . . . 2 Independent Study Registration Form and Instructions. . . . . . . . . . . . . . . . . . . . . 3
Doc “Q” umentation in Nursing: Recording for Quality Client Care . . . . . . . . 7 Fundamentals of Mentoring. . . . . . . . . . . . . 10 ONA Partners with PerformanceScrubs.com to Offer Nurses Exclusive Savings. . . . . . . 10
OHIO NURSE The official publication of the Ohio Nurses Foundation, 4000 East Main St., Columbus, OH 43213-2983, (614) 237-5414. Web site: www.ohionursesfoundation.org Articles appearing in the Ohio Nurse are presented for informational purposes only and are not intended as legal or medical advice and should not be used in lieu of such advice. For specific legal advice, readers should contact their legal counsel. ONF Board of Directors Officers Davina Gosnell, Barb Welch, Chair Director Kent Rushville Lori Chovanak, Diane Winfrey, CEO/President Director Columbus Shaker Heights Jill Frey, Susan Stocker, Secretary Director Hamilton Hamilton Kathryn Peppe, Elaine Mertz, Treasurer Director Columbus Cridersville Daniel Kirkpatrick, Director Fairborn The Ohio Nurse is published quarterly in March, June, September and December. Address Changes: The Ohio Nurse obtains its mailing list from the Ohio Board of Nursing. Send address changes to the Ohio Board of Nursing.
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Join the Ohio Nurses Association The Ohio Nurses Association does a lot for the nursing profession as a whole, but what does ONA do for its members? FREE AND DISCOUNTED PRODUCTS AND SERVICES Members take advantage of a wide array of discounts on products and services, including professional liability insurance and continuing education. WORKPLACE ADVOCACY ONA provides members access to a wide range of resources to help them make a real difference in the workplace, regardless of work setting. ONA provides members with resources to create healthy and safe work environments in all healthcare settings by providing tools to help nurses navigate workplace challenges, optimize patient outcomes and maximize career benefits. EDUCATION Whether you’ve just begun your nursing career or are seeking to enhance or maintain your current practice, ONA offers numerous resources to guide you. For example, the Ohio Nurses Foundation awards several scholarships annually with preference to ONA members. Members also save up to $120 on certification through ANCC, and can earn contact hours for free through the independent studies in the Ohio Nurse or online at a discounted rate, among many other educational opportunities. NURSING PRACTICE ONA staff includes experts in nursing practice and policy that serve our members by interpreting the complexities of the Nurse Practice Act and addressing practice issues with a focus of ethical, legal and professional standards on a case-by-case basis. LEGISLATIVE ADVOCACY ONA gives members a direct link to the legislators that make decisions that affect nursing practice. Members can become Legislative Liaisons for their district, join the Health Policy Council and participate in the legislative process in many other ways through their ONA membership. These are just a few of the benefits nurses receive as ONA members. Dues range from $33–$50 a month and we offer reduced dues rates to new graduates, unemployed and retired nurses. Go to www.ohnurses.org to start taking advantage of what ONA has to offer.
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ONA MEMBERS: Each study in this edition of the Ohio Nurse is free to members of ONA if postmarked by 11/30/15. Please send posttest and this completed form to: Ohio Nurses Association, 4000 East Main Street, Columbus, OH 43213. Studies can also be completed for free by going to www.CE4Nurses.org/ohionurse. NON-ONA MEMBERS: Each study in this edition of the Ohio Nurse is $15.00 for non-ONA Members. The studies can also be completed online at www.CE4Nurses.org/ohionurse for $12. Please send check payable to the Ohio Nurses Association along with post-test and this completed form to: Ohio Nurses Association, 4000 East Main Street, Columbus, OH 43213. Credit cards will not be accepted. ADDITIONAL INDEPENDENT STUDIES Additional independent studies can be purchased for $15.00 plus shipping/handling for both ONA members and non-members. ($12.00 if taken online). A list is available online at www.CE4Nurses.org ONA OFFICE USE ONLY Date received:________________________ Amount:_____________________________ Check No.: ___________________
Independent Study Instructions To help Ohio’s nurses meet their obligation to stay current in their practice, three independent studies are published in this issue of the Ohio Nurse. To Complete Online • Go to www.CE4Nurses.org/ohionurse and follow the instructions. Post-test The post-test will be scored immediately. If a score of 70 percent or better is achieved, you will be emailed a certificate and test results. If a score of 70 percent is not achieved, you may take the test a second time. We recommend that the independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be e-mailed to you. Instructions to Complete By Mail 1. Please read the independent study carefully. 2. Complete the post-test and evaluation form for each study.
3. Fill out the registration form indicating which studies you have completed, and return originals or copies of the registration form, post test, evaluation and payment (if applicable) to: Ohio Nurses Association, 4000 East Main Street, Columbus, OH 43213 References References will be sent upon request. Questions Contact Sandy Swearingen (614-448-1030, [email protected]
ohnurses.org), or Zandra Ohri, MA, MS, RN, Director, Continuing Education (614-448-1027, [email protected]
). Disclaimer: The information in the studies published in this issue is intended for educational purposes only. It is not intended to provide legal and/or medical advice. The Ohio Nurses Association (OBN-001-91) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Evidence-Based Practice continued from page 1 works.” Nurses enter practice with a knowledge base that has been acquired through formal education, including opportunities for both didactic learning and clinical practice. This education forms the basis for beginning practice and serves as a springboard for future professional development. This is NOT the end of the learning process! New evidence comes into play every day as research is completed, technology advances, and patients present with unique challenges and personal experiences. The nurse who bases practice solely on what was learned in basic nursing education soon becomes outdated, and then becomes dangerous. Patients are not safe if they do not receive care that is based on the best evidence available to assist them at the time their needs arise. Titler (2008, p. 1-113) defines evidence-based practice as “the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.” Evidence comes from several sources, including research, our past experiences, the knowledge and experience of colleagues, and the patient/family. One of these alone does not constitute a solid frame of reference for determining a plan of care. Similarly, Sigma Theta Tau International (2005), in its position paper, defines evidence-based nursing as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served.” This takes into account not only the research-based evidence, but the unique situations nurses face when implementing best practices with people of various cultures, needs, and healthcare preferences. Sigma Theta Tau considers evidence-based nursing as a foundation for nursing practice. Melnyk and Fineout-Overholt (2005) also address the fact that evidence-based practice is predicated on several factors: evidence from research, opinion leaders, and expert panels; evidence from assessment of the patient and related healthcare resources; clinical expertise, and information about the patient’s preferences and values. Taken together, this framework empowers the nurse to plan and implement evidence-based clinical decision making. Using Research When available, research studies that have been conducted in controlled circumstances provide strong evidence to support practice decisions. For example, research has been done to determine various types of wound care dressings that are most appropriate for different kinds of wounds. The nurse caring for a patient with a decubitus ulcer needs to thoroughly assess the patient and the wound, and then review the research to determine the best option to aid wound healing. As the nurse and the physician review the patient’s situation, they can develop a plan that incorporates recommendations based on research findings, the specific characteristics of the wound, and the patient’s situation – lifestyle, current self-care capability, availability of resources, and other factors that will determine how the treatment plan is carried out. There are many areas of nursing practice, however, in which structured qualitative and/or quantitative research has not yet been done. There may be anecdotal evidence from others’ experiences, or there may be some “soft” data generated by one or two research studies with small populations or with a different focus than the area of current concern. New research is being conducted in a variety of areas of nursing practice and is disseminated through resources such as the National Institute of Nursing Research (NINR) at the National Institutes of Health, the Agency for Healthcare Research and Quality (AHRQ), and Sigma Theta Tau International.
September 2015 The following information is provided in the “frequently asked questions” of the NINR, found a t ht t p s://w w w.n i n r.n i h.gov/s it e - st r uc t u re/f a q #. VWh6GdjbK1s. Q: What is Nursing Research? A: Nursing research develops knowledge to: • Build the scientific foundation for clinical practice, • Prevent disease and disability, • Manage and eliminate symptoms caused by illness, • Enhance end-of-life and palliative care. Many nurses cringe at the topic of “research.” They are unsure of how to read research articles and how to discern the “take home” points from lengthy descriptions of statistical data collection and analysis. Several sources, including the University of Southern California (Guide to Reading Research Articles, 2010), have published tools to aid in reviewing this literature. Key questions they suggest include: • What is the purpose of the research and how does it relate to the problem? • How was the investigation done? Was the study conducted in accordance with sound principles and without bias? • What are the findings and conclusions, and how do they relate to the problem? • How are the findings applicable to my practice? Other factors the reader might want to consider when reviewing published research data include: • How big was the data base in the study? A study that only looked at responses of 10 patients to a nursing intervention may not yield data that is as beneficial as a study in which 100,000 patients were assessed. After all, if six out of ten patients responded positively to a nursing intervention, the response rate would be 60%. That number looks impressive. It isn’t nearly as impressive, however, if six out of 100,000 patients had the same response - then it would only be .006%! • What was the population in the study? If the study looked at the effects of an antidepressant medication on adults and your patients are children, the results of the study will not benefit your current practice. • Who funded the study? Publishers and authors disclose the sources of funding for their research. If a study comparing the effectiveness of two antihypertensives was conducted by a pharmaceutical company that makes one of the medications, what steps were taken during the design, implementation, and analysis of the study to ensure that the study was factual? Please note that it is not unethical or illegal for a pharmaceutical company to fund research about its medications. In fact, this is a critical tool for evaluating the effectiveness of a medication. What is critical is to ensure that (1) bias is prevented in the conduct of the study, and (2) readers of the study have full disclosure about funding. • Who conducted the study? What were the qualifications of the people who carried out the work? Did they have a particular “vested interest” in the outcome? Unfortunately, there have been situations where researchers have had a particular desire to see a certain outcome of a study, so data are manipulated in such a way to make the desired outcome a reality. To protect integrity and try to prevent misuse of subjects and data related to them, facilities in which research is conducted have institutional review boards (IRBs). Prospective researchers submit their proposals to IRBs to get approval prior to conducting their research if human subjects are involved. There may be situations where a researcher is receiving funding from a product manufacturer, or the researcher serves on the speakers’ bureau for the company that makes the
product. In these cases, the researcher has to be sure that his/her involvement with the company does not introduce bias into the research process. Some organizations allow this researcher to continue with the research as long as disclosure is provided and integrity is maintained; other organizations disallow the researcher from participating in that particular research project. Publishers are required to disclose any potential “conflicts of interest” of authors and to indicate how these potential conflicts were resolved. • What were the outcomes of the study? Do they make sense in relation to the original research question that was asked? Do they have any relevance to your practice or your population of patients? If so, you will want to look further into the statistical analysis of the data to see how the researchers arrived at their conclusions. If not, consider the review of this study as an adventure in new learning, and move on to something else! While research is an important component of evidencebased practice, an important factor to remember is that one research study does not generally provide “evidence.” A nurse can search databases for individual articles. These include CINAHL, MEDLINE, and others. More valuable is a compendium of research studies that have resulted in publication of evidence that comes from several sources. Three notable sources of this type of data are the Cochrane Collaboration, the National Guideline Clearinghouse, and the Agency for Healthcare Research and Quality. All three of these sources provide searchable databases that enable the user to collect evidence compiled from a number of sources in relation to a specific clinical problem. In some cases, such as the National Guideline Clearinghouse, the evidence has been used to formulate a guideline that is then considered to be a “standard” of practice, based on best-available evidence at the time the standard was written. That is another significant factor to consider: when was the study done, and how current are the findings? Review of the literature may point to evidence of change in a standard over time - the prudent nurse will be aware of the most recent sources of evidence. Spector (2007) states in the NCSBN paper that it is important for nurses to recognize the difference between “research utilization” and “evidence-based practice.” While research utilization suggests that one adopt the findings of a research study as “standard practice,” evidence-based practice indicates that findings from multiple studies, in conjunction with thorough assessment of the current patient situation, form the basis for nursing plans and interventions. She states that goals of this process are to give nurses tools to provide excellent care, provide a valid and reliable way to solve clinical problems, and encourage innovation and creativity in how evidence-based data is implemented to meet specific patient needs. As additional clinical problems and challenges are identified, there is opportunity for more innovation as new strategies are implemented to address ongoing quality improvement initiatives. Tools and Resources Policies and procedures of facilities should be based on evidence, not on tradition. One recommendation is to include a footnote with each policy, stipulating the foundational documents that were used in formulating the policy. Regularly scheduled policy reviews can then be conducted by referring to the original sources of data to look for updates and changes. One example of an evidence-based practice standard that has been shown to increase patient safety is the SBAR tool for interprofessional communication (IHI, 2010). Numerous studies over the past several years have indicated that a major cause of patient safety lapses in acute care settings has been poor communication among members of the healthcare team. As noted earlier, The Joint Commission issued a sentinel event alert in July of 2008, indicating that hospitals must take a more active approach in ensuring respectful, appropriate communication that fosters a culture of teamwork and trust. The SBAR communication tool has proven to be an effective resource to assist healthcare team members in addressing that concern. The model uses the acronym SBAR to stand for situation, background, assessment, and recommendations. When one member of the team is giving report to another or calling a colleague for guidance, use of this framework provides a consistently reliable way of collecting, analyzing, and organizing data to share with the other person. It is a particularly valuable tool for new members of the team, as they are learning strategies for effective communication. The process is more intuitive for more proficient practitioners. Regardless of whether use of the standard is formal or informal, it provides a way to share data that is understood by both parties, includes relevant information, and excludes extraneous information that might “muddy the water” in making sure the patient’s needs are appropriately addressed. Evidence has shown that integration of this technique in shift-to-shift reports, transfer of a patient from one department to another, or call to a prescriber regarding a change in plan of care has resulted in clearer communication and better patient outcomes. Several models have been developed to assist people in using evidence to guide their practice. One is the ACE Star Model of Knowledge Transformation©, developed at the
September 2015 University of Texas Health Science Center at San Antonio (Stevens, 2004). According to this model, the five points of a star represent key points in development of evidence-based practice: discovery; evidence summary; translation; integration; and evaluation. New data is discovered, but only as evidence from several studies supporting that finding are accumulated can the data be summarized into a framework that then can be translated into expectations for practice. At that point, nurses need to be educated and system-wide adjustments have to be made in order for those expectations to be incorporated into practice. For example, evidence could show that providing report at the patient’s bedside is an effective tool to promote patient safety and enhance staff functional ability, but if staff is not educated about how to do this new process effectively, it will not be utilized appropriately. Similarly, if staff are educated, but policies and procedures are in place that dictate how report is to be given in the conference room with certain people present at each change of shift, the new practice still will not be able to be implemented. At times, changes in policy/procedure, technology, and/or the culture of the unit or organization are needed in order for new evidence to be incorporated into practice. Many healthcare organizations have implemented quality improvement or process improvement initiatives, such as the PDCA (plan/do/check/act) process and Six Sigma. These are examples of use of evidence-based practice, starting from the premise that organizations need to work toward quality, cost-effectiveness, and efficiency. While the initial onset of quality improvement initiatives has taken place in the manufacturing and industrial sectors of the economy, hospitals and other healthcare organizations have embraced their value. In light of the IOM reports referenced earlier in this study that indicate hospitals have issues that affect safety for patients and preclude effectiveness and efficiency of providers of care, healthcare organizations are now realizing the need to be more accountable in both the services they provide and the infrastructure that supports provision of those services. According to the American Society for Quality (2009), hospitals have reported success rates in both clinical and non-clinical services as a result of using quality improvement processes. Another model is one suggested by The University of Minnesota (2010). In this model, there are five key processes one uses to collect, use, and evaluate evidence-based data. First, the nurse must frame the correct question in order to search databases for appropriate supportive literature. Second, from the literature resources available, find those which are most appropriate to your particular situation, patient need, or clinical challenge. Next, review those articles using some of the questions and suggestions in the “Using Research” section above. After finding supportive evidence of the initiative to be implemented, develop and use the evidence. The final step in the process is then to reevaluate. Did the process work as intended? Did the generalized evidence support the particular need in this case? Is this something that could be used by this facility in similar situations in the future? Megel (2009) suggests a framework similar to the University of Minnesota model to develop processes staff nurses can use to frame research questions, collect and analyze relevant data, and implement the findings to improve quality of care. She suggests that formulation of the question is a key to the process of data mining. Since there is so much data available, strategically framing the question to be asked significantly reduces the amount of material that is retrieved by the search engine and aids in focusing on the most helpful information. A well-designed question is thought to include the following: P: the patient or population I: the intervention that is being considered C: comparison interventions, if available (is “A” better than “B”?) O: desired outcome For example, a question might be posed as “for a normal-weight newborn, is breastfeeding or bottle-feeding more effective in protecting the immune system?” The population under consideration is the normal-weight newborn, so you can immediately rule out any articles that discuss breast feeding benefits for premature babies. The intervention being considered is breast feeding, and the desire is to compare the relative benefits of breast feeding and bottle feeding to achieve the desired outcome of protecting the newborn’s immune system. Data from the evidence retrieved will guide the nurse in education of new mothers. Nursing interventions are thus based on evidence, rather than on “usual” practice at the hospital or the personal preference of the nurse who happens to be caring for the patient that day. Stillwell, Fineout-Overholt, Melnyk, and Williamson (2010), provide helpful information in their article, Searching for the Evidence. They suggest, too, use of the PICO formula, with addition of a “T,” to address the time required to achieve the outcome (PICOT). This article also presents a “hierarchy of evidence” to help the nurse evaluate the relative quality of various sources of evidence. The National Database of Nursing Quality Indicators® was established in the late 1990’s as a vehicle for collecting data about nurse-sensitive indicators - those variables that reflect the structures, processes, and outcomes that affect the quality of nursing care that is provided to patients in hospitals. The database has grown significantly in its ten-year history and has contributed substantially to the evidence supporting nursing’s critical role in patient safety. Data are collected from member hospitals and benchmarked with other facilities and quality standards. Reports are provided to the members, which can be used for internal quality improvement initiatives, reporting requirements, staff education, and recruitment/retention efforts. Evidence of quality nursing practice is substantiated through controlled data bases such as that maintained by NDNQI.® Professional nursing associations also have a wide variety of activities currently underway to investigate and support evidence-based practice in particular areas of nursing. As an example, the Oncology Nursing Society has substantial evidence-based practice information available in regard to nursing care of patients with cancer. The Emergency Nurses Association has practice standards, publications, and guidelines based on best practices in emergency nursing. Contact a professional association of interest to you to learn about the resources, education, and data bases they currently have available. Other Sources of Evidence Clinical Expertise With all of this discussion surrounding research and data bases, don’t lose sight of the fact that collecting evidence from the literature is only one step in implementing evidence-based practice. Going back to the definition of evidence-based practice, remember that there are three key components: the evidence, clinical expertise, and the patient. Clinical expertise is a required element of evidence based practice. That might be the expertise you have, or the “borrowed” expertise of a colleague or mentor. Recognizing when you need help, and finding the appropriate person to provide that assistance, enables you to “data mine” to develop a strong evidence-based plan of care. Clinical expertise comes with clinical experience. The novice nurse is very focused on policy and procedure and “how to do,” rather than “what to do” or “why to do,” let alone “how and when to modify” based on a patient’s need at any given point in time. As clinical experience grows, the nurse transitions to higher levels of thinking and functioning (Benner, 1984). As the nurse progresses from novice through the stages of advanced beginner, competent practitioner, proficient provider, and expert, the ability to think about “what if” strategies increases significantly. The nurse who is able to do “what if” thinking explores options and alternatives and uses research-based evidence to support recommendations to modify a plan of care to meet unique needs of an individual patient. Critical thinking, while taught in nursing schools, is more of a theoretical exercise until there is a practice framework to guide the thinking. The more experience the student has,
the better the critical thinking ability will be. Critical thinking derives from the ability to look at the big picture, ask relevant questions, seek additional information, and challenge the “usual.” It includes the nurse’s ability to not only collect data, but to analyze that data in context with the patient situation. Critical thinking requires that the nurse be present in the moment and not act reflexively in providing what may be perceived as “routine” care. According to Benner and colleagues (2008, p. 1-88), “critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes.” You may have a significant amount of clinical expertise, based on years of practice and continued learning. It is a misjudgment, however, to assume that expertise and length of practice are equivalencies. Many nurses have practiced for a significant number of years but have not continued their professional development, either formally or informally. This often leads to ineffective, inefficient, and ultimately dangerous practice, as this nurse is not able to keep up with new advances in knowledge and technology. Because of the increased specialization of nursing, no one nurse can be expected to be knowledgeable about every aspect of the profession. Therefore, it is most helpful to have trusted resources that can be called upon to provide expert guidance. For example, a patient with chronic depression is admitted to a medical-surgical unit after having a stroke. The med-surg nurse might feel quite capable of handling the post-CVA needs of her patient but is not sure of the right approach in dealing with the co-morbidity of chronic depression. A phone call to the psychiatric unit can elicit the support of a mental health nurse to provide guidance and direction in addressing the unique needs of this patient. Expertise can be gained in a number of ways. Certainly, years of experience helps. Continuing education, both formal advanced academic education and continuing professional development, helps to keep the nurse updated and aware of new developments in his/her area of practice. Attending activities such as the hospital’s “grand rounds” or other in-service opportunities helps the nurse continue to learn and grow. Membership in a professional association expands the nurse’s horizons in a particular practice area of interest. The Patient As important as critical thinking is, by itself, it is not enough. Critical thinking forms the foundation for applying clinical judgment (sometimes called clinical reasoning) to a specific situation. Clinical reasoning is defined (Benner, 2008, p. 1-90) as occurring “within social relationships or situations involving patient, family, community, and a team of health care providers.” In other words, clinical judgment takes the ability to critically think and applies it to a particular patient with a particular need at a particular point in time. All of the evidence in the world is not going to matter if it is not relevant in this specific instance. True understanding of the patient includes many facets and is based on the nurse’s knowledge of biological and social sciences in general and an assessment of the patient/ family situation in particular. Knowledge of the patient’s spiritual frame of reference, cultural background, decision-making processes, and health-related values is just as important in planning appropriate care as knowing the person’s HgA1C or triglyceride levels. Another factor to keep in mind is that the patient’s condition is not static. A nursing assessment is only valid for the moment of time in which it was conducted. The nurse must be continually vigilant to changing conditions, which call into play new “evidence” that must be considered in adjusting the plan of care. Additionally, the nurse must always be thinking forward - anticipating what is probably going to happen next, while at the same time being prepared to respond if things don’t go as planned. Nurses have often been called a hospital’s “first-responders” because they are typically the ones who first recognize that a hospitalized patient is in need of emergent assistance based on a changing condition. In fact, the rise of rapid-response teams in healthcare facilities has been brought about by evidence suggesting that the nurse at the bedside is in the best position to recognize a patient’s need and call for the appropriate resources to aid in care of the patient. Summary Evidence-based practice is a reality, and a critical component, of today’s healthcare practice. The nurse must be aware of and able to use evidence-based practice in order to promote patient safety. Effective utilization of evidence-based practice depends on the ability to find and analyze data, critically examine a patient’s current condition and needs, and apply the appropriate interventions to achieve the desired outcome. Patient safety and quality of care are at stake. Evidence-based practice provides an efficient, effective, and cost-beneficial way to provide care.
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Evidence-Based Practice: Why Does It Matter Post-Test and Evaluation Name:_____________________________________________ Date:_______________________ Final Score: ___________ DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per questions. The evaluation questions must be completed and returned with the post-test to receive a certificate. 1. Learning from prelicensure education is adequate to enable the nurse to practice safely throughout his/ her career. a. False b. True 2. Evidence to guide practice decisions can come from: a. Experience b. Patients c. Research d, All of the above 3. In the PICO formula, the “O” is indicative of the: a. Objective b. Operation c. Opportunity d. Outcome 4. In the PICO formula, the “P” stands for: a. Possibilities for actions b. Prediction of the desired outcome c. Problem the patient has d. Procedure the nurse is considering 5. In the PICO formula, the “I” stands for: a. Individual needs of the patient b. Intervention being considered c. Investigation technique to be used d. Involvement of the healthcare team 6. In the PICO formula, “C” is used to indicate: a. Coordination of the plan b. Communication strategies c. Comparative interventions d. Comprehensive plans 7. The group that represents all of the state boards of nursing is the: a. NCSBN b. NNSDO c. NNCOC d. NRB 8. The Ohio Board of Nursing has a rule regarding practice according to ____ knowledge, skills, and ability. a. Acquired b. Current c. Previously learned d. Tested 9. The National Council of State Boards of Nursing states that evidence based practice is a a. Buzz word b. Fad c. Fallacy d. Reality 10. A nurse who practices only based on what was learned in nursing school becomes: a. Dangerous b. Inefficient c. More proficient d. Stronger
11. The purpose of the Ohio Board of Nursing is to: a. Perform public service b. Protect the public c. Provide post-graduate nursing education d. Safeguard the nurse 12. Policies and procedures are best written based on: a. Accreditation requirements b. Evidence c. Experience d. Tradition 13. One research study is usually not adequate to provide evidence for clinical decision-making. a. False b. True 14. Sigma Theta Tau International considers evidence based practice to play what role in nursing practice? a. Experiential b. Foundational c. Guiding d. Supportive 15. SBAR is an evidence-based practice standard used for: a. Communication among health professionals b. Maintaining adherence to Joint Commission standards c. Reporting patient safety violations d. Working through patient clinical problems 16. The National Institute of Nursing Research is part of the: a. American Nurses Association b. National Honor Society of Nursing c. National Institutes of Health d. World Health Organization 17. Pharmaceutical companies cannot conduct research about medications they make. a. False b. True 18. An important aspect of reading a research article is to look at: a. How bias was prevented in the design, implementation, and analysis of the study b. How many people researched and/or authored the study c. How the results of the study have been used by other organizations d. Why the investigators chose to study this particular issue 19. A process to validate the integrity of a research study is use of an: a. Administrative Research Review b. External Panel of Experts c. Institutional Review Board d. Optimal Research Outcomes Analysis 20. Evidence-based practice suggests that findings of several research studies support the planned intervention. a. False b. True 21. Education of nurses about change in practice based on new evidence is sufficient to create new practice. a. False b. True
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22. For new evidence to be integrated into practice, there needs to be: a. Education, system-wide support, and availability of resources to make the change b. Enough staff to implement the new plan c. Data from at least five sources to support the need for a change in current practice d. Wide-spread understanding that the new process will not cost more than the current one 23. The National Database of Nursing Quality Indicators® is a data collection venue for nursing indicators of quality in: a. All healthcare settings b. Ambulatory Care c. Hospitals d. Nursing Homes 24. The SBAR acronym stands for: a. Sample size, Biology, Anatomy, and Research b. Situation, Background, Assessment, and Recommendations c. Suggestions, Basis of opinion, Algorithms, and Responses d. Surgery, Bariatric, Anesthesia, and Radiology 25. Evidence to support evidence based practice comes from: a. Empirical research, previous experience, and clinical data b. Evidence-based study, analytical data, and NDNQI c. Supportive data, use of EBP models, and nonbiased research d. The literature, clinical expertise, and the patient 26. Sigma Theta Tau defines evidence based practice to include: a. Evidence based on the nurse’s personal value system b. Information that was learned in nursing education programs c. Standards of practice from licensure boards d. Values and preferences of individuals and families Evaluation: 1. Were you able to achieve the following objectives?
a. Define evidence-based practice. Yes No b. Describe ways to use evidence-based practice to ensure safe patient care.
2. Was this independent study an effective method of learning?
If no, please comment:
3. How long did it take you to complete the study, the post-test, and the evaluation form? 4. What other topics would you like to see addressed in an independent study?
Doc “Q” umentation in Nursing: Recording for Quality Client Care Developed by Pam Dickerson, PhD, RN-BC and reviewed and updated by Wynne Simpkins, MS, RN This independent study has been developed for nurses who wish to increase understanding documentation and Ohio nursing laws. 1.13 contact hours of Category A (Ohio Nursing Law and Rules) will be awarded for successful completion of this independent study. The authors and planning committee members have declared no conflict of interest. This information is provided for educational purposes only. For legal questions, please consult appropriate legal counsel. For medical questions or personal health questions, please consult an appropriate healthcare professional. The Ohio Nurses Association (OBN-001-91) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Expires 1/2017. Copyright © 2008, 2010, 2012, 2014, 2015 Ohio Nurses Association OBJECTIVES 1. Identify Ohio Board of Nursing rules related to documentation. 2. Relate documentation activities to quality client care. STUDY What is quality documentation in nursing care? Why do we do it? How does it help us provide better care? How does it help to keep our patients safe? This article explores issues related to complete, accurate, and timely documentation as a primary consideration in the provision of quality care in any healthcare environment. Why do we document? There are several purposes for documentation of the healthcare services that nurses provide. All of them are related to enabling nurses to communicate effectively with other members of the healthcare team as we work together to provide safe, appropriate care to our patients. Documentation is a skill that most nurses learn early in their student experiences. As student progresses to licensed nurse, the focus on documentation often lessens to the point that the “ job” of documenting becomes simply another task that the nurse must perform. Unfortunately, little attention is paid to the critical role documentation plays in interdisciplinary communication and collaboration in enabling the entire team to work together to plan, implement, and evaluate safe patient care. Legal validation of practice is the reason most nurses have been taught to document their work. The adage, “If it wasn’t documented, it wasn’t done,” is as true today as it was when it was first stated. In a court of law or board of nursing disciplinary hearing, documentation serves as evidence that assessments were done, care was provided appropriately and timely, and outcomes were evaluated. There is a corollary to the above statement, though. Think about this one: “If it is documented, it was done.” In other words, there is an expectation that the nurse truthfully documents care that was provided and does not falsify records. This might be as simple as being sure that a medication was given before such an action is documented, or as complex as being asked by an employer to deliberately falsify a record to make it look like care was provided when it really wasn’t. It is an obligation of the nurse to document accurately, and the nurse is held to that standard (4723-4 OAC). Interdisciplinary communication is another critical reason for our documentation. Nursing does not provide care in a vacuum, but works with people of other disciplines to plan and implement total patient care. Typically, patient healthcare records are also used by physicians, dietitians, social workers, respiratory therapists, and numerous other providers involved in the patient’s plan of care. Each of us needs information from the others so that our care is coordinated and collaborative. Depending on your area of practice, there may be different people involved in use of the patient record. For example, in a clinic setting, a patient may be referred to a specialist, so records would be sent to and received from that person to aid in quality care. In the case management setting, records might be utilized by nurses, physicians, physical therapists, and employers. In home care, community agencies might be involved to some extent in sharing data for documentation. All of the “players” on the patient’s care team must have an effective way to communicate with one another on an ongoing basis. Records of patient care are used for quality improvement purposes. Retrospective chart reviews may show, for example, that one unit in a healthcare facility has a higher rate of facility-acquired infections than others. A process improvement team might then look at activities such as hand washing and other infection control measures on the different units to see what factors are contributing to the difference and how changes can be made to promote better, safer care. Unfortunately, statistics show that there
is a very high rate of errors in patient care, contributing to millions of dollars in unnecessary expense and resulting in significant increases in morbidity and mortality. Use of patient healthcare records for quality improvement has taken on great value in our efforts to find and fix problems so that care can be safer. Subsequent record review will hopefully show that the process improvement efforts have made a positive difference. Documentation data may be used for research. The health department may use aggregate data from patient healthcare records to determine how many people have been diagnosed with a certain disease. Studies may be done to examine the relative effectiveness of different types of therapies for a particular condition. Use of human subjects in research is protected by institutional review boards (IRBs). These panels of reviewers often include representatives from different areas of healthcare practice as well as persons representing patient rights and ethics. The IRB considers what the researcher plans to do, what data will be obtained, whether the data can be used in the aggregate or whether particular patient identifiers are necessary, and, in the case of the latter, what steps will be taken to ensure patient confidentiality. Further, this group makes sure that the research project will not jeopardize the patient’s wellbeing beyond reasonable risk and ensures that informed consent is obtained from the research subjects. Documentation of care provided is used by organizations that accredit healthcare facilities. The Joint Commission (formerly known as JCAHO, the Joint Commission for Accreditation of Healthcare Organizations) is probably the best known. There are other accrediting bodies for healthcare organizations, home care, rehabilitation, community-based care, and other areas of healthcare practice. These include, among others, the Accreditation Commission for Healthcare, URAC, the National Committee for Quality Assurance, the Community Health Accreditation Program, and the Commission on Accreditation of Rehabilitation Facilities. These organizations have the right to review patient records when they examine the organization’s total processes for planning and providing care. Patient charts and other records are reviewed to determine that the facility’s policies and procedures were followed, that care was provided in a timely and appropriate manner, that appropriate care decisions were made based on patient needs, that care was provided as planned, and that outcomes were monitored and recorded. Facilities can have their accreditation status placed in jeopardy as a result of ineffective or spotty documentation. Increasingly, third party payers are using patient healthcare records to determine what payment is to be received by the facility. Medicare, Medicaid, and private third-party insurance companies base reimbursement on services provided and/or products used. At times, payment is made based on initial data: the payer will provide a certain amount of money to cover a particular condition or diagnosis. At other times, the payment is based on the diagnosis, treatment, products used, and other aspects of care as noted in the documentation after care is provided. In an attempt to control healthcare costs, some payers are using standard of care documents that have been developed as a result of research studies. If a provider follows the standard of care, payment is provided; deviations from the standard require additional documentation of need in order for payment to be received. Above all, and encompassing all of the above reasons, documentation is used to help us provide quality patient care. If you didn’t know what your colleagues on a previous shift had done, how would you plan your care? If you didn’t know what the wound looked like during last week’s home visit by another nurse, how will you be able to determine the relevance of your assessment findings today? If you are unaware of the activities the patient has been learning in physical therapy, how can you support those behaviors on your clinical unit or in home-going instructions? Documentation is evidence, and evidence gives us tools for assessment, planning, implementation, and evaluation of nursing care.
Ohio Board of Nursing Rules Regarding Documentation Note: Each state has a regulatory board for nursing practice. Laws and rules vary in different states and change periodically. Information in this study is based on rules of the Ohio Board of Nursing as of 2/1/14. Review Ohio nursing law/rules by visiting the Ohio Board of Nursing web site at www.nursing.ohio.gov and clicking on the law/ rules link. For other states, visit their respective web sites for law/rules information. The Ohio Board of Nursing has a number of rules that relate to documentation. Most of these are found in Chapter 4723-4 of the Ohio Administrative Code (OAC). This entire chapter is devoted to standards of safe and effective nursing practice. A number of rules related to documentation are noted in this study. However, this is not intended to be a comprehensive list or to address all possible issues related to Board of Nursing or facility requirements for documentation. Please refer to nursing law/rules – 4723 ORC and 4723 OAC – available at www. nursing.ohio.gov, your facility’s policies and procedures, and/or appropriate legal counsel for specific advice. There is a rule (4723-4-06[E] OAC) regarding general requirements for documentation. This rule states that “A licensed nurse shall, in a complete, accurate, and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the patient, and the patient’s response to that care.” The definition of complete is a rather logical one. Does your documentation give others a clear picture of what is happening to that patient? Would a colleague or healthcare provider from another discipline be able to walk into that patient’s room or home and know what he/she should expect to see, based on your documentation? Accurate documentation means just that – your written account of your interactions with the client are truthful and a clear reflection of what you saw, heard, and/or did. The term “timely” might be a bit more challenging to describe. What is “timely” documentation? The short answer is that “it depends.” A more specific answer is that “timely” depends on your nursing judgment of each and every situation where documentation needs to be done. The answer is not always going to be the same. While accrediting bodies or facilities often have a “window” of time during which particular aspects of care should be completed and documented, your time frame might be shorter. For example, if you are working in a long-term care facility and have a resident whose condition is changing rapidly, you will want to document your assessments, interventions, and patient responses much more expediently than you would if this resident were having a “normal” day, much as he/she has had for the past several weeks. You are accountable for your decision as to what is “timely” documentation in any given situation. Note that this rule also addresses use of the nursing process. The nurse is expected to document nursing assessments or observations. What subjective data has the patient given to you? What did you see, hear, smell, or touch that gave you data about this person? What information have you collected about the family or support system, the environment, or other factors affecting this patient’s needs? Remember that your data serves not only to guide your own plan of care but to be a frame of
Doc “Q” umentation in Nursing continued on page 8
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Doc “Q” umentation in Nursing continued from page 7 reference for others. Clear and specific documentation will convey evidence that is most helpful to others. Actual care that is provided must then be documented. Again, this is more than a list of tasks. There should be clear support for your interventions, based on the assessment data and the patient’s plan of care. Finally, the rule requires that the nurse document the patient’s response to care. Was your care effective? Were there things that happened after the care was provided that altered the expected outcome? What assessment data is different now that the care has been given? If there is a change in the plan of care based on your interventions that too, must be documented. In general, nurses are pretty good about documenting assessment data and reasonably conscientious about documenting care provided. The weakest link in the process is usually going back to re-assess the patient after care has been provided and documenting outcomes. Throughout the entire documentation process, there should be evidence that critical thinking is being used to make decisions and take actions. The steps of the nursing process for the registered nurse are noted in nursing rules (4723-4-07 OAC) as assessment, analysis and reporting, planning, implementation, and evaluation. The registered nurse’s documentation must indicate that those processes have occurred and that data are analyzed as a basis for care planning and interventions, as opposed to rote performance of tasks and following “doctor’s orders.” The nursing process steps for the registered nurse include development of nursing diagnoses and establishment of desired outcomes as part of the analysis and planning phases of care. When evaluation occurs, the RN then considers whether the desired outcomes have been met and/or whether there needs to be a change in the nursing diagnoses. Evaluation includes reassessment of the patient. Documentation and communication are included throughout all phases of the nursing process. All of this information is evidence that supports the RN’s provision of quality care. The licensed practical nurse has a similar rule (4723-408 OAC) regarding the nursing process. A key difference is that for the LPN, the nursing process identified in rule consists of four steps: contribution to assessment; planning; implementation; and contribution to evaluation. Further, the law in Section 4723.01 (F) of the Ohio Revised Code (OAC) stipulates that the LPN functions at the direction of an RN, a physician, dentist, optometrist, podiatrist, or chiropractor. In other words, the LPN participates in collection of data, development and implementation of the plan of care, and evaluation of outcomes. However, the LPN does not have the authority to independently carry out the nursing process. Again, documentation serves to validate the functions of the LPN and to show the collaborative process by which the LPN shares data with and receives direction from an RN or one of the other persons authorized by law to direct the LPN’s care. Another part of nursing’s rules (4723-4-06[G] OAC) addresses truthfulness in documentation. This rule states that “a licensed nurse shall not falsify any patient record or any other document prepared or utilized in the course of, or in conjunction with, nursing practice. This includes, but is not limited to, case management documents or reports or time records, reports, and other documents related to billing for nursing services.” No matter where nursing is practiced, whether the nurse is self-employed or works for someone else, documents are legal records which should be completed and maintained with integrity.
September 2015 There are standards for both RNs (4723-4-03[F] OAC) and LPNs (4723-4-04[F] OAC) stating that the nurse has an obligation to clarify any order or direction if he/she believes that it is not in the best interest of the patient. In cases where the nurse has concerns about patient safety in regard to implementation of a prescribed plan of care, the registered nurse has the duty to “document that the practitioner was notified of the decision not to follow the direction or administer the medication or treatment as prescribed, including the reason for not doing so.” In the case of the LPN, he/she should also notify the directing RN. Reasons that a nurse might choose not to follow a prescribed plan of care include, but are not limited to, concerns about the accuracy of the order, concerns about patient safety, or contraindications based on information you have at hand (for example, administration of a drug that is excreted by the renal system when you know the patient’s lab studies indicate renal insufficiency). When you notify the prescriber about your decision, be sure to document who you notified (Phone call to Dr. Smith), why the call was placed (regarding order for xyz medication in light of new lab result showing impaired renal function), and what new orders were received, if any (order for xyz medication discontinued). Documentation is also addressed in rules related to use of the nursing process. For the registered nurse, nursing process information is found in 4723-4-07 OAC. Several specific items in this rule include: • Documentation of collected assessment data; • Reporting data as appropriate to other members of the healthcare team • Establishing relevant nursing diagnoses that are to be addressed with applicable nursing interventions; • Developing, establishing, maintaining, and/or modifying a nursing care plan that is consistent with current nursing science; • Implementing the nursing plan of care; • Evaluating and documenting the patient ’s response to care and progress toward expected outcomes; and • Reassessing the patient’s health status and documenting the patient data. Licensed practical nurse requirements related to use of documentation in the nursing process are contained in 4723-4-08 OAC. These items include: • Collecting and documenting subjective and objective data related to the patient’s health status; • Contributing to development, maintenance, or modification of the nursing component of the care plan; • Implementing the nursing plan of care; • Documenting the patient’s response to nursing interventions; and • Contribute to the reassessment of the patient’s health status. Rules for nursing practice specified by the Ohio Board of Nursing carry the full weight of the law. In other words, violation of a rule is the same as breaking the law. Nurses can be disciplined by the Ohio Board of Nursing for failure to follow rules, including those related to documentation (Section 4723.28 [B] ORC). Rules are designed to promote patient safety, and documentation is a key issue in promoting that safety. Relating Documentation to Patient Safety Each year, the Joint Commission establishes “patient safety” goals. For 2014 and 2015, several of these goals have direct bearing on documentation. For detailed
information about patient safety goals, visit http://www. jointcommission.org/assets/1/6/2014_AHC_NPSG_E.pdf. One goal addresses the issue of enhancing reporting of critical test results timely. Consider several factors here: What is a critical test? What results are normal and expected, as opposed to those which are abnormal or unexpected? What should be reported? What is “timely” reporting of data? To whom should the information be reported” How should documentation reflect the reporting? Developing and implementing facility-specific policies and procedures will help you be sure you are addressing this goal. Be sure documentation of the reporting is addressed in your policy and procedure, and be sure the procedure is followed consistently. Particularly when reporting is verbal, there needs to be evidence that this sharing of information occurred, and how it affected a change in the plan of care, if appropriate. Other Joint Commission patient safety goals relate to improving safety in medication use. There are again several factors related to how these goals are implemented. In relation to documentation, consider how you document what medications the patient is taking when admitted to your care and how you pass this information along to the person who will be caring for the patient next. Joint Commission refers to “reconciliation” of medications as the process by which lists of current medications are obtained from new patients, adjusted as new orders are implemented, and conveyed as another complete list when the patient moves to another unit, is discharged, or is transferred to home care or another service line. Further, Joint Commission specifies as part of this safety goal that the patient receive a copy of the list of medications and be considered an active participant in promoting his/her safety. As a suggestion when obtaining and documenting information about a patient’s medication profile, it might be helpful to have your documentation form divided into sections to remind you to ask about prescription medications, over-the-counter medications, herbal substances, and things that people don’t always consider to be “medications,” such as eye drops, ear drops, nasal sprays, and topical products. Reconciling medications and promoting consistency in communication means knowing about and documenting all of the medication products that the patient is taking. Use of evidence-based practice to prevent unintended outcomes is part of several patient safety goals. How does this relate to documentation? What evidence do you use? Where is that information documented? How is it revised and updated as new information becomes available? How does your documentation reflect deviations from a standard based on unique needs in a particular patient context? There is a patient safety goal related to the need for psychiatric hospitals and general hospitals that treat people for emotional/behavioral disorders to conduct a suicide risk assessment. Document your assessment data and any related interventions. Beware of the assumption that if you don’t work in a psychiatric setting, you don’t have to pay attention to this goal. It is not at all uncommon for patients in a medical/surgical setting to have underlying or duallydiagnosed mental health issues along with their physical reasons for needing care. Charting Logistics: Guides for Appropriate Paper Documentation There are a number of “rules” for effective, legally defensible documentation. Most of these are familiar to
nurses, but sometimes they get ignored or overlooked in the haste to get documentation done. Just as a review for use of paper/pen documentation: • Use blue or black ink. There was a time in health care when different colors of ink were used for different shifts. Colors don’t always copy, fax, or microfilm well, so the current standard is for use of either blue or black ink. Some facilities have a policy stipulating either blue or black – follow your facility’s policy if it has one. • Be sure you have the right patient’s chart and the right page on the chart before you begin your notation. In a rush to get documentation “done,” it is easy to grab the wrong chart or the wrong form, especially if charts are kept in a central location. Take a moment to be sure you have the right chart and the right form. Also, when receiving print-outs of lab results or reports from other departments, double-check the names on both the report and the chart. It is not uncommon, but potentially very dangerous, to have Mr. Smith’s lab results attached to Mr. White’s chart. • Fill out all forms completely and accurately. Again, follow your facility’s policy and procedure for use of any forms. If you are unsure about how to complete a form, get guidance from an appropriate resource to be sure your documentation is correct. If using a checklist, mark the appropriate space or mark a “not applicable” space. Do not leave items blank – that makes it look like you did not pay attention to that particular information. Instead write N/A if the item does not apply to a particular patient. • Use the first available line on a progress note or other narrative document. Don’t start your note at the end of a line used by someone else or try to squeeze information into a partial line that is available. • When you have finished your note, draw a single line from the end of your entry to the end of the line. This will prevent anyone else from documenting on the same line as your entry. • Write neatly and legibly. Keep a regular dictionary and a medical dictionary close at hand if you need these resources. Poor spelling and grammar are sometimes used in court to convey to a jury a sense that the nurse is “poor” in providing quality of care, too. • Follow your facility’s policy for error correction. In most cases, drawing one line through the erroneous information, then writing “error” or “mistaken entry” above the information and adding your initials is the policy. However, be sure you use the policy and procedure as specified in your organization. • Never use erasures, “white-out,” or any other process that would cover a notation. This gives the impression that you have something to hide. • Use only standard abbreviations. Many of the abbreviations that have been common in healthcare for many years are no longer considered appropriate. For example, the abbreviation “qd,” long recognized as meaning “daily” or “once a day,” is no longer deemed acceptable. The “q” might have a short tail, making it look like an “o.” OD means something very different from QD. The correct notation now is to write the word “daily.” Another abbreviation “rule out” is use of “U” for “unit.” If the writing is not clear, the opening at the top of the “u” might appear to be closed, and the letter could look like “o.” Or the “U” might have a tail, making it look like a “4.” To avoid possible
confusion, write the word “unit.” It only takes a second or two more, but the additional letters can make a big difference in promoting patient safety. Another thing to think about – a “standard” and acceptable abbreviation might mean two different things in different contexts. The above abbreviation “OD” might mean “right eye” in an ophthalmology clinic or “overdose” on a psychiatric unit. If in doubt, write it out. Use quotations as appropriate. Don’t try to “put words in the patient’s mouth” or interpret meanings. Sometimes, the best approach is to document exactly what the patient said. Be sure to use quotation marks so the source of the data is clear. The same approach can be used to document family comments or information from other caregivers. Avoid personal input. Remember that this is the patient’s chart, not your diary. Avoid personal comments, “asides,” or information not related to the assessment, planning, implementation, and evaluation of care for this patient. End each entry with your signature and credentials, if that is the standard in your organization, or in the absence of a different policy. Some organizations use a “signature page,” where the nurse records his/her full signature and credentials on the signature page, then subsequently uses initials for each individual chart entry. This is acceptable if you follow the facility’s policy for how it is used. Be cautious if two members of the healthcare team have the same initials – use of middle initials or some other option might be necessary. Be clear and concise in your documentation. Remember that this is your official evidence of your work with this patient. Board of nursing disciplinary hearings and/or court cases often arise a year or more after an incident has occurred. Will you remember everything you saw, said, and did when you cared for this patient? Will you be able to read your own writing later? Will you be able to explain why you made the decisions or took the actions you did? Write today with an eye toward tomorrow – you’ll want to be sure your charting is an accurate reflection of your nursing care.
Computerized Documentation Many healthcare facilities have switched from paper/ pen to computerized documentation, more often called electronic health records (EHRs), and many more are transitioning to EHRs. There has been much discussion in patient safety literature about the value of computerized documentation in reducing errors, promoting safety, and ultimately improving quality. Many nurses who have gone through the transition from paper to computerized charting acknowledge that the process was slow and somewhat frustrating at first, but after becoming used to the new system, they indicate such benefits as charting time decreased, time at the bedside increased, and patient safety increased. Some of the common early complaints about computerized documentation have been software related – no appropriate fields to put specific types of data, difficulty switching from a worksheet screen to a screen with lab values, etc. Close communication between nursing and the information systems personnel helps tremendously as people learn how to use a new system and learn to work as a team to establish processes for safe, effective documentation.
Be sure nursing is represented in development or selection of software and hardware as your facility makes this transition. Speak up if you have concerns. Learn “computerese” so you can speak the same language as the information technology (IT) people when they ask what the problem is with your system. Work together with your IT experts to critically analyze issues and concerns and develop workable solutions. The 2011 Institute of Medicine/Robert Wood Johnson report, The Future of Nursing, includes as one of its fundamental issues that nursing must be not just a user, but an active participant in the design, development, implementation, and evaluation of technology in healthcare. This is your opportunity to explore new horizons, and potentially a new arena of practice. Just as there are “rules” for paper documentation, there are guidelines that will help you be effective with computerized documentation as well. • Protect your password. Don’t write your password on a “sticky note” and attach it to your monitor. Be sure no one has access to your information except you and other authorized users. • Report inappropriate use of codes and passwords. Protect the integrity of the system by assuring that you and others are using it appropriately. For example, when a staff member transfers from one department to another, he/she may no longer need access to certain areas in the computer, but may now need access to areas that were previously not available. If you become aware of another person using the system inappropriately, report that information to the responsible person. A large amount of confidential, patient-sensitive data is at potential risk. • Protect your equipment. Whether you are using a computer that “floats” from one patient room to another, or taking a laptop into someone’s home for a home visit, be sure the equipment is used appropriately only by those designated as “users.” For home care nurses, the computer with patient data should not also be used at home for children’s homework or other purposes. • Use screen savers or “screen blockers.” Set the computer so that a screen saver will come up within just a few seconds if you need to walk away from an active screen to conduct your nursing actions. There are blockers you can put over your screen so that only you, standing or sitting directly in front of it, can see the display. This is not a bad idea if your computer is in a hallway or another space where someone could be beside or behind you and able to look at the information displayed on the screen. • Log off when you finish with your work. Do not allow another person to pick up where you left off. When you are finished with what you need to document, log out of the system. • Follow facility policies and procedures for documentation and error correction. Just as there are policies and procedures for written documentation, there should be facility policies for how you complete documentation and correct errors using the computer. Be familiar with and consistent with those processes. • Know the facility’s backup process. Even the best computers can crash. There can be problems with software and/or hardware. Know how to use all of the equipment needed to do your job. Know the
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• This video has been developed to give nurses a better understanding on how to become a mentor and the strategies involved in developing a mentoring relationship. This video has been developed and presented by: Dan Kirkpatrick, MS, RN. The author and planning committee members have declared no conflict of interest. This information is provided for educational purposes only. For legal questions, please consult appropriate legal counsel. For medical questions or personal health questions, please consult an appropriate health care professional. 1.25 contact hours will be awarded for successful completion of this webinar. The Ohio Nurses Association (OBN-001-91) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Expires 3/2017, Copyright © 2015 Ohio Nurses Association OBJECTIVES 1. Define Mentoring. 2. Describe the evolution of mentoring. 3. Identify a model and phases of mentoring relationships. 4. List areas of potential concern in mentoring relationships. 5. Describe strategies/tools for developing/maintaining mentoring relationships. To Complete Online • Go to www.CE4Nurses.org/ohionurse and follow the instructions. Post-test The post-test will be scored immediately. If a score of 70 percent or better is achieved, you will be emailed a certificate and test results. If a score of 70 percent is not achieved, you may take the test a second time. We recommend that the independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be e-mailed to you.
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information technology people and work collaboratively with them to identify and solve computer-related problems. If you are fortunate enough to work in a facility where there are nurses certified in nursing informatics, use their expertise to help you. Be familiar with the processes to be used if the system fails – how to retrieve data, how to save work in process, and how to continue the uninterrupted flow of patient care despite what may be happening to the “system.” Protect the security of other electronic devices that may be used to enhance documentation. Increasingly, hand-held electronic devices are being used in the healthcare environment. As with the computer, be sure passwords are protected, data is stored securely, and the device itself is maintained in a secure environment. For battery operated equipment, be sure the charge is adequate to conduct the business at hand. Document in real time to avoid late entries. This prevents others from documenting ahead of you and making it appear that your documentation may not be accurate. Be sure to document in the correct patient record. With computers, it is very easy to pull up a different record and begin to document in the wrong patient record. Double check your entries. It is very easy to click on the wrong box by accident and manually checkmark it. NEVER copy and paste someone else’s documentation. Patient information may have changed and your run the risk of not changing pertinent data if you copy and paste. Also some computer systems are able to track the use of the copy and paste function. Legal professionals may view this as a shortcut and question other shortcuts you may have used. ALWAYS use barcodes on both patients and medications. Don’t take shortcuts and override barcodes except in true emergencies. Use the same safeguards for documentation, that you have always used, and as discussed previously in the section on paper documentation. Those basic rules of documentation still apply.
Meaningful Use The concept of “meaningful use” has come into play in relation to the creation and utilization of EHRs. The idea is that there will be value derived from data in health records, not just that computers provide a different way to chart. The Health and Human Services Department of the United States government was empowered to establish programs to improve patient care through use of health information technology as a result of the Health Information Technology for Economic and Clinical Health (HITECH) act. This legislation was part of the more comprehensive American Recovery and Reinvestment Act of 2009 (US HHS, 2011). “Beginning January 1, 2014, all public and private healthcare providers and hospitals were required to adopt and demonstrate meaningful use of EHRs to remain eligible for Medicare and Medicaid reimbursement” (Lori a. Catalano, 2014). The meaningful use objectives include: 1. Improving quality, safety, and efficiency of care and reducing disparities 2. Engaging patients and families in their care 3. Improving care coordination 4. Improving population and public health 5. Ensuring adequate privacy and security protection for personal health information There are three steps in the HITECH process for integration of technology for meaningful use in the healthcare environment (McBride, et al, 2012). The first step is the purchase, installation, and use of certified electronic medical record systems. Not only must these systems function to document the care provided for an individual patient, they must be integrated so that the systems “talk to” each other to provide for seamlessness of data transmission and information sharing. In step two, clinical quality measures must be reported to the Centers for Medicare and Medicaid Services (CMS) beginning in 2014 as use of the HITECH process was expanded. Providers will be held accountable for adherence to quality standards, as evidenced by the data in patient records. The ultimate goal, step three, is improving patient outcomes. These will be measured in relation to data reporting about both individual patient care and public health outcomes for issues such as increasing adherence to immunization recommendations and patient education to reduce incidence of obesity. What Does Meaningful Use Mean for Nursing? Transition to use of electronic medical records has been a challenge for many nurses, especially those who are not familiar or comfortable with “digital age” technology. Additionally, early systems for electronic documentation were not always user-friendly or easy to navigate. It became easy to “blame” the computer on lack of attentiveness to patient needs, more time required to document, and frustration with the practice of nursing. As hospitals rolled out mandatory education for all nurses on the “how to” process for electronic documentation, the “why” often got left out or glossed over. As more nurses, particularly those in hospitals, become more comfortable with use of the technology, and as the technology itself improves, it is now critical to switch thinking from the computer as the barrier to patient care to the computer as one tool to enhance patient care. Nurses will need to be diligent in documenting not just subjective and objective data, but analysis of that data supported by actions and outcomes. Additionally, nurses will use the computer to provide evidence of healthcare team collaboration and interactions to ensure clear communication and consistency in provision of care. The computer, and data accessed from it, will serve as a powerful tool to validate the critical importance of nursing in providing quality patient care. Summary In summary, documentation is critical to quality patient care. The method – paper or computer, doesn’t really make a difference. Key points are to recognize the need for documentation that is complete, accurate, and timely, and to integrate documentation into the plan of care with just as much significance as doing an assessment or performing a skilled task. Documentation is not a “left-over” that we do after all the work is done, or a chore that detracts from time giving care. It is a critical part of the care that we provide and helps to ensure quality outcomes for our patients.
Enjoy writing? Interested in sharing cutting-edge healthcare information with your nurse colleagues? Would you like author credits to add to your resume or professional portfolio? Want to get paid for writing? The Ohio Nurses Association is seeking nurse authors to help us expand our continuing education catalog.
Authors can earn up to $500 for each article that meets our standards and criteria. For more information, please visit www.ohnurses.org/preferred-author-program.
Doc “Q” umentation in Nursing: Recording for Quality Client Care Post-Test and Evaluation DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per question. The evaluation questions must be completed and returned with the post-test to receive a certificate. Name:______________________________________________ Date:_______________________ Final Score: ____________ Please circle one answer. 1. The general standard for documentation as noted in Ohio Board of Nursing rules (4723-4 OAC) is that documentation is: a. Complete, accurate, and timely b. Comprehensive, client-centered, and computerized c. Specific, detailed, and completed within two hours of when care was provided d. Truthful, thorough, and effective 2. If an employer requires that a nurse document care that was not provided: a. The nurse has no recourse b. The nurse is legally accountable for his/her own decision c. The nurse is obligated to follow that requirement d. The nurse would not be found liable in a civil suit 3. After calling a prescriber to question a medical order, the nurse should: a. Document that the prescriber did not adhere to the standard of care b. Give the client more information than is noted in the chart c. Never use the prescriber’s name in the documentation d. Provide rationale for questioning the order in the documentation 4. An Ohio LPN practices: a. Independently b. Only in the hospital setting c. With a restricted license d. With direction from an RN or specified others
9. Nurses are generally least proficient in documenting: a. Assessment data b. Interventions c. Patient responses to nursing care d. Vital signs 10. A registered or licensed practical nurse may be disciplined by the Ohio Board of Nursing for failure to document appropriately: a. If he/she does not follow rules related to documentation b. Only if harm is done to the patient c. Subsequent to other disciplinary actions d. When a physician is not notified of changes in a patient’s condition 11. To adhere to the Joint Commission safety goal of medication reconciliation: a. Ask the family to protect patient confidentiality by refusing to share medication information b. Give the patient a complete list of his/her medications c. Provide an overview of any side-effects of medications d. Tell the prescriber if the patient is taking any contraindicated medications
6. General “rules” of paper charting include: a. Use blue, red, or green ink b. Erasure of any errors c. Incorporation of caregiver perspectives about client behaviors d. Complete forms correctly and accurately 7. An institutional review board is responsible for: a. Determining that appropriate documentation is completed b. Examining institutional policies and procedures c. Making sure that client’s rights are protected d. Requiring that researchers get appropriate funding 8. Accrediting bodies: a. Cannot look at current records b. Have the right to review patient records c. May only review 30% of a facilities’ records d. Will not take action based on findings in records
18. The best determination of “timely” documentation is that which is: a. Always within the window of time allotted b. Based on the needs of the patient c. Completed during your shift d. Consistent with national standards 19. A registered nurse’s documentation should reflect: a. Nursing diagnoses and desired outcomes b. Reasons that errors were made c. Receipt of direction to provide care d. Statements about staffing and support services
Evaluation: 1. Were you able to achieve the following objectives?
12. If a person is to take a medication once a day, the correct notation is: a. As prescribed b. Daily c. Once a day d. QD 13. The correct notation for “unit” is: a. U b. u c. unit d. 4 14. Meaningful use relates to: a. Developing a standardized language for computerized health records b. Establishing a computerized network for pharmacists to check prescriptions c. How electronic data is used to improve quality of care d. Paper documentation reviewed by medical records
5. Process improvement initiatives often stem from: a. Evidence in disciplinary hearings b. Findings in chart reviews c. Literature reviews d. Providers of quality care
17. The U.S. federal government’s plan is to require providers and hospitals to report clinical quality measures by: a. 2014 b. 2020 c. 2041 d. 2050
15. If a patient is found on the floor in his room, an appropriate statement in the chart might include: a. “Don’t know what happened, but he was on the floor when I entered the room” b. “Fell out of bed” c. “Fell because nurse aide was not watching him” d. “Found on floor” 16. For a home health nurse using a laptop for documentation, which of the following guidelines is most appropriate: a. Assign different passwords to different members of your family so no one can access your patient information b. Keep your work laptop separate from the family’s computer system(s) c. Save your work information to a disk before allowing other family members to use the computer d. Talk with your family about the best way to protect your patient-sensitive data
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a. Identify Ohio Board of Nursing rules related to documentation.
b. Relate documentation activities to quality patient care.
2. Was this independent study an effective method of learning?
If no, please comment:
3. How long did it take you to complete the study, the post-test, and the evaluation form?
4. What other topics would you like to see addressed in an independent study?
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