Evidenced Based Practice Group Presentation

1. Evidenced Based PracticeGroup Presentation Rick Loenser, RN and Mary Anne Gross, RN

2. Environmental Model • Florence Nightingale’s theoretical framework for environment was a detailed account of her concepts upon ventilation, warmth, light, diet, cleanliness, and noise (Alligood, 2010, p. 75). • She believed nursing was “to assist nature in healing the patient. This was to be accomplished by managing the internal and external environments in an assistive way-in a way that was consistent with the laws of nature” (Chinn & Kramer, 2008, p. 31).

3. Florence Nightingale • First to use a theoretical foundation in nursing • Unsanitary conditions posed health hazard (Notes on Nursing, 1859) • External influences can preventor cause disease and or death

4. Nightingale’s Concepts • Person • Patient who is acted on by nurse • Affected by environment • Has reparative powers • Environment • Foundation of theory. Included everything, physical, psychological, and social • Health • Maintaining well-being by using a person’s powers • Maintained by control of environment • Nursing • Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate person’s reparative process Retrieved from http://currentnursing.com/nursing_theory/nursing_theorists.html

5. “It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light” (Nightingale, 1860).

6. Light Theory Applicationby Rick Loenser, RN

7. Evidence base for the benefits of light theory Increasing evidence recognizes the importance of everyday sunshine. “In 1863 Florence Nightingale appealed to hospital designers to include wards that were brightly lit by natural sunlight” (Genius, 2006, p. 422). Research supports the benefits of sunshine to help alleviate symptoms of : Depression Cancer Post-operative pain (Genius, 2006, p. 422) (Genius, 2006, p. 422) • Although sun exposure has been used therapeutically throughout history, it’s use has been doubted as of late (Genius, 2006, p. 422).

8. Rationale for Use of Nursing Theory • Does Nightingale’s light theory still have applications for today’s nursing environment?

9. Research supports Nightingale’s light theory and has used the evidence to support hospital design.

10. Even though Nightingale does not mention the term, evidence base practice, her theory is the basis for the concepts contained within the term evidence base practice for nursing (McDonald, 2001).

11. The Study Eighty-nine people, aged sixty and older All of the individuals diagnosed with depression “Forty-two of the participants underwent phototherapy consisting of 60 minutes of strong, pale blue light treatment every morning for three weeks.” “The remaining 47 people underwent a placebo treatment of dim red light for the three-week period.” (Ritsaert L., et. Al., 2011)

12. The Framework • The framework used in this study was based upon light therapy and its effects upon depression. • A light box has been used to treat seasonal affective disorder, or SAD, but this was the first time it had been reviewed for treating non-seasonal depression in older patients. (Ritsaert L., et. Al., 2011)

13. Research Results • “Immediately after the phototherapy session, people who received the bright pale blue light had a significant (7%) improvement in the symptoms of depression as compared to people who had the dim red placebo treatment” (Ritsaert, L., et. Al., 2011). • “ And three weeks later, there was a 21% improvement over the placebo group” (Ritsaert L., et. Al., 2011). • This study shows that phototherapy might have real benefit for older people who are living with mild depression, especially those who can't tolerate antidepressants. (Ritsaert, L., et. Al., 2011)

14. Limitations of the Study • Demographics of patient population are limited to older adults • Limited time frame for collected data • Small scale • Methods for data collection were not described to identify if consistency was observed • Application of the study is not identified

15. Strengths of the Study • Objective is clearly defined • The function and the purpose of the study was supported by findings • Observable differences noted in the statistics

16. How can I use this in my practice? • Open the curtains when it is daytime. • Place patients near the window • Take patients on a walk

17. Cleanliness Theory Applicationby Mary Anne Gross, RN

18. Why cleanliness theory? “Every nurse ought to be careful to wash her hands very frequently during the day. If her face too, so much the better.” “One word as to cleanliness merely as cleanliness.” • “the excretion, which comes from the skin, is left there, unless removed by washing…” Retrieved from http://nursingplanet.com/Nightingale/personal_cleanliness.html • Every nurse should keep this fact constantly in mind----for, if she allow her sick to remain unwashed she is interfering injuriously with the natural processes of health just as effectually as if she were to give the patient a dose of slow poison by the mouth.” Retrieved from http://nursingplanet.com/Nightingale/personal_cleanliness.html

19. Rationale for Use of Nursing Theory • “It is classified as lower-level theory but it provided the greatest foundation of nursing education, practice and theories.” • “As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.” Retrieved from http://currentnursing.com/nursing_theory/Florence_Nightingale_theory.html • Practice • Disease control • Sanitation and water treatment • Utilized by modern architecture in the prevention of "sick building syndrome" applying the principles of ventilation and good lighting Picture taken by Mart Anne Gross, RN

20. Rational for Use of Theory Cont. • Waste disposal • Control of room temperature • Noise management • Education • Principles of nursing training • Better practice result from better education • Skills measurement through licensing by the use of testing methods, the case studies • Research • Use of graphical representations like the polar diagrams • Notes on nursing Retrieved from http://slsu-coam.blogspot.com/2008/08/nightingales-environmental-theory.html Notes on nursing picture retrieved from Florence Nightingale Museum Guidebook, 2001, p. 23

21. Hand Hygiene

22. Why Hand Hygiene? • “ Every day, 247 people die in the USA as a result of a health care-associated infection. This is equivalent to a 767 aircraft crashing every day or more than 90,000 deaths annually” • “Hand Hygiene is the primary measure to reduce health care-associated infection” Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

23. The Study Best Practices from 8 Hospitals • Cedars-Sinai Health System – California • Exempla Lutheran Medical Center – Colorado • Froedtert Hospital – Wisconsin • The Johns Hopkins Hospital – Maryland • Memorial Hermann The Woodlands – Texas • Trinity Health-St. Joseph Mercy Hospital – Michigan • Virtua-Memorial – New Jersey • Wake Forest University Baptist Medical Center – North Carolina Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

24. Each organization set up one or more hand hygiene projects for each unit or area of care. • Staff were selected to be observers – to secretly observe peers and to record hand hygiene performance. • Data from the observers were typed into the Targeted Solutions Tool (TST) to measure and track actual staff performance. • After 10 days of data collection, staff could start to see how they were doing. • The TST used three types of charts to track progress and target problem areas. Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

25. Data Collections Target Observers & Just-in-Time Coaches • After two weeks, the organization began to implement solutions that were targeted to the barriers they had identified through data collection and measurement. • Observers continued to observe and collect data and just-in-time coaches began coaching and supporting staff as they began to change behaviors and improve hand hygiene. • The entire process took between to weeks, on the organization’s resources and experience. • Continuous improvement was measured and tracked through the TST. Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

26. P Chart of Compliance This is a statistical process control chart, also called a proportion chart or P chart, which shows hand hygiene compliance rates on a typical unit. UCL – Upper control limits Each point on the blue line represents the day’s compliance. The points on the line that fall outside of the control limit lines are represented by a red dot, signifying that the process has changed. In this sample chart, the average compliance and point-to-pointlines have shifted up in the direction of improved performance. Mean – Represents the proportion or overall averagecompliance rate. The mean may be recalculated every time data are entered into the database LCL – Lower control limits. The control limits reflect variations in the compliance rates over time. Typically, 95 percent of the data falls within the control Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

27. Research Results:Identifying Causes, Targeting Solutions Causes Solutions Hand Hygiene compliance data are not collected or reported accurately or frequently __________________________________ Ineffective placement of dispensers or sinks Date provide a framework for a systematic approach for improvement Utilize a sound measurement system to determine the real score in time Scrutinize and question the data Measure the specific, high impact causes of hand hygiene failures in your facility and target solutions to those cause __________________________________ Provide easy access to hand hygiene equipment and dispensers Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

28. CausesSolutions • Safety culture does not stress hand hygiene at all levels ___________________________________ • Hands full • Make hand washing a habit-as automatic as looking both ways when you cross the street or fastening your seat belt when you get in the car • Commitment of leadership to achieve hand hygiene compliance of 90+ percent • Serve as a role model by participating proper hand hygiene • Hold everyone accountable and responsible-doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists ________________________________________ • Create of place for everything: for example, a health care worker with full hands needs a dedicated space where he can place items while washing hands Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf www.picturesof.net/pages/110112-181964-997053.html

29. More Causes • Lack of accountability and just-in-time coaching • Ineffective or insufficient education • Wearing gloves interferes with process • Perception that hand hygiene is not needed if wearing gloves • Health care workers forget • Distractions Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

30. Limitations of the Study • Since the study was very structured and targeted to specific hospitals, there were very limited limitations to the study, if any. • Key to Compliance: • Hold EVERYONE accountable and responsible • Apply progressive discipline • Commitment of leadership to achieve 90+% • Serve as a role model by practicing proper hand hygiene Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf

31. Strengths of the Study Performed by Joint Commission Center for Transforming Healthcare 8 of the top hospitals in the country were targeted All use Lean Six Sigma methodologies Used measureable successes Used targetable solutions Was sustainable

32. Cleanliness Theory Today • The principles of nursing practice by Florence Nightingale are continuously used to this very day. With the advent of technology and with it globalization comes the threats from the environment. • Global warming • Industrial noise • Air pollution • Fad diets • Vanity • Nurses of today still need to: • Maintain adequate ventilation • Promote adequate & appropriate nutrition • Maintain normal homeostatic body temperature • Observe basic hygiene • Comfort measures including environmental sanitation

33. How can the cleanliness theory be used in my practice? • Be proactive instead of reactive • Assure that there is a soap dispenser near by • Place all items in my hands down prior to entering a patient room • Wear gloves when process requires it • Be accountable and responsible • Don’t get distracted • Don’t forget

34. Critical Reflection • “Theory guides practice, but current knowledge and practice must be based on evidence..” (Kearney, 2008, p. 104). • We must use research supported evidence in our practice to help alleviate problems that impede health (Kearney, 2008, p. 104). • Gather the most current knowledge and support the research by adjusting our practice to fit it’s findings.

35. References Alligood, M.R., & Tomey, A. M. (2010). Nursing Theorists and Their Work (7th ed.). Maryland Heights, MO: Mosby Elsevier Attewell, A. (2001). Florence Nightingale Museum Guidebook, LondonSE1 7EW, UK. Chinn, P., & Kramer, M. (2008). Theory and nursing: A systematic approach. St. Louis, MO: Mosby CSL Cartoonstock. (2011). Wash Hands cartoon 9 - search ID sat0313. Retrieved from ` https://www.cartoonstock.com/directory/w/wash_hands.asp Current Nursing. (2010). Florence Nightingale 1898: Notes on Nursing What It Is, and What It Is Not. Personal Cleanliness, Chapter XI. Retrieved from http://www.nursingplanet.com/Nightingale/personal_cleanliness.html

36. References Cont. Joint Commission Center for Transforming Healthcare. (2011). Hand Hygiene: Best Practices from Hospitals. Retrieved from http://www.hpoe.org/resources-and-tools/resources/hand-hygiene-project.pdf Genius, S. J. (2006). Keeping Your Sunnyside Up. Can Fam Physician, 52(4), 422-423, 429-31. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1481673/?tool=pubmed Kearney-Nunnery, R. (2008). Advancing Your Career: Concepts of Professional Nursing (4th ed.). Philadelphia, PA.:F.A. Davis Company McDonald, L. (2001). Florence Nightingale and the early origins of evidence-based nursing. Evid Based Nurs 4, 68-69. doi:10.1136/ebn.4.3.68. Retrieved from http://ebn.bmj.com/content/4/3/68.extract

37. References Cont. Nightingale, F. (1860). Notes on Nursing: What it is and What it is not. New York, NY.: D. Appleton and Company. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#IX Nursing Theories. (2011). A companion to nursing theories and models: Nursing Theorists. Retrieved from http://currentnursing.com/nursing_theory/nursing_theorists.html Riesart, L., Eus J. W., Van Someren M., Nielen, M. A., Bernard Uitdehagg, M. J., Smit, J. H.,… Hoogendijk, W. (2011). Bright Light Treatment in Elderly Patients With Nonseasonal Major Depressive Disorder: A Randomized Placebo-Controlled Trial. Archives of General Psychiatry, 68(1),61-70. Retrieved from http://alternativemedicine.healthcommunities.com/depression/light-therapy.shtml#adjump

38. References Cont. Scribd. (2011). Nursing Theories with Applications. Retrieved from http://www.scribd.com/doc/25944745/Nursing-Theories-with-applications Theoretical Foundations of Nursing. (2008) Nightingale’s Environmental Theory. Retrieved from http://slsu-coam.blogspot.com/2008/08/nightingales-environmental-theory.html