Advanced Practice Nursing Research: Focus on Outcomes

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Advanced Practice Nursing Research Focus on
Outcomes

• Diane Lowden, N. MSc(A), MSCN
• Clinical Nurse Specialist
• Multiple Sclerosis Program
• McGill University Health Centre

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When you are up to your neck in alligators, it
is difficult to think about draining the
swamp Price-Hopkins, 1991
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Goals
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Alligators, Swamps, and MS

• Alligators
• Day to day workload
• Unpredictable crises
• Unrelenting symptoms
• Phone calls!
• I did my job, but

• Swamp
• The big picture of MS
• Emotional, physical and social sequelae
• Patient and family issues that arise when trying
  to cope with the disease
• Did I do the job that needed to be done?

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Road Less Traveled or a Well Worn Path?

• The creative person always walks two steps into
  the darkness. Everyone can see what is in the
  light. But the real heroes delve into the
  darkness of the unknown
• Golson, Jazz musician and composer
• The Creative Spirit

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Why Study Outcomes?
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Why Study Outcomes?

• Accountability
• Demonstrating value
• Need for hard evidence that we make a
  difference
• - Pringle Doran, 2003

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Demonstrating Impact

• In the current health care climate,
  demonstrating positive changes in patients and
  nursing behavior attributable to the CNS is not
  only desirable, it is a necessity for survival
• - Hamric, 1989

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APN as Researcher

• Interpretation and use of research
• Evaluation of practice
• Participation in collaborative research
• - Hamric, 2001

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Donabedians Model of Patient Care Evaluation

• Structure human, material resources
• Process activities or interventions
• Outcomes what want to achieve

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Advanced Practice Nurse Advisory Meeting

• Niagara-on-the-Lake
• Canada
• 2002

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Results of the Working Group on Outcomes

• Adherence
• Cost
• Symptom Resolution and Reduction
• Complication Prevention / Reduction
• Well-being
• Satisfaction with care by patient / family
• Continuity of care / care management
• Patient and family knowledge

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APN Influence on Outcomes(Interventions)

• Adherence
• Assess non-adherence risk factors, monitor
• adherence, support, educate, review
  medications.
• Cost
• Referrals (e.g. home therapy vs admission),
  control complications

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Interventions (contd)

• Symptom Resolution / Reduction
• Diagnose, prescribe, educate, modify treatment
  plan, prevent, refer, focus on functional
  outcomes
• Prevention of Complications
• Assess, identify risk factors, educate,
  compensatory strategies, health promotion
• Well-being
• Holistic approach, focus on family, impact of
  illness and not focus only on disease

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Interventions (contd)

• Patient and family satisfaction
• Questionnaires, review goals and check in on
  goal attainment, clarify needs and expectations
• Continuity of care / care management
• Referrals, follow-up visits, telephone follow-up,
  use of clinical pathways, partnerships with
  community agencies
• Patient and family knowledge
• Education distinguishes us from others

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Ways to Measure Outcomes

• Adherence
• Chart review, patient and family report, drug
  renewal sheets
• Cost
• Departmental tracking mechanisms, chart reviews
  of interventions, managed care resource
  utilization, costs to patients and families
• Symptoms Resolution and Reduction
• Scales and instruments (e.g. Fatigue Impact
  Scale, SF-36, MSQOL)

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Outcome Measures

• Prevention of Complications
• Chart review, patients report, E.R. visits
• Well-being
• E.g., Jalowiec Coping Scale, Mishel Uncertainty
  Scale, Herth Hope Index
• Satisfaction
• Patient and family satisfaction questionnaires

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Outcome Measures

• Continuity of care / care management
• Referrals, E.R. visits, admission rates, supports
  and resources number, adequacy
• Patient and family knowledge
• Pre-test and post-tests, perceived knowledge,
  performance, return demonstrations, telephone
  logs why calling, knowledge deficits

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Dissemination of Information

• Publishing
• Presenting at conferences
• Education
• Political involvement
• Advocacy

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Taming the Beast
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Nursing research is the research that gets done
after everyone elses research is
completed-Nursing Research SubgroupThe MS
Nurse Specialists Consensus CommitteeWashington,
D.C., 2000
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Roadblocks to Nursing Research

• No time to think
• No reimbursement for outcomes research
• Support of colleagues (or not)
• Supportive management climate
• Access to library, computers, protected time and
  space
• Need for databases to capture care

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Finding the Bridge Over the Alligators
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Reproduce other Studies

• Experience is a wonderful thing. It enables you
  to recognize a mistake when you make it again.
  unknown
• Many MS studies have been performed only once
• Replication studies are needed for confirming
  findings
• Larger sample size, different population
• Build on body of nursing knowledge

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Getting Support for Nursing Outcomes Research

• Collaborate with others
• Joint research with other MS colleagues
• Nursing students, summer student research grants
• Ensure balanced, homogeneous, sample population
• Find a mentor
• Hospital or University faculty to help with
  research question, design, statistical analysis
• Academic nurses have research training
  resources
• Take advantage of funding sources IOMSN

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