The Use of Innovative Educational Strategies to Increase Knowledge and Change Attitudes Regarding Children s Pain Marti Michel, MSN, RN, PCNS-BC, CPNP Kathy Haughan, MSN, RN, NE-BC Roberta Szumski, MSN, RN-BC 10/1/2013 1 Conflicts of Interest Disclosure Authors Conflicts of Interest: M. Michel no conflict K. Haughan no conflict R. Szumski no conflict 10/1/2013 2 Indiana University Health Indiana University Health is Indiana s most comprehensive healthcare system. A unique partnership with Indiana University School of Medicine, one of the nation s leading medical schools, gives patients access to innovative treatments and therapies. IU Health is comprised of hospitals, physicians and allied services dedicated to providing preeminent care throughout Indiana and beyond. 10/1/2013 3 1
Riley Hospital for Children at IU Health Available beds: 295 Total admissions: 10,465 Total ambulatory visits: 258,679 Emergency medicine & trauma visits: 34,303 Indiana s only nationally ranked pediatric hospital, recognized in 10 out of 10 pediatric specialties by U.S.News & World Report for the third year in a row Magnet designation (as a system with IU Health University and Methodist hospitals) Level 1 Trauma Center designation Member of Children s Hospital Association 10/1/2013 4 The Opportunity Inconsistent pain management practice across hospital, evidenced by observations and patient/family complaints/comments Patient and family perception of pain management, evidenced by patient satisfaction results (NRC Picker) Inconsistent documentation of pain management efforts and pain assessments, evidenced in compliance audits of nursing documentation 10/1/2013 5 PNKAS Pediatric Nurses Knowledge & Attitude Survey regarding pain Modification of Ferrell and McCaffery's Nurses' Knowledge and Attitudes Survey regarding pain (NKAS) (1997) by Renee Manworren s work at Children s Medical Center in Dallas, TX reported in Pediatric Nursing, 2001 Further validation of tool with minor adjustments to tool resulted in 2002 PNKAS-- Shriners Version of tool 10/1/2013 6 2
Our History PNKAS 2004 results educational gaps identified Completed on paper forms and required manual entry of results into Excel to identify opportunities Online education developed with Indiana University School of Nursing Education developed for basic orientation of pediatric pain management by all RNs and all new RN hires in pediatric areas 10/1/2013 7 2011 PNKAS Survey Repeated Repeated PNKAS in inpatient units and emergency department to identify opportunities Survey Monkey with automated results Manual entry into Excel/database to identify trends and any changes from needs identified in 2004 RN survey fatigue in 2011 NDNQI, IU Health employee engagement, decisional involvement scale, RN Look of Assurance focus groups, etc. 10/1/2013 8 Knowledge/Attitude Gaps Seen Common results across all units regardless of patient population Confusion around assessment scales and when to use which tool Anything related to pharmacology and medications Confusion around the concepts of addiction, opioid tolerance and physiologic dependence When assessment/pain rating matched the patient, they did not know how to intervene with medications always wanted to give a low, low dose Misunderstanding of multi-modal and complementary therapies 10/1/2013 9 3
The Question Could education of pediatric RNs in a children s hospital using the techniques of simulation and unfolding case study methodology regarding optimal pain management skills address both knowledge deficits and attitudinal barriers identified in the gaps identified from the PNKAS results? 10/1/2013 10 The Intervention Roberta Szumski, MSN, RN-BC 10/1/2013 11 Background Benner and colleagues Call for Radical Transformation IOM Future of Nursing Report QSEN competencies 10/1/2013 12 4
Teaching Strategies Simulation Realistic clinical experience Live vs. videotape Debrief Unfolding case study Situated coaching Gets to the why Integrates know how and reasoning Allows for reflection on practice 10/1/2013 13 Themes Choosing pain scale/educating patient and family Assessment of pain Making a case Using multimodal therapy Managing side effects 10/1/2013 14 Choosing Pain Scale/Educating Patient Objectives: Complete a patient pain history Demonstrate effective communication with patient, family and other team members Demonstrate effective teaching of patient and/or parent 10/1/2013 15 5
Pain Assessment Objectives: Identify patient report as gold standard for pain reporting Determine when self report does not match objective clinical data Verbalize appropriate action for pain management in the scenarios provided 10/1/2013 16 Multimodal Therapy and Making a Case Objectives: Demonstrates appropriate use of SBAR to make the case for additional pain management orders Evaluates clinical findings on a post-operative patient complaining of increased pain Explore options for multimodal therapies in pain management Applies principles of Family Centered Care when communicating with patient and family 10/1/2013 17 Take Aways Highlight learning in context Collaboration among RNs at all levels of practice Accelerate development of experience-based practical knowledge Teaches interpretation vs. skill 10/1/2013 18 6
Results & Discussion Marti Michel, MSN, RN, PCNS-BC, CPNP 10/1/2013 19 Research Question Evaluate knowledge and attitudes regarding pain management and identify gaps and attitudinal barriers that warrant further education Could education of pediatric RNs in a children s hospital using the techniques of simulation and unfolding case study methodology regarding optimal pain management skills address both knowledge deficits and attitudinal barriers identified in the gaps identified from the PNKAS results? 10/1/2013 20 Methods IRB approval obtained Sampling Non-probability convenience sample of direct care RNs Completion of the survey implied consent of participants 42 item survey taking 15-20 minutes to complete Participation was voluntary Responses were anonymous without names or personal identifiers 10/1/2013 21 7
Methods - The Sample 2011 335 RNs (50.2%) Educational level 71.2% BSN 21.6% ASN 1.5% Diploma 5.7% MSN Years of experience 0-1 years 18.8% 2-3 years 21.2% 4-5 years 18.8% 6-10 years 14.3% >10 years 26.9% 2013 434 RNs (65.3%) Educational level 76.8% BSN 17.9% ASN 1.2% Diploma 4.2% MSN Years of experience 0-1 years 16.2% 2-3 years 24.6% 4-5 years 13.9% 6-10 years 19.0% >10 years 26.2% 10/1/2013 22 Intervention: Simulation & Unfolding Case Study Sim 1 April-June 2012, October, 2012 Unit-based clinical practice councils 10 offerings 122 participants Sim 2 November-December 2012 Managers to target two groups for attendance champions and nurses with need for improvement CEUs provided 13 offerings 144 participants 10/1/2013 23 Intervention: Simulation & Unfolding Case Study Unfolding case study 3 February-March, 2013 Managers to target two groups for attendance champions and nurses with need for improvement CEUs provided 13 offerings (only two held due to low attendance) 15 participants 10/1/2013 24 8
Results Mean score 2011 70.3% correct responses Top 5 incorrect responses Risks of respiratory depression Pain pharmacology Question 31 80.5% incorrect Question 9 76.5% incorrect Question 10 75.7% incorrect Question 28 75.4% incorrect Question 26 69.2% incorrect Mean score 2013 73% correct responses Top 5 incorrect responses Risks of respiratory depression Pain pharmacology Question 31 78.5% incorrect Question 9 68.9% incorrect * Question 10 74.0% incorrect Question 28 75.4% incorrect Question 26 69.2% incorrect *sd at p 0.005 10/1/2013 25 Results 25/42 questions demonstrated increase in correct responses (59.5%) Six questions demonstrated significant increase in correct response (p 0.05) Questions addressed assessment of pain, use of multimodal and complementary therapies, pharmacologic management of pain and risk of respiratory depression First 25 (T/F) questions, when analyzed collectively, demonstrated improvement at p 0.012 level of significance 10/1/2013 26 Discussion Limitations Pre-test/post-test study design with no randomization or control group Demographic data collection did not allow for individual level of analysis Unable to differentiate respondents who participated in intervention Convenience sample hinders generalizability History and maturation bias risks Participation in intervention low 10/1/2013 27 9
Summary Analysis of T/F questions demonstrate significant increase in correct responses Significant improvement on questions related to pharmacologic management, multimodal treatments and respiratory depression No trends toward improvement in case scenario questions Items address both knowledge and attitude toward pain 10/1/2013 28 Summary Online survey completion provides anonymity and convenience for respondents and researchers Small group discussion and debriefing methodology useful to correct misunderstandings and explore attitudes that limit optimal pain management Participants consistently rate intervention(s) positively but attendance was limited 10/1/2013 29 Recommendations & Implications Quality improvement research can be robust with comprehensive pre-planning Use control group or collect data to permit subset analysis Consider use of respondent generated personal identifier to permit individual level analysis Unit level analysis and discussion facilitates local action plans to drive improvement Analysis consistent with previous research using PNKAS regarding knowledge and attitude gaps 10/1/2013 30 10
Recommendations & Implications PNKAS is reliable and valid instrument to measure knowledge and attitude towards pain in pediatric nurses Simulation and use of unfolding case studies are engaging to adult learners Impacts knowledge in context of practice Challenges learners to explore attitudes which influence art of pain management 10/1/2013 31 References Altmiller, G. Summary of unfolding case study lecture. Presentation at the 2011 Quality and Safety Education for Nurses (QSEN) National forum, Milwaukee, WI, May 31-June 2, 2011. Benner, P., Sutphen, M., Leonard, V., Day, L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass. Manworren, R.C.B. Development and testing of the Pediatric Nurses Knowledge and Attitudes Survey regarding pain. Pediatric Nursing, March-April 2001, 27 (2), p 10/1/2013 32 11