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MON 2011 - Slide 2 - L. Sharp - Keynote lecture - Developing the evidence base for oncology nursing practice
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MON 2011 - Slide 2 - L. Sharp - Keynote lecture - Developing the evidence base for oncology nursing practice


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  • Strategy: A nurse can strive to use best available knowledge when making health care decisions Process: Critical thinking, to systematically search, use and evaluate research results.
  • Reviews and Meta analyses Sounds easy, doesn’t it?
  • In both these two example it has been more difficult to make nurses stop using strategies with no evidence that to implement new ones.
  • Moving on to the next area of change…. To implement briefing/debriefing was suggested by the project leaders and were discussed during the courses. The small team of nurses that work together during a shift met for a few minutes to plan their day. The purpose is that everyone have the same information and the same idea on how the job should be done. A set of issues is written down on a card. The first evaluation showed that this could save time and improve the communication within the team. At the end of each shift the debriefing is taken place and now the team is focusing on how everything went. What went well? What could have been better? What needs to be reported to the next shift? Any safety issues?
  • The weaknesses were that it took a long time to implement. Maybe because the idea came from the management? Another thing that might affect this was that there were no obvious leader. If briefing/debriefing should work everyone need to initiate it.
  • Another result of the project is the implementation of a check list. Before each RT the team tick of the items on the checklist to reduce the risk of errors. The first item is ID control, then if the right body area is treated. Is the set-up and positioning correct? And then it continues with couch settings etc. All of these areas have been involved in errors. The evaluation is on going but we can already see that the checklist have helped avoid medical errors.
  • Interrater and intrarater
  • Case 4 Conflict/ poor communication/failure to communicate b/w nurse and oncologist. The hospital and the national board of welfare have recently emphasized the risk of infectious disease, such as MRSA, and new rules on how the staff should be dressed etc has been introduced to reduce the risk of transmitting disease. The new rules includes, among other things: No rings, bracelets or watches are allowed Staff is not allowed to mix their scrubs with private clothes (except underwear) All scrubs should be changes every day Only scrubs with short sleeves are allowed in direct patient care A lot of focus is on the compliance of these rules, including unannounced controls. One of the oncologists, Olle, at the RTU is particularly liked by the nurses. He always have the patients best interest in mind, make prompt medical decisions and treat other team members with great respect. One of the nurses, Katrin, has a special responsibility for the compliance of the new rules and she is obligated to report the response to these rules. Some of the oncologists ignore these new rules, and Olle is one of them, He constantly mixes scrubs with private clothes and he is always wearing his watch and his rings. This issue is often discussed, during coffee breaks among the nurses and nurse assistants. Katrin starts to get hints from her colleagues, that it is her job to confront Olle. She feels a bit unease but decides to bring it up one day, when she met Olle in the lunch area and no one else is around. She simply asks him why he doesn’t follow the rules, since the risk of transmitting disease has been proven to drop radically, if staff follows the rules. Olle leaves smiling and says , well I just don’t believe in that. Katrin feels frustrated and feel she has to back off a bit since she is anxious to keep a good relation with Olle, since there has been some problems with one of there patients and they need to cooperate well to deliver good care. However, after a while she confronts Olle again. This time he tells her to get off his back and that he doesn’t believe in the scientific value of the studies that the hospital has built the new rules on. He also tell her that he always uses Alco gel and that he is definitely not is transmitting any germs to his patients. After this situation, Katrin drops the subject to avoid more conflict but feel at the same time that she is not doing her job as a nurse in a good way.
  • Transcript

    • 1. Evidence Based Nursing (EBN) Lena Sharp, RN, PhD, Karolinska University Hospital, Stockholm, Sweden
    • 2. Disposition
      • Background
      • How to use EBN
      • Hinders
      • A few successful and not so successful examples
      • Creating evidence-based guidelines
      • Case discussion
      • Conclusions
    • 3. Background
      • Evidence based nursing aims to guarantee high quality care, built on the best knowledge available, and to ensure that the health care systems resources are being used as efficiently as possible.
      • Nurses have the responsibility to apply evidence based nursing to guarantee that their patients receive care according to science and clinical experience
      • Swedish Society of Nursing 2011
    • 4. Background
      • Increased evidence base
      • Variations in clinical practice
      • Gap between available knowledge and clinical practice
      • Nurses have e central role in most health care settings and therefore a great responsibility to close this gap
    • 5. Background
      • EBN could be described as both a strategy and a process
      • In clinical practice, the scientific foundation and clinical experience should be integrated.
      • Available resources, patients preferences and experiences should also be taken into account.
    • 6. Evidence based practice is “doing the right thing in the right way for the right patient at the right time”
    • 7. How?
      • Formulate the questions?
      • Search relevant data bases
      • Identify best available knowledge
      • Adapt to local resources
      • Pilot
      • Implement
      • Evaluate
      • “ Spread the news!”
    • 8. Hinders
      • Lack of scientific knowledge
      • Conflicting research results
      • Lack of time
      • Lack of supervision
      • Resistance from colleagues and management
    • 9. Hinders
      • Hierarchy
      • Overemphasis on randomized control trials, systematic reviews and meta-analysis
      • Clinical nursing and nursing research are two different worlds!
    • 10. How to overcome hinders
      • Task for master prepared nurses
      • Involve colleagues
      • Establish a plan with your boss
      • Information and feedback
      • Document the progress carefully
      • Give credit
    • 11. How to overcome hinders
      • Interdisciplinary team involvement
      • Careful planning
      • Commitment
      • Enthusiasm
      • Networking
    • 12. At the clinical level
      • Discussion and reflection of practice
      • Monitor relevant research and development
      • Create networks
      • Article clubs
    • 13. . Developing clinical practice is not a simple and straightforward task….
    • 14. Group discussion
      • What possibilities do you have in your daily practice to work with evidence based guidelines?
      • What areas of nursing should you focus on?
    • 15. From evidence ……….. to practice. A long way
      • “ Old habits die hard and
      • clinical practices are motivated
      • more by comfort and tradition
      • than challenge and growth”
    • 16. An unsuccessful example…
      • RT
      • Immobilization device
      • Head mask vs Head-shoulder mask
      • Different opinions
      • Randomised trial
      • Clear results in favour of the Head mask
      • Not implemented!
    • 17. A successful example
      • RT
      • Skin care
      • Two units, different strategies
      • Evidence-based guidelines
      • Initial problems with implementation and other professions
    • 18. Another successful example
      • Communication errors within and between professional groups at the RT-units
      • A large number of reported errors caused by poor communication
      • Treating the wrong patient
      • Treating the wrong body area
      • RT field shifts not performed as prescribed
    • 19. Is the care safe for patients??
      • 10-12 % of patients involved in a medical error/adverse event
      • 20 % of the hospital budget
      • Lack of communication within and between the professional groups are the most common cause
      • Transitions
      • Crew resource management (CRM) are evidence-based models for improved patient safety but have not been used in cancer care
      • 1000 times greater risk for a serious adverse event in radiotherapy compared with flying
    • 20. Communicate better!
      • Research/ care development project
      • Intervention to improve patient safety
      • Education program
      • Implemented
      • Evaluated
    • 21. Briefing/debriefing
      • Evidence-based model to improve patient safety
      • Every shift, a few minutes
      • Do not disturb!
      • Plan the daily work/evaluate the day
      • Focus on safety issues!
    • 22. Briefing/debriefing
      • Time saving
      • Better information to patients and staff
      • Less confusion
      • Evaluation is on going
      • Spread to other parts of the department
    • 23. RT-specific check list
      • Before start of RT for each patient
      • Areas known to cause errors
      • Reduced errors in 5 % of treatments
      • Easy to implement
        • Developed, initiated and driven by course participants
    • 24. A “Good” Guideline
      • Validity
      • Clinical applicability
      • Clinical flexibility
      • Reliability/ Reproducibility
      • Clarity
      • Multidisciplinary process
      • Scheduled review
      • Documentation
      (Cluzeau & Littlejohns 1999)
    • 25. Hierarchy
      • Effect patient safety!
      • … . I can’t see why the nurses have to keep notes…It must be better if they just talk to each other between the shifts….
    • 26. Hierarchy
      • Effect patient safety!
      • … . I saw that the doctor did not notice that the patient had radiotherapy before….but I thought….he is a senior oncologist and knows what he is doing so I didn’t say anything…
    • 27. Nurses role
      • … .. Helping the patients ….
      • … looking after the patients…
      • … . Run the machines…..
    • 28. What do we really do?
      • Cure cancer
      • Reduce the risk for side effects and complications
      • Coordinate, evaluate and develop health care
      • Reduce the risk for infections
      • Give psychosocial care
      • Educate and inform patients and their families
      • Cancer prevention
      • etc….
    • 29. Assessments
      • Scoring systems
      • Validation?
      • Lost in translation
      • Training/clinical discussions
    • 30. Assessments, an example
      • Pilot study
      • 100 patients with breast cancer
      • Skin toxicity
      • Two observers
      • Independently
      • RTOG/EORTC and WHO
      • Only 50-60 % agreement
    • 31. Challenges
      • Improved scoring scales
      • Faster and more systematic implementation of research results
      • Better documentation
      • Safety strategies must be a part of all cancer care (guidelines, error management, work climate etc.)
    • 32. Leadership in nursing care
      • Competence
      • Humility
      • Be a role model and show the way
      • Clearly communicate goals and approaches
      • Communication
      • Cooperation
    • 33. Case Discussion
      • Read the case
      • Discuss in small group
      • What should Katrin do?
    • 34. The way forward
      • The future depends on…
      • Educational initiatives
      • Organizational commitment – support
      • Funding
      • Patient involvement
      • Inter professional collaboration
    • 35. Conclusions
      • EBN is here to stay!
      • Master prepared nurses play an important role
      • Differences in nursing practice need to be reduces
      • Attitudes and other hinders need to be adressed
      • More clinical guidelines at national and international level need to be developed
    • 36. Thank you! [email_address]