Category: Journal & Book Club

IRIS Cricoid Pressure Trial & Deimplementation (Journal Club)

Paul Ross

Journal Club Article: Birenbaum, A., Hajage, D., Roche, S., Ntouba, A., Eurin, M., Cuvillon, P., … & Menut, R. (2018). Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial. JAMA Surgery.

Background: 

Cricoid pressure or Sellick’s maneuver (first described by Dr. Sellick in the 1960’s) aims to reduce the risk of regurgitation. The technique involves the application of pressure over the cricoid cartilage with the thumb and 1-2 additional fingers, to to occlude the esophagus and prevent regurgitation of stomach contents into the upper airway.

Study Aim:

Does the cricoid pressure prevent pulmonary aspiration in patients undergoing rapid sequence induction of anesthesia?

Study Design:

A randomized, double-blind, noninferiority trial conducted across 10 academic centers. Patients undergoing anesthesia with rapid sequence intubation (RSI) were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge. 3472 patients were assigned to cricoid pressure (Sellick group) or a sham procedure group. Mean age was 51 years and 51% were men. Inclusion: all adults; Exclusion: pregnancy.

Key Results: 

Primary measure of pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group.

Secondary Measures:

  • No significant difference in pneumonia, length of stay and mortality.
  • The Cricoid (Sellick maneuver) group had significantly longer intubation time (median, 27 vs. 23 seconds).
  • Longer intubation time >30 seconds, Cricoid 47% vs Sham 40%; P <.001.
  • Comparison of the Cormack and Lehane grade (Grades 3 and 4) in Cricoid (10%) vs Sham (5%; P <.001).
  • All suggests an increased difficulty of tracheal intubation in the Cricoid (Sellick) group.

Summary: 

Investigators summary: “the results failed to demonstrate the noninferiority of a sham procedure in preventing pulmonary aspiration compared with the cricoid pressure. Mortality, pneumonia, and length of stay did not differ significantly between groups, and differences in intubation time and laryngoscopic exposure suggest more difficulties in the Sellick group”.

Nursing Clinical Questions:

  • Is cricoid pressure needed if there is no harm prevention and gives inferior views of the airway?
  • This study population was in theatre, can the results be transferred into the pre-hospital, ED or ICU populations (and in pregnancy)?
  • Should nurses use the evidence base to encourage the deimplementation of ‘ritualistic’ practice? See below in Deimplementation Resources.
  • Should nurses just refuse to perform a non-evidence based procedure?

Additional Resources:

Recommended Viewing on Cricoid: Cricolol by John Hinds on Vimeo.

Deimplementation Resources

Rogers, E. M. (1995) Diffusion of innovations. (5th ed.) Simon and Schuster, New York, USA. [summary article]

Nursing Education Network. (2017) Deimplementation of Practice.

Nursing Education Network. (2016) Human Centred Design.

 

 

 

 

 

Barriers to using research findings in practice: The clinician’s perspective

Paul Ross

Journal Club Article: Funk, S. G., Champagne, M. T., Wiese, R. A., & Tornquist, E. M. (1991). Barriers to using research findings in practice: The clinician’s perspective. Applied Nursing Research, 4(2), 90-95. [abstract]

In 1991, Funk and colleagues highlighted the progress made in the quantity, quality and new areas of nursing research being instigated.  This paper produced the BARRIERS scale, which has been used as a validated tool to further investigate research in nursing in different settings and countries.

Aim: To determine clinicians’ perceptions of the barriers to using research findings in practice and to solicit their input as to what factors would facilitate such use.

Method:  Questionnaires to 5000 selected full time working nurses based on five educational strata (those with diplomas, associate degrees, bachelor’s, master’s, and doctoral degrees). 40% completion of the questionnaire.

Nice touch part: “Each questionnaire included an individual packet of coffee and a letter inviting the recipient to take a few moments to relax and complete the questionnaire”.

BARRIERS scale: 28-item scale requires respondents to rate the extent to which they think each item is a barrier to nurses’ use of research to alter or enhance their practice. Responses are circled on a 4-point scale (I, to no extent; 2, to a little extent; 3, to a moderate
extent; and 4, to a great extent).

The scale is divided into four subscales:

  1. characteristics of the nurse (related to the nurse’s research values, skills, and awareness).
  2. characteristics of the setting (related to the barriers and limitations perceived in the work setting).
  3. characteristics of the research (methodological soundness and the appropriateness of conclusions drawn from the research).
  4. characteristics of the presentation of the research and its accessibility.

Results:  “Insufficient time on the job to implement new ideas was cited most frequently, with lack of support from administration and physicians following closely behind.

The two greatest barriers were the nurse’s not feeling that she/he had “enough authority to change patient care procedures” and “insufficient time on the job to implement new ideas,” both of which are barriers of the setting.

The characteristics of the setting were rated among the top 10 barriers. They included lack of cooperation and support from physicians, administration, and other staff; inadequate facilities for implementation; and insufficient time to read research.”

The characteristics of the nurse in recognising the limits of their knowledge and skills to review and conduct research.

Summary: Nurses need to use and understand research to deliver evidence based practice. Research improves critical thinking and clinical decision making in clinicians. There are numerous barriers that hinder the use of research in the clinical setting, mainly linked to culture and traditional leadership hierarchies.

Limitation: The world and healthcare has changed since 1991, so aspects such as technology and the mass of information may lead to questions of validity for the BARRIERS scale, despite it’s historic use. Take a read of this systematic review by Kajermo et al. (2010). It may also help to understand the drivers of change, which can then be replicated in other settings to increase nurses involvement in research.

Resources

The Barriers Scale. (2018). The BARRIERS to Research Utilization Scale. UNC.edu

Kajermo, K. N., Boström, A. M., Thompson, D. S., Hutchinson, A. M., Estabrooks, C. A., & Wallin, L. (2010). The BARRIERS scale–the barriers to research utilization scale: A systematic review. Implementation Science, 5(1), 32.

Journal Club: Defining the key roles and competencies of the clinician–educator of the 21st century.

Paul Ross

Journal Club: Sherbino, J., Frank, J. R., & Snell, L. (2014). Defining the key roles and competencies of the clinician–educator of the 21st century: a national mixed-methods study. Academic Medicine, 89(5), 783-789.

Background

This paper looks at the challenges of the clinician educator in the medical profession, the challenge of being a clinician and an educator. Defining an educator and the roles they perform in the clinical and educational environments varies considerably in terms of the scope of abilities or competencies.

Aims

  1. Create a consensus definition of what is a clinician–educator.
  2. Understand the domains of competence of being a clinician–educator.
  3. Types of training and preparation is required for the clinician–educator.

Method

Two-phased mixed method study:

  • Phase 1: focus groups using a grounded theory analysis.
  • Phase 2: a survey of 1,130 deans, academic chairs, and residency program directors to validate the focus group results.

Results

Results from phase 1 focus groups:

  1.  Being active in clinical practice,
  2. Applying education theory to education practice,
  3. Engaging in education scholarship.

Results from phase 2 survey:

Domains of competence and core competencies for clinician–educators:
  1. Designs assessment designs programs.
  2. Employs effective communication strategies.
  3. Learning theories and best practice for curriculum development, and conducts evaluations.
  4. Knowledge of education theory and application to education practice.
  5. Leadership in educational programs.
  6. Scholarship: “Contributes to the development, dissemination, and translation of health
    professions education knowledge and practices.”
  7. Uses effective teaching in teaching environments. Develops other faculty members.

Conclusion

Key roles of the clinician-educator: participates in clinical practice, applies theory to education practice, engages in education scholarship and consults on education issues. Identified the need for clinician-educator formal training programs.

Relevance For Nursing

What is interesting in this article is the continued mention of clinical competence or expertise in medical education. In nursing is the higher education setting seen as the source of educational knowledge, research and scholarship? But is higher education too far removed from the clinical environment to understand real world clinical challenges? Is there a different approach to engage both worlds for delivery of evidence based practice?

Resources

ICE Blog. (2014). Defining a Clinician Educator.

Sherbino, J., Frank, J. R., & Snell, L. (2014). Defining the key roles and competencies of the clinician–educator of the 21st century: a national mixed-methods study. Academic Medicine, 89(5), 783-789.

The Role of Debriefing in Simulation-Based Learning. 

Paul Ross

Journal Club Article: Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125.

Purpose

Determining what is important in the aspects of debriefing within simulation based learning.

Background

The importance of remembering the adult learner, and all the experience they bring through knowledge, assumptions and feelings. Active participation and leveling (#Heutagogy) of the traditional hierachies between teacher and learner are part of the adult learning philosophy. The adult learner is seen as self-directed, motivated and learns from meaningful and work related education that can applied in workplace.

“Adults learn best when they are actively engaged in the process, participate, play a role, and experience not only concrete events in a cognitive fashion, but also transactional events in a emotional fashion. The learner must make sense of the events experienced in terms of their own world” (pg. 115).

“The concept of reflection on an event or activity and subsequent analysis is the cornerstone of the experiential learning experience.” (pg. 116).

Origins of debriefing in simulation were from critical stress incident debriefing and to do this in a timely manner post incident, with the aim to stimulate group cohesion and empathy.

The Debriefing Process

  • Supportive climate; open, sharing, honest, free to learn.
  • Environment of trust; the pre-brief to explain the purpose of the simulation and what is to be expected.
  • The roles of debriefer and those to be debriefed.

Models of Debriefing

The aim of the debrief is to make sense of the event. The structure of the simulation may be:

  1. Experience the event,
  2. Reflect on the event,
  3. Discuss the event with other participants,
  4. Learn and modify behaviour learnt from the experience.

Objectives

As ever match learning such as the debriefing to the learning objectives. Allow emergent and evolving learning that occurs throughout the simulation process. “Two main questions:

  1. Which pieces of knowledge, skills, or knowledge are to be learned?
  2. What specifically should be learned about each of them?”

Role of The Facilitator

The facilitator will be a Co-learner in the simulation with the aim to guide and direct, rather than a traditional lecture based authoritarian approach. Debriefing is a skill and requires training and development. Resources such as the support from experts to guide and develop are important in developing simulation skills.

Debriefing 

Dismukes & Smith (2017) describe three levels of facilitation:

  1. High: High level facilitation actually requires low level of involvement from the facilitator. “Participants largely debrief themselves with the facilitator outlining the debriefing process and assisting by gently guiding the discussion only when necessary, and acting as a resource to ensure objectives are met” (pg 119).
  2. Intermediate: “An increased level of instructor involvement may be useful when the individual or team requires help to analyze the experience at a deep level, but are capable of much independent discussion” (pg 119).
  3. Low: “An intensive level of instructor involvement may be necessary where teams show little initiative or respond only superficially” (pg 120).

Summary 

The debrief is described as ” the heart and soul of the simulation”.

Resources

Dismukes, R. K., & Smith, G. M. (2017). Facilitation and debriefing in aviation training and operations. Routledge.

Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125.

Lederman, L. C. (1991, July). Differences that make a difference: Intercultural communication, simulation, and the debriefing process in diverse interaction. In Annual Conference of the International Simulation and Gaming Association, Kyoto, Japan (pp. 15-19).

Petranek, C. (1994). A maturation in experiential learning: Principles of simulation and gaming. Simulation & Gaming, 25(4), 513-523.

Thatcher, D. C., & Robinson, M. J. (1985). An introduction to games and simulations in education. Hants: Solent Simulations.

Book Club: Visible learning for teachers: Maximizing impact on learning by John Hattie

Paul Ross

Book Club: Hattie, J. (2012). Visible learning for teachers: Maximizing impact on learning. Routledge.

6 signposts towards education excellence:

  1. Teachers are one of the most powerful learning influencers,
  2. Teachers need to be passionately engaged,
  3. Teachers need to provide effective individualistic feedback,
  4. Both student and teacher need to know and understand the learning intentions,
  5. The learners construction of knowledge and ideas is critical,
  6. Safe learning environments where mistakes are encouraged and exploration of knowledge occurs.

Education Holy Grail improving education and interactions between student and teacher.

What are the core attributes to schooling that make the difference? The focus is not the buildings or programs but on the practice of teaching. Students learn to become their own teacher, to exhibit attributes of self-monitoring, self-evaluation, self-assessment and self-teaching.

Visible teaching and learning occurs when there is feedback given and sought, and when there are active, passionate, and engaging people (teacher, students, peers) participating in the act of learning” (pg 18).

“The act of teaching requires deliberate interventions to ensure that there is a cognitive change in the student” (pg 19).

Safe Environment

Idea rich environment where experimenting can occur and sharing ideas.

“A safe environment for the learner (and for the teacher) is an environment in which error is welcomed and fostered” (pg 19).

The Challenge

“When students become their own teachers, they exhibit the self-regulatory attributes that seem desirable for learners (self-monitoring, self-evaluation, self-assessment, self-teaching)” (pg 19).

Deliberate practice needs to occur and the student to be challenged in this safe environment, to aid the construction of knowledge.

“It is challenge that keeps us investing in pursuing goals and committed to achieving goals” (pg 57).

Preparing Lessons

4 critical parts in planning:

  1. “Students starting levels of performance (prior),
  2. The desired level of performance (target),
  3. Rate of progress (progression),
  4. Teacher collaboration and critique in planning” (pg. 41).

Best Practice Lesson Plans

  1. Know the learning intentions (the teacher),
  2. Understand expected standards of performance (the student),
  3. Build commitment and engagement in the learning task.
  4. Guide for the teacher on best delivery of the lesson (guided delivery),
  5. Guided practice for students to complete a task and receive constructive feedback,
  6. Closure provides clear cues when students are at important points in learning,
  7. Independent practice follows mastery of a topic.

Structured of Observed Learning Outcomes (SOLO)

SOLO taxonomy: Levels of understanding can be grouped as surface, deep and conceptual and the use of SOLO taxonomy can integrate them into learning intentions and achievement criteria.

Starting The Lesson

The climate of the classroom is a critical factor in promoting learning. A high level of relational trust and respect for each person’s role in learning. The classroom is a place for the student to dominate, not the teacher where there is a “need to talk, listen and do”.

Learning

Start with the desired results and then work backwards, the focus is then on the gap. This knowledge gap is where the teachers focus on the student and how they learn. The importance of motivation on goal setting and strategies to close the gap, and to recognise motivation varies at any given time.  Deliberate practice allows learning to meaningful and a meta-cognitive approach to instruction allows multiple opportunities for practice.

Visual Learning Infographics

Resources

Hattie, J. (2012). Visible learning for teachers: Maximizing impact on learning. Routledge. [GoodReads review]

Hattie, J. (2008). Visible learning: A synthesis of over 800 meta-analyses relating to achievement. Routledge [sample].

Nursing Education Network. (2017). John Hattie and Visible learning for Teachers.

 

Dialogic Leadership by William Isaacs

Paul Ross

Journal Club Article: Isaacs, W. (1999). Dialogic leadership. The Systems Thinker, 10(1), 1-5.

“Human beings create, refine, and share knowledge through conversation.”

The Concept of Dialogue

“In the new knowledge-based, networked economy, the ability to talk and think together well is a vital source of competitive advantage and organizational effectiveness.

Think Together

A hallmark for many of us is that there are “no surprises” in our meetings. Yet this is the antithesis of dialogue. In dialogue people learn to use the energy of their differences to enhance their collective wisdom.

Dialogue Versus Discussion

Dialogue signifies a flow of meaning while “discussions are conversations where people hold onto and defend their differences. The hope is that the clash of opinion will illuminate productive pathways for action and insight. Yet in practice, discussion often devolves into rigid debate, where people view one another as positions to agree with or refute, not as partners in a vital, living relationship. Such exchanges represent a series of one-way streets, and the end results are often not what people wish for: polarized arguments where people withhold vital information and shut down creative options.”

Dialogic Leadership

“Dialogic leadership” is the term given to a way of leading that consistently uncovers, through conversation, the hidden creative potential in any situation. Four distinct qualities support this process, the abilities:

  1. to evoke people’s genuine voices,
  2. to listen deeply,
  3. to hold space for and respect as legitimate other people’s views, and
  4. to broaden awareness and perspective.

Four-Player Model

Four distinct kinds of actions that a person may take in any conversation:

  1. Move
  2. Follow
  3. Oppose
  4. Bystand

Balancing Advocacy & Inquiry 

To advocate well, you must move and oppose well; to inquire, you must bystand and follow.

Four Practices for Dialogic Leadership

  1. Listening: the ability to listen together
  2. Respecting: true respect enables genuine inquiry
  3. Suspending: to bystand with awareness
  4. Voicing: courageous speech

Changing the Quality of Action

Dialogic leadership focuses attention on two levels at once: the nature of the actions people take during an interaction and the quality of those interactions.  Dialogic leadership implies being a living example of what you speak about – that is, demonstrating these qualities in your daily life.”

Keywords: Advocacy; Inquiry; Dialogic; Leadership.

Thanks to Intensivist and Education Specialist Cameron Knott for guiding towards this resource (#CoP).

Resources:

Isaacs, W. (2008). Dialogue: The art of thinking together. Crown Business. [GoodReads review]

Isaacs, W. (1999). Dialogic leadership. The Systems Thinker, 10(1), 1-5.

Coelho Amestoy, S., Schubert Backes, V. M., Buss Thofehrn, M., Gue Martini, J., Schlindwein Meirelles, B. H., & de Lima Trindade, L. (2014). Dialogic leadership: strategies for application in the hospital environment. Investigacion y educacion en enfermeria, 32(1), 119-127.

Teamwork and team training in the ICU: Where do the similarities with aviation end?

Paul Ross

Journal Club Article: Reader, T. W., & Cuthbertson, B. H. (2011). Teamwork and team training in the ICU: Where do the similarities with aviation end?. Critical care, 15(6), 313.

Background

Comparing the lessons learnt and development of team training approaches in the aviation industry to the complex needs of the Intensive Care Unit (ICU). The importance of teamwork and the coordination of behaviours in terms of patient care provided and subsequent outcomes. Higher levels of doctor-nurse collaboration improve safety and mortality rates. The recognised importance of poor communication which has been identified as a factor in medical error.

Team input and team processes = team output

  • Teamwork

“Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. ”

  • Active & Latent Failures

“team-related ‘active failures’ (for example, failures to communicate the proximity of nearby aircraft) and ‘latent failures’ (for example, lack of team training, poor ergonomic design, and organizational culture) that influence behavior and error in the cockpit.”

  • Decision Making Under Stress

“Techniques include exposing teams to high-stress situations, training pilots to facilitate team discussions before and after stressful team activities, and cross-training aircrew team members to understand the demands and needs of one another’s role. Teams are trained in a multidisciplinary environment…….”

  • Hierarchical Team Structures

The ability to understand other roles, so in stressful events still work together as a team and negative behaviours and attitudes don’t effect performance.

  • Environmental Factors

“Fatigue and stress are known to negatively influence performance in the ICU, and non-technical factors such as team communication, situation awareness, and decision making frequently underlie error.”

Developing a workplace culture based upon safety requires supporting and valuing staff in the high risk environment of ICU, with models of training and supervision that focuses not only on the norms of practice (normative) and educative training, but on restorative and supportive resources to improve stress and burnout, and aid personal development.

Keywords: Intensive Care Unit; Team Performance; Human Factors; Team Training; Aviation Industry; Cognitive Load; Situation Awareness.

Relevant additional resources around some of the themes identified in this articles to aid collaborative educational teamwork:

 

 

 

Nursing Theories: Back to basics

Paul Ross

Nursing is often voted the most trusting profession, is this due to the humanistic approach of traditional nursing or looking further back into the history of nursing and the vocational ‘Florence’ holistic caring approach? As nurses engage in technology to deliver care and encroach into areas of medicine to increase the nursing scope of practice, are we at risk of losing the therapeutic nurse-client relationship?  If we reflect on the fundamentals of nurse training, it was likely based around nurse theory and systems of care, and surprisingly not the core standards that hospitals use as measurements of quality that nurses are faced with on a day to day basis no matter what the level of acuity or staffing. Theorists and models of care such as Benner, Henderson,  Orem, Rogers, Roy and Roper, Logan & Tierney – and each country will likely have certain theories that form the backbone of its nurse training curriculum. Look at the concepts, and see we are still trying to encourage independence, return power to the patient, end pyjama paralysis, provide effective rehabilitation and ensure healthcare is evidence based and ideally available for all.

Keywords: Care, compassion, competence, communication, courage and commitment (The 6 C’s).

Below are some great online resources, don’t forget to revisit those text books gathering dust on your healthcare book shelf.

Books

Online Resources

 

 

 

Journal Club: Factors influencing nurses’ intentions to leave adult critical care

Paul Ross
Journal Club Article: Khan, N., Jackson, D., Stayt, L., & Walthall, H. (2018). Factors influencing nurses’ intentions to leave adult critical care settings. Nursing in critical care.

 

Background:

“Nurse retention is a global problem across all specialities but is exacerbated in critical care areas where elevated nurse–patient ratios and the use of advance technologies require greater numbers of highly educated and specialized nurses impacting costs and quality of patient care.”

Factors identified in previous research such as working conditions, burnout syndrome, organisational climate, staffing levels, empowerment, personal health and work pressure.

Relevance to practice:

“The shortage of critical care nurses is currently a global issue impacting costs and quality of patient care.”

Method:

A systematic mixed-method literature review.

Findings:

3 themes identified were quality of the work environment, nature of working relationships and traumatic/stressful workplace experiences.

  1. Quality of the work environment

Empowerment and professional development opportunities. Having enough time to recover from night shifts and the impact of inflexible rotations on work–life balance.

2. Nature of working relationships

When conflict occurs with families and relatives. Poor relationships between nurse to manager and nurse to physician, especially not being involved in the decision making process.

3. Traumatic/stressful workplace experiences

Futility in the level of care being provided, caring for the dying patient and decisions to forego life‐sustaining treatments.

Conclusion:

High nursing turnover is a global issue and nurse leaders in critical care areas need to take these findings into consideration when developing strategies to improve turnover and support strategies.

Keywords: Burnout; Culture: Nurse Retention; Stress; Teamwork.

Additional Resource: Best Nursing Degree from Shanna Shafer (BSN) regarding shortage of nurses and also nurse faculty in the US, and reshaping the future of nursing and nurse education.

 

The Top Ten Websites in Critical Care Medicine Education Today (Journal Club)

Paul Ross

Journal Club Article: Wolbrink, T. A., Rubin, L., Burns, J. P., & Markovitz, B. (2018). The Top Ten Websites in Critical Care Medicine Education Today. Journal of intensive care medicine, 0885066618759287.

Background

Looks at the rapid growth of online educational resources in the critical care environment. From another review by Kleinpell et al (2011) which identified 135 websites, only 67 now are still available online. This demonstrates a rapidly changing environment and provides a rationale for this papers focus.

Methods

  • Literature review and web search.
  • Website assessment using the Critical Care Medical Education Website Quality Evaluation Tool (CCMEWQET).
  • Evaluation and ranking of identified websites.

Results

  • 97 websites relevant critical care websites were identified and scored.
  • Common types of resources, included blog posts, podcasts, videos, online journal clubs, and interactive components such as quizzes.
  • Almost one quarter of websites (n 22) classified as Free Open Access to Medicine (FOAM) websites.
  • Top 10 websites analysed and described. “Most often included an editorial process, high-quality and appropriately attributed graphics and multimedia, scored much higher for comprehensiveness and ease of access, and included opportunities for interactive learning.”

The Top Ten 

In alphabetical order:

FOAM Highlight

“The majority of FOAM website domains were not educational, nonprofit, or governmental. The FOAM websites were updated more recently than the other critical care medicine educational websites” (pg. 5).

References

Kleinpell, R., Ely, E. W., Williams, G., Liolios, A., Ward, N., & Tisherman, S. A. (2011). Web-based resources for critical care education. Critical Care Medicine, 39(3), 541-553.

Olusanya, O., Day, J., Kirk-Bayley, J., & Szakmany, T. (2017). Free Open Access Med (ical edu) cation for critical care practitioners. Journal of Intensive Care Medicine.

Wolbrink, T. A., Rubin, L., Burns, J. P., & Markovitz, B. (2018). The Top Ten Websites in Critical Care Medicine Education Today. Journal of Intensive Care Medicine. 0885066618759287.