What drives YOUR practice?

[CraigB-RN, MSN, RN]

A couple of recent threads here have really brought to my attention that much of our pracitce isn't based on any sound evidence. We practice out of fear, or tradition, or even misinformation. We do intial, 90 min and 6 hour cardiac panels on 20 yo's with no risk factors and reproducable chest pain for example. Now in that case we as nurses may not have any say in the matter, but there are area's that we can make a difference in how care is delivered.

My question is, how do we as a proffesion, develop our practice to be based on sound evidence, tempered with the knowlege and gut feeling that is gained by experience? There is a lot of talk about Evidence Based practice and Critical Thinking, but in reading some of the recent thread, out practice is driven by dogma. I guess the first qustion should actually be, do we need to change how our proffesion advances the delivery of emergency nursing care.

[Nightcrawler, BSN, RN]

I really wish that the example that you had given was based upon something that nursing has control over. When talking about lack of evidence based practice in nursing, you have to look at interventions which are primarily nursing based. Many of the evidenced based practices out there now are based upon ICU and floor based care, because it is easier to get solid evidence to support nursing practices in those environments because the patients are there for more than a few hours, so it is easier to determine real nursing- influenced outcomes.

If you are concerned about the practice of emergency nursing, you may be best suited by looking at the practice in your ED and formulating a series of studies in which you can gather evidence toward practice change. With evidence of ED best practices, you can then publish and have a real effect on ED nursing as a whole. It is easy to look at practices and say that they are based upon dogma or fear, but harder to do the actual work to get things changed.

If you work in a hospital that has protocols in place for the delivery of care in the patient with chest pain, it may be possible to have the physician over-ride the protocols for that 20-year old patient, but with the continuing surge in meth use, ruling out that 20-year old may not always be a bad idea- reproducible pain or not.

[CraigB-RN, MSN, RN]

I guessI wan't clear about what I was asking. I wasn't asking about me and my work environment personally. I was asking more globally as a nurse. How can we as a corperate body of nurses, address this. Obviously based on discussions like the backboarding discusion, we are doing a good job of teaching "Critical Thinking" to nurses. I"m taking a side in that argument here, but a large number of responses were based on emotion, and not on a logical, thought out response to todays evidence. I"m not looking for specifics as in how we address chest pain. I"m not loking to insult anyones intelegence. The meth or crack addict who presents with tachycardia and chest pain, of course needs a full evaluation.

So again, How can WE as the corperate body called nursing, and specificly emergency nurses, best go about instilling change in how we and out peers develp and drive our practice nationaly, to provide the best care possible to our patients.

[Nightcrawler, BSN, RN]

I think that I answered your question AND commented upon the example that you gave. If you want to go about making change for the better in using evidenced based practice, you must first find the data to influence practice. The only ways to do that is to do your own research and publish, or to find research and work to institute it.

To complain that nurses practice based upon emotion, dogma and fear is one thing. To actually take steps to change that practice and make large scale change- you have to be willing to put in the work to make policy and practice changes in your setting, then take it to a larger venue.

There is no easy way to make change.

[daydreamer7130]

Does your facility have an educator, CNS or trauma coordinator? I have presented scientific evidence articles regarding trendelenburg positioning (for example) to them to break the urban myths. Then they spread the word and include the article as evidence based practice.

[ZippyGBR, BSN, RN]

I really wish that the example that you had given was based upon something that nursing has control over.

here in lays the problem the assumption that interventions sit in nice little pockets with names of professions on them ... they don't Nursing staff are often the main source of stability in an any hospital environment particularly any where with any kind of teaching responsiilities as Foundation Doctors and Specialist trainee Doctors move around developing their skills , knowledge and experience the nursing staff are the continutiy of a clinical area as much or more than the Senior Doctors

When talking about lack of evidence based practice in nursing, you have to look at interventions which are primarily nursing based. Many of the evidenced based practices out there now are based upon ICU and floor based care, because it is easier to get solid evidence to support nursing practices in those environments because the patients are there for more than a few hours, so it is easier to determine real nursing- influenced outcomes.

again puts things into nice little pockets and says other professions don't influence them ... and forgets that Nursing as well as being plenty of bricks in the healthcare wall is also the cement that holds the wall together ...

If you are concerned about the practice of emergency nursing, you may be best suited by looking at the practice in your ED and formulating a series of studies in which you can gather evidence toward practice change. With evidence of ED best practices, you can then publish and have a real effect on ED nursing as a whole. It is easy to look at practices and say that they are based upon dogma or fear, but harder to do the actual work to get things changed.

Systemic changes are needed to make impact on patient care , yes we can be good little nurses and confine changing practice onlty to what we have direct control over, but it still doesn't stop Nursing being in the firing line over inappropriate prescribing ( because someone is adminstering the drug (nurse) or filling the prescription ( pharmacy and nurses) )it doesn't stop nursing being i nthe firing line over iatrogenic harm caused by poor patient handling or sub optimal management of certain presentations ... - what happened to Nurses being the patient's advocate and back to the wall analogy being effective cement in the wall ?

there is nothing magical aobut being a Doctor, Doctors will 'misbehave' through laizness and/or intertia , it doesn't mean that it should be tolerated especially if they are also causing harm to the patient

If you work in a hospital that has protocols in place for the delivery of care in the patient with chest pain, it may be possible to have the physician over-ride the protocols for that 20-year old patient, but with the continuing surge in meth use, ruling out that 20-year old may not always be a bad idea- reproducible pain or not.

the issue is the blind adherence to 'protocols' or the treatment of a 'guideline' as a 'protocol' and also the way in which individuals and groups of professions are happy to give up independence and autonomy due to a perception that another is either prima inter pares or somehow 'above' you in status.

[ZippyGBR, BSN, RN]

To complain that nurses practice based upon emotion, dogma and fear is one thing. To actually take steps to change that practice and make large scale change- you have to be willing to put in the work to make policy and practice changes in your setting, then take it to a larger venue.

There is no easy way to make change.

however to ridicule , belittle and accuse people of mental illness and/or substance misue becasue they don't agree with the Dogma strikes me as an attitude that is best left in Stalin's USSR or Honecker's East Germany.

and to do that without an evidence bases when an evidence base and National clinicla guidelines supporting that evidence base strikes as patently ridiculous and something which is very worrying when it comes from an RN of whatever nationality.

[Nightcrawler, BSN, RN]

here in lays the problem the assumption that interventions sit in nice little pockets with names of professions on them ... they don't nursing staff are often the main source of stability in an any hospital environment particularly any where with any kind of teaching responsiilities as foundation doctors and specialist trainee doctors move around developing their skills , knowledge and experience the nursing staff are the continutiy of a clinical area as much or more than the senior doctors

again puts things into nice little pockets and says other professions don't influence them ... and forgets that nursing as well as being plenty of bricks in the healthcare wall is also the cement that holds the wall together ...

systemic changes are needed to make impact on patient care , yes we can be good little nurses and confine changing practice onlty to what we have direct control over, but it still doesn't stop nursing being in the firing line over inappropriate prescribing ( because someone is adminstering the drug (nurse) or filling the prescription ( pharmacy and nurses) )it doesn't stop nursing being i nthe firing line over iatrogenic harm caused by poor patient handling or sub optimal management of certain presentations ... - what happened to nurses being the patient's advocate and back to the wall analogy being effective cement in the wall ?

there is nothing magical aobut being a doctor, doctors will 'misbehave' through laizness and/or intertia , it doesn't mean that it should be tolerated especially if they are also causing harm to the patient

the issue is the blind adherence to 'protocols' or the treatment of a 'guideline' as a 'protocol' and also the way in which individuals and groups of professions are happy to give up independence and autonomy due to a perception that another is either prima inter pares or somehow 'above' you in status.

great. all of your comments are duly noted. but in a career that is so fractured into neat little pockets created by specialized care, how do you propose to make all of these system changes? a lot of work needs to be done to change how large systems operate, and productive change usually starts small and builds as it gains momentum. i proposed doing research on evidenced based practice, or better yet doing on site studies focused on patient outcomes. you can't have evidenced based care without the evidence.

as for protocols, they exist in the ed to give productive care to the greatest number of people. does a protocol fit appropriate care for each patient? no, but that is where the nurse becomes an advocate for their patient to get the protocol overridden and appropriate interventions ordered.

i do not believe that the doctors that i work with are above me in status- we have different careers, and different priorities in patient care. i have refused to carry out orders in the past when i felt that it would cause patient harm. the flip side of that is that i am legally incapable of writing my own orders. i can advocate for the patient, i can go all the way up the chain of command and document to my hearts content, but i cannot practice medicine.

what i can do is stay up to date in current movements in patient care, so that i am able to make educated suggestions to physicians as i urge them to do what i feel is in the patient's best interest. i can go to conferences and be active in nursing activism. i can read journals and nursing practice studies to better inform my care, and i can take new information that i find to my unit manager or hospital practice committees to make real changes. and i do all of these things.

i hear a lot of complaints about the suggestions and comments that i have made, but i have not heard one realistic suggestion of how to work to make things better. you talk about making real system changes, without any ideas on how to make the practice of nursing more autonomous, and to make those in the profession believe that they are "the glue that holds the wall together".

i don't really disagree with anything that you have said, but i would like to hear how you would change things if my ideas are so off the mark.

[Nightcrawler, BSN, RN]

however to ridicule , belittle and accuse people of mental illness and/or substance misue becasue they don't agree with the dogma strikes me as an attitude that is best left in stalin's ussr or honecker's east germany.

and to do that without an evidence bases when an evidence base and national clinicla guidelines supporting that evidence base strikes as patently ridiculous and something which is very worrying when it comes from an rn of whatever nationality.

it sounds as though you have worked with some people that are very set in their ways, and who will fight tooth and nail to prevent change. that is too bad. i sense a very long and involved story behind this post, and would love to hear it. without more details i could not begin to make suggestions.

good luck to you in your attempt to make change. we need more people that are committed to giving the best care to each patient. sometimes the only thing to do to protect your license when you are working in an environment committed to staying in the past is to move on.

[traumaRUs, MSN, APRN]

If I'm understanding correctly, the OP is asking about change in practice. My first response is you must have a change agent, be that an individual person or a set of processes like Six Sigma. Is that what you are getting at?

[ZippyGBR, BSN, RN]

it sounds as though you have worked with some people that are very set in their ways, and who will fight tooth and nail to prevent change. that is too bad. i sense a very long and involved story behind this post, and would love to hear it. without more details i could not begin to make suggestions.

good luck to you in your attempt to make change. we need more people that are committed to giving the best care to each patient. sometimes the only thing to do to protect your license when you are working in an environment committed to staying in the past is to move on.

i don't work in those environments thank god , but it appears that many of the posters in a recent thread do and actively support that and the iatrogenic harm they cause becasue of their complicity in sub optimal practice, they also consider that these practices are 'safe', 'good ' a and 'competenet' and want to 'agree to disagree' over such matters, despite the complete absence of evidence for their practice and an evidence base that supports other practice.

the suggestions made were on this board in various threads, in som cases the posts have been removed because the members that posted them were felt by the modsand admins to have crossed the boundary into insulting / libelling other members of the site.

.

[ZippyGBR, BSN, RN]

If I'm understanding correctly, the OP is asking about change in practice. My first response is you must have a change agent, be that an individual person or a set of processes like Six Sigma. Is that what you are getting at?

Craig is trying to extract an important point from a thread which turned into a bunfight from the dogma following , we can't think for ourselves , camp vs those who at least understand evidence bases, and the fact that sometimes the dogma and accepted truths will be overturned and that in some cases there is no justification for 'old' ways regardless of what others may want.