Christine Hedges

Effects of nursing unit spatial layout on nursing team communication patterns, quality of care, and patient safety.

Studies investigating factors contributing to improved quality of care have found that effective team member communication is among the most critical and influential aspects in the delivery of quality care. Relatively little research has examined the role of the physical design of nursing units on communication patterns among care providers. Although the concept of decentralized unit design is intended to increase patient safety, reduce nurse fatigue, and control the noisy, chaotic, and crowded space associated with centralized nursing stations, until recently little attention has been paid to how such nursing unit designs affected communication patterns or other medical and organizational outcomes. Using a pre/post research design comparing more centralized or decentralized unit designs with a new multi-hub design, the aim of this study was to describe the relationship between the clinical spatial environment and its effect on communication patterns, nurse satisfaction, distance walked, organizational outcomes, patient safety, and patient satisfaction. Hospital institutional data indicated that patient satisfaction increased substantially. Few significant changes were found in communication patterns; no significant changes were found in nurse job satisfaction, patient falls, pressure ulcers, or organizational outcomes such as average length of stay or patient census.

Rethinking healthcare education and training.

T he movement toward evidence-based practice (EBP) has prompted both healthcare organizations and professional disciplines to challenge not only the way in which care is delivered, but also the way in which healthcare education and training is provided. According to the recommendation from the Institute of Medicine’s (IOM’s) Health Professions Education Committee, health professionals, including physicians, nurses, and pharmacists, should be educated in five core competencies: developing patientcentered care, working as interdisciplinary teams, practicing evidence-based care, focusing on quality improvement, and using information technology (IT).1 These core competencies are interrelated, with EBP as one of the central processes by which patient-centered care can be delivered. Although the patient is always at the “center of care,” EBP can be envisioned as

Not too big, not too small, but just right: the dilemma of sample size estimation.

P one of the most frequently asked questions of nurse researchers in the clinical setting is “How many subjects do I need for my study?” Our reply can be one of 3 possible responses. The first response is the scientific answer, to which we reply: “How sure of your results do you want to be?” Our second option is to perform the Goldilocks maneuver and respond: “Not too big, not too small, juuust right!” The third option (and the one used most often) is to say simply, “It depends,” and at this point, the individual probably thinks, “I’d be better off guessing.” Why is answering this question like nailing jello to the wall? As you have probably gathered by now, estimation of sample size is a complex and often puzzling task that requires both mathematical precision and practical considerations. By examining the reasons behind the 3 responses described above, you should be able to decide how to determine a reasonable and defensible sample size for your study. The scientific approach to the estimation of sample size is to use mathematical formulas to calculate the number of subjects (participants) needed in the study to detect a statistically significant finding, if indeed, there is one. This becomes important when asking the question: “How sure of your results do you want to be?” Researchers investigate a “sample” of a population in order to make inferences to the larger population, so they want to be sure, with some degree of certainty, that the sample is large enough to uncover existing statistical significance. Practically speaking, this means that the sample needs to be big enough to “capture” any effects of the intervention tested. If the “effect” of an intervention (also known as effect size) is subtle, then the sample size will need to be larger to “capture” that effect. Similarly, if the effect of an intervention is very obvious, then a smaller sample size will do. If this effect is not captured, this is known as committing a Type II error, in which the false null hypothesis was not rejected when it should have been (or, in plain English, there was an effect, but it was not found). Conversely, researchers also try to avoid accepting erroneous positive results (also known as committing a Type I error or falsely rejecting the null hypothesis), which could potentially result in implementing a practice change or treatment when it really is ineffective. This error is tied closely with the significance level (also known as the alpha level) of the study. For example, if the maximum acceptable significance level of a study is .05, AACN Advanced Critical Care

Panning for Gold: In Search of the Meta-analysis.

A the movement toward evidence-based practice (EBP) is sweeping through the corridors of health care, it is being embraced with enthusiasm as a way to render care that is based on sound, scientific foundations while taking into account local resources, clinical expertise, and individual patient preference. When institutions realize positive patient outcomes based on the use of the best evidence, it encourages them to spend the financial and human resources required to effectively perform EBP. Health care organizations are then more willing than ever to devote a proportion of scarce nursing resources to scholarly activities such as literature searches, research conduct and appraisal, and quality improvement activities in support of EBP and excellent outcomes. Furthermore, many of these health care organizations are investing in a variety of EBP databases and electronic resources such as UpToDate Online (http://www. utdol.com), The Cochrane Database of Systematic Reviews (www.cochrane. org), or EBSCO Host Nursing Reference Center (http://search.ebscohost.com), to name a few. By providing the busy practitioner with “tools of the trade,” searching the best evidence can be accomplished in an expeditious manner. Nurses who practice EBP are well aware of the steps in the process, from identifying the burning clinical question through review and appraisal of the literature and implementation of evidence-based recommendations. In fact, I have devoted several columns in this journal to these mechanisms that support the EBP process. Furthermore, nurses who practice EBP are well aware of the relative weight of randomized controlled trials in the clinical hierarchy when practicing EBP. It is no wonder, then, that those searching the literature independently or searching within a national guideline or recommendation feel a sense of having “struck gold” when they find a systematic review or metaanalysis of randomized controlled trials. But just as care is taken in appraising and reviewing a single study of any design, so must the reader proceed with the same critical eye when reading a meta-analysis.

Show me the guidelines

Y have been informed at a critical care unit staff meeting that your practice committee has approved a new protocol for a procedure you do every day. Or perhaps a different treatment is now being prescribed to manage a disease you see frequently on your unit. It is important, you are told, that everyone adopt the new practice or treatment because it is based on “the guidelines.” Does this situation sound familiar? You make a note and think, “Hmm...that’s good to know... and it surely must be the right thing to do, because it’s based on ‘the guidelines.’” And who among us would argue with “THE GUIDELINES”? What are these guidelines? Who develops guidelines? How do you obtain copies of them? How do you evaluate guidelines to make sure they are appropriate and current? And how do you incorporate guidelines into practice changes? This column addresses the topic of finding and evaluating guidelines and a future column will discuss how to incorporate guidelines through your practice committees. Guidelines, which are also called practice guidelines in database searches, are developed by teams of experts to provide recommendations to clinicians on how to best manage specific diseases and treatments. Guidelines are usually based on the results of clinical research trials. When clinical trials are not available, guidelines are based on the opinions of experts. Where do you find guidelines? If you have access to the Internet, your searching will be simplified. One of the most useful Web sites is the National Guideline Clearinghouse (NGC), which was developed by the Agency for Healthcare Research and Quality, US Department of Health and Human Services. The NGC was originally created in conjunction with the American Medical Association and the American Association of Health Plans and now includes more than 1000 guidelines from a multitude of practice disciplines. The mission of the NGC is to serve members of the healthcare community to obtain “objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.” You can access the NGC Web site at http://www.guidelines.gov/ and then type in key words pertaining to your clinical questions to find a variety of guidelines and links. For example, by typing the word sepsis in the search field on the NGC Web site, you will obtain as many as 125 guidelines related to sepsis in the adult and pediatric population from guideline developers representing various healthcare disciplines worldwide. Among the guidelines listed that may be useful to critical care nurses are guidelines for drotrecogin alfa for severe sepsis, practice parameters for hemodynamic support of sepsis in adult patients, and guidelines for the prevention of intravascular catheter–related infections. The NGC also provides links to other AACN Advanced Critical Care