Susan E. Shapiro

Impact of California Mandated Acute Care Hospital Nurse Staffing Ratios: A Literature Synthesis:

California is the first state to enact legislation mandating minimum nurse-to-patient ratios at all times in acute care hospitals. This synthesis examines 12 studies of the impact of California’s ratios on patient care cost, quality, and outcomes in acute care hospitals. A key finding from this synthesis is that the implementation of minimum nurse-to-patient ratios reduced the number of patients per licensed nurse and increased the number of worked nursing hours per patient day in hospitals. Another finding is that there were no significant impacts of these improved staffing measures on measures of nursing quality and patient safety indicators across hospitals. A critical observation may be that adverse outcomes did not increase despite the increasing patient severity reflected in case mix index. We cautiously posit that this finding may actually suggest an impact of ratios in preventing adverse events in the presence of increased patient risk.

Guidelines for Developing and Testing Clinical Decision Rules

Clinical decision rules (CDRs) are decision support tools that synthesize evidence for use in bedside practice. They differ from other decision support tools in the methodological rigor with which they are developed. This article describes the important considerations in developing a CDR, including identifying the need for the rule, carefully defining the outcome variable, identifying and selecting the possible predictor variables, and guidelines for initial testing of the CDR. The process of developing and testing CDRs is best undertaken by teams of researchers, with clinical nurses providing important input in both the development and testing. Its important that clinical nurses understand both the contributions of CDRs and their inherent limitations, as appropriate use of well-developed, well-validated CDRs will become more and more a necessity in evidence-based nursing.

Clinical decision rules as tools for evidence-based nursing.

Nursing practice is fraught with uncertainty and our patients do not always respond predictably to our interventions. Properly developed and tested Clinical Decision Rules (CDRs), a special type of decision support tool, help organize research evidence into standardized patient assessments and treatments, thereby increasing the probability of attaining the desired outcome and reducing uncertainty in practice. The purpose of this article is to examine CDRs as one kind of decision support tool that can be used to facilitate nursing decision making and evidence-based practice (EBP). CDRs differ from both treatment algorithms and clinical pathways in the ways they are developed and in their scope of applicability. CDRs are developed using strict methodological standards, with the goal that they function well when used by a variety of care providers, with various patient populations, and in different patient care settings.

Intimate partner violence, depression, and substance abuse in women presenting to emergency departments for care

The Research to Practice column is intended to elevate the research critique skills of the advanced practice nurse and to assist with the translation of research into practice. For each column, a topic and a particular research study are selected. The stage is set with a case presentation. The research paper is then reviewed and critiqued, and finally, the implications for translation into practice are discussed with particular attention to the case study. In this column, we address the topics of intimate partner violence and substance abuse, among African American women by presenting the following study: Hankin, A., Smith, L. S., Daugherty, J., & Houry, D. (2010). Correlation between intimate partner violence victimization and risk of substance abuse and depression among African American women in an urban emergency department. Western Journal of Emergency Medicine, 11(3), 252–256.

Evaluating Clinical Decision Rules

Clinical decision rules (CDRs) are decision support tools that synthesize evidence into bedside tools for practice. Before adopting CDRs into practice, nurses must be assured that there is sufficient evidence in the literature that the rule performs as expected, can do so in a variety of settings (especially in settings similar to one’s own), and that using it will likely result in improved patient outcomes at no additional cost (or conversely, that it will lower costs with no adverse effect on clinical outcomes). This article provides a framework for clinical nurses to evaluate CDRs. The framework focuses on the processes used to establish the external validity of the rule, and the evidence that using the rule results in improved patient or systems outcomes, including cost-effectiveness. The Braden Scale is used as an example and is evaluated using the framework described.

A Pragmatic Descriptive Study of Rewarming the Newborn After the First Bath

OBJECTIVES To evaluate two methods of rewarming newborns after the first bath: radiant rewarming and skin-to-skin maternal newborn contact. DESIGN A nonrandomized clinical trial in which mothers chose the rewarming method, with 200 participants in the skin-to-skin rewarming group (experimental condition), and 200 in the radiant rewarming group (control). SETTING A teaching hospital in the Southeast United States. PARTICIPANTS Healthy, term infants after vaginal delivery. METHODS Newborn temperatures were taken immediately prior to the bath (T1), and 30 minutes (T2) and 60 minutes (T3) after the bath. Descriptive statistics and t tests were used to determine differences between groups and between time points. Logistic regression was employed to assess risk factors for newborns with temperatures less than 36.4°C 30 minutes after the bath. RESULTS Because 96 of the first 100 mothers chose skin-to-skin rewarming, we concluded the study early and analyzed the data. Of the 96 mothers who chose skin-to-skin, 91 infants were successfully rewarmed and five required rescue rewarming under the radiant warmer. Careful review of newborns requiring rescuing showed inadequate skin-to-skin contact or removal of the protective covering. In this sample, African American mothers were significantly younger, had smaller newborns, and their newborns had lower temperatures than non-African American newborns. CONCLUSIONS Given a choice, mothers overwhelmingly preferred skin-to-skin rewarming. Newborns can safely rewarm skin-to-skin if staff pay special attention to how they are positioning the newborn and recheck mother and newborn frequently. The unexpected finding of racial differences in maternal and newborn characteristics will require further investigation.

Enhancing care of older adults in the emergency department.

The findings from a recent comprehensive systematic review, in combination with a case study, are used to illustrate the importance of translational research to inform advanced practice nursing. The review article discussed in this column is a comprehensive systematic review of age-friendly nursing interventions in the management of older persons in the emergency department (ED). Two themes were synthesized from the research and texts: (1) the ED can be a foreign and challenging environment for older patients, and (2) older ED patients need specialized care to meet their complex physical and psychosocial needs. At the same time, these authors acknowledged that much more high-quality research is needed in this field. Comments by a certified geriatric nurse practitioner elaborate on these findings and provide practical suggestions for the ED advanced practice registered nurse.

Evidence-Based Practice for Advanced Practice Emergency Nurses, Part III: Planning, Implementing, and Evaluating an Evidence-Based Small Test of Change

In this article, we describe the steps involved in implementing an evidence-based practice change in an emergency department. Using the hypothetical case of changing from a 3-tier to a 5-tier triage system, we present an overview of change theory, microsystem analysis, and rapid cycle change. We then provide practical as well as theoretical suggestions for planning, implementing, and evaluating an evidence-based practice change. We also provide practical tools for conducting a gap analysis and creating a project plan that advanced practice emergency nurses will find useful as they take on this leadership role in their department.

The intentional development of nurses as leaders: a proposed framework.

In their 2010 report on The Future of Nursing, the Institute of Medicine called for nurses to be prepared to lead in all areas of healthcare. However, the nursing profession lacks consensus on a framework to guide the development of nurses as leaders and has yet to define essential leader competencies. This article reviews the Army’s intentional, sequential, and progressive leader development program that is grounded in essential leader competencies. The applicability of this model to nursing is discussed, and examples of how it could be applied are highlighted. This article proposes the use of the military framework as a successful model for the intentional development of nurses as leaders to meet the triple aims of better care for patients, better health for populations, and reduced costs of care through more efficient use of resources.

Diagnosing and treating mild traumatic brain injury in children.

Review of recent evidence with translation to practice for the advanced practice nurse role is presented using a case study format for “Mild Traumatic Brain Injury in Children.” This “short review” describes the state of the science regarding diagnosis and treatment of mild traumatic brain injury in children, demonstrating multiple challenges to synthesizing existing research into practice guidelines. Implications of this lack of clear research evidence on advanced practice nursing are discussed along with suggestions for using alternative sources of evidence.