CAPSTONE)) -...
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CAPSTONE Quinn Crosta, MN, RN
University of Washington March 11, 2014
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NMETH 801 COURSE OBJECTIVES
1. Appreciate and successfully engage in collaborative partnership building with clinicians, consumers, faculty and/or fellow students. 2. Demonstrates a scientific curiosity and critique stance towards specialized practice. 3. Value and adhere to ethical and human subject guidelines. 4. Design and implement a scholarly project that entails addressing a question about some element of translating evidence to practice. 5. Analyze results and its implications for future clinical research and practice at agency and at the local, regional and/or national level. 6. Disseminate results to appropriate audiences within the agency and whenever possible outside the agency at the local, regional and national level.
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OVERVIEW
• Background
• Purpose
• Methods & Outcomes • Parent interview • Interface • Introductory education • Super-user training
• Lessons learned
• Implications for future practice
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BACKGROUND
Adverse Safety Event
Complex pain
assessments
Lack of Specialized
Measure
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r-‐FLACC
• Revised- Face, Legs, Activity, Cries & Consolability Scale (r-FLACC) • Additional pain behaviors (i.e. spacticity,
head-banging) • Parent report
• Valid and reliable pain measure for
hospitalized children with cognitive impairment (Malvia et al., 2006)
• Evidence suggests that the r-FLACC has
greater clinical utility compared to other pain measures (Voepel-Lewis et al., 2008; Chen-Lim et al., 2012)
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PURPOSE
• Implement the r-FLACC at SCH improve pain intensity assessments in children with CI who are unable to self-report
• Specific goals • Electronic interface for bedside use and charting • Introductory education • Training for super-users
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PARENT INTERVIEW
• Parent was an active member of Family Advisory Council and the mother of a child with severe cognitive impairment
• Feedback was incorporated into r-FLACC interface design and nurse education
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THE IN
TERFACE -‐ iV
iew
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POW
ER FORM
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TEACHING METHODS
Me
Teaching RN
RN RN RN
Teaching RN
RN RN RN
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POWERPOINT DEVELOPMENT
Introductory PowerPoint Parent
Teaching RNs
DNP Student
Committee Members
(Lisa Peters)
Best Evidence (Chen-Lim et
al., 2012)
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CHALLENGES
• Learner fatigue • End of a 4-hour training
session • Efforts made to re-focus
attention
• 20-minute time limit • Limited content • Preserved essential
teaching elements (flowchart)
• Slide design
“Like an optical illusion, pain behaviors in children with DD might not be easy to recognize.”
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Should this child’s pain intensity be assessed with the r-FLACC?
• 4 year-old with severe autism, non-verbal. Family speaks Spanish only.
• Yes. They key is that this child with DD cannot self-report pain intensity. Note: an interpreter is needed to individualize.
Pain intensity assessment indicated.
Is the child able to self-report pain intensity?
r-FLACC
Assess pain intensity with developmental age
appropriate standard pain tool.
Ø > 7 yrs: 0-10 scale Ø 4-6 yrs: Faces Ø 1-3 yrs: FLACC Ø 0-12 mos: NPASS Ø ICU pt., sedated: ICU
Comfort Scale
No Yes
No Yes
Is the child typically
developing?
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SUPER-‐USER TRAINING
• Goal to sustain appropriate use of the r-FLACC long-term
• Medical Unit Practice Council nurses • These nurses often cared for patients with CI • Council committed to improving patient care
• Two teaching sessions at Practice Council meetings
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SESSION #1
• Needs Assessment Questionnaire • Low response rate (n=3)
• In-depth teaching session • Case-study & role playing • Q&A; discussion encouraged
• Nurse-identification of barriers and solutions
• Teaching evaluation • “Outstanding performance” • Positive comments
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SESSION #2
• One month after the r-FLACC went “live”
• Objectives • Observe the super-user nurses using the r-FLACC at the
bedside • Observe super-user nurses teaching (peer coaching)
bedside nurses
• Created a peer coaching exercise outline and handout
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PEER COACHIN
G
• A colleague-to-colleague discussion, observation and reflection of practice
• Direct peer feedback most effective (Chen-
Lim et al., 2012)
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OBSERVATIONS
• Observations • r-FLACC assessments in 2 children • Individualization of the r-FLACC with a parent • Super users teaching 2 bedside nurses
• Strengths • Super users appropriately identified patients for r-FLACC
assessment • Individualized the r-FLACC when possible
• Areas for Improvement
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LESSONS LEARNED
• Flexibility is essential • Change in project timeline • Cooperative effort of many people with additional
responsibilities • Time constraints – “make the most of what you have”
• New practice requires critical thinking & creative solutions • Selecting terminology “developmental disability” • Minimum age for the r-FLACC
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IMPLICATIONS FOR PRACTICE
• Implementing the r-FLACC improved patient care • Provided method for improved pain
intensity assessments • Increased nurse knowledge • Encouraged partnership with parents
• Potential for improving patient outcomes… • Better pain management • Safer care • Increased family satisfaction
• Possible ripple effect to other children’s hospitals
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ACKNOWLDEGMENTS
• Dr. Teresa Ward, PhD, RN
• Lisa Peters, MN, RN
• Dr. Amy Walker, PhD, RN
• My husband Nic
• My family
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REFERENCES
Chen-Lim, M. L., Zarnowsky, C., Green, R., Schaffer, S., Holtzer, B. & Ely, Elizabeth. (2012). Optimizing the assessment of pain in children who are cognitively impaired through the quality improvement process. J Pediatric Nursing. Advanced online publication. doi:10.1016/j.pedn.2012.03.023
Malvia, S., Voepel-Lewis, T., Burke, C., Merkel, S. & Tait, A. R. (2006). The revised FLACC observational pain tool: Improved reliability and validity for pain assessment in children with cognitive impairment. Pediatric Anesthesia, 16, 258-265. doi:10.1111/j.1460- 9592.2005.01773.x
Voepel-Lewis, T., Malviya, S., Tait, A. R., Merkel, S., Foster, R. & Krane, E. (2008). A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Anesth Analg, 106(1), 72-78. doi: 10.1213/01.ane.0000287680.21212.d0