ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION ICU Nurses Beliefs and Values Towards an Innovative ICU Risk Assessment Application Jane Foley Doctor of Nursing Practice Simmons College School of Nursing and Health Sciences Boston, Massachusetts
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ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION
ICU Nurses Beliefs and Values Towards an Innovative ICU Risk Assessment Application
Jane Foley
Doctor of Nursing Practice
Simmons College
School of Nursing and Health Sciences
Boston, Massachusetts
@ 2018 Jane Foley
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION ii
Simmons College
Doctor of Nursing Practice Program
Capstone Manuscript Approval Form
Name: Jane Foley
Title of Project: ICU Nurse Beliefs and Values Toward an Innovative Risk Assessment
Application
Date: April 27, 2018
___x_____Capstone Manuscript is approved
_________Capstone Manuscript is approved with the following revisions:
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION iii
Abstract
The aim of this study was to explore the Intensive Care Unit (ICU) Resource Nurses’ beliefs and values regarding an innovative on-line risk assessment tool, ICU Intensity Index (I3), at Beth Israel Deaconess Medical Center (BIDMC). The I3 is an IT application that predicts the risk of a patient harm occurring in the ICU. With the support from the Gordon and Betty Moore Foundation the I3 application was developed in collaboration with ICU leaders at BIDMC and system engineers. A retrospective analysis of environmental factors, such as patient admission, transfers, and discharges within the ICU; staff factors, including level of nursing experience, and patient factors such as the Sequential Organ Failure Assessment Score (SOFA) and nursing intensity as measures of patient acuity, were used to understand the impact they collectively have on actual patient harms. Assessing the intensity of the ICU environment, and how it relates to the likelihood of patient harm as a way to describe risk state of the unit, is a fundamentally different approach that has potential to improve patient safety. The successful adoption and implementation of the I3 application has the potential to change how ICU nurses and physicians assess intensity and subsequent risk in the ICU. Additionally, this application has the potential to change how ICU workflow and resources are deployed. (Stevens, 2017) The ICU Resource Nurses are key stakeholders in the ICU environment and their beliefs and values towards an innovative risk assessment tool will inform the development of the implementation and dissemination plan for the I3.
Method:
Two semi structured focus group interviews were conducted with the ICU Resources Nurses. Twelve of the seventeen ICU resource nurses participated. Using open ended questions, the focus groups were designed to answer the research question “what are the ICU resource nurses’ beliefs and attitudes towards using an electronic tool to assess overall risk in the ICU environment”. The participants were given the opportunity to reflect and respond on how the functionality of the I3 application would influence their decisions in the allocation of nursing resources; the impact the tool would have on nursing workflow; and how could the tool inform strategies to mitigate the risk of patient harm. A Qualitative Analysis of the focus group transcripts was conducted.
Results:
The main thematic finding was the nurses’ descriptions of skepticism. This was reflected by expressed lack of trust in the accuracy of the tool’s ability to in capture the full range of factors that represented risk to a patient, as well as in statements of concern that the tool would result in loss of control/autonomy in staffing decisions currently made by the Resource Nurses. Additionally, there were concerns expressed related to the changing landscape of critical care and general initiative overload. Qualitative data may not be widely generalizable, but this study suggested a lack of readiness by frontline ICU Resource Nurses at BIDMC to adopt the use of an innovative risk assessment tool; and a preference to rely on their clinical experience and nursing intuition for decision making. Findings from this study may be of importance in the future planning and design of innovation and quality improvement initiatives in an ICU at an academic medical center.
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 46
Appendix C
(Rogers, Diffusion of Innovations, 2003)
The innovation process consists of a sequence of five stages, two in the initiation sub process and
three in the implementation sub process. The first two of the five stages in the innovation process,
agenda –setting and matching, together constitute initiation, defined as all the information gathering,
conceptualizing, and planning for the adoption of an innovation, led up to the decision to adopt. (Rogers,
Diffusion of Innovations, 2003)
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 47
Appendix D
Focus Group Discussion Guidelines
Topic Area Question
1. ICU Resource Nurse Role What do you see as the Resource Nurse role in the assessment of unit risk for patient harm?
In the Resource Role how are you alerted to a patient harm event?
2. “Risk” in the ICU How do you think about risk? Nurses often describe a unit as out of control, are these two things the same or different?
How do you currently know when the unit is “out of control”? What are the things that contribute to this?
3. Current Decision Aids/ Sources of Information
What tools does the ICU Resource Nurse currently rely on to make decisions? What tools do you rely on to manage situations that are out of control?
4. I3 as a Potential Decision Aid How would the I3 Dashboard impact the care of patients in the ICU?
How would the I3 Dashboard impact the patient assignment and staffing decisions for the ICU? How could the I3 Dashboard be used at the bed meeting?
What if any do you see as the major benefits of the I3 Dashboard?
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 48
5. Barriers to Implementation What challenges would you anticipate in the implementation of this innovative technology in the assessment of unit risk?
What, if any, do you see as the major concerns about using the I3 Dashboard in the ICU?
6. “Reality Check” How often would you rely on the I3
Dashboard in making decisions for the unit?
What other roles in the ICU do you think might find the I3 Dashboard of value? How do you think they could use it, different from how you might use it?
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 49
Appendix E
Focus Group Demographic Information
No person identifiers should be included
How Long Have You Been an ICU Nurse ____________________________________________?
How Long Have You Been an ICU Resource Nurse at BIDMC ___________________________?
Have You Received an Overview of The ICU Intensity Index Application (I3)? Y____N____
Have You Had the Opportunity to Monitor the Functionality of the I3? Y_____N______
If Yes How Much Time Have You Spent on the I3 Application
10-20 minutes ______
20-30 minutes_______
1hr – 2hrs ___________
More than 2 hrs. ________
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 50
Appendix F
ICU Resource Nurses Beliefs and Values Towards a Risk Assessment Application, ICU Intensity Index (I3): A Focus Group Study
Study Information Summary
Q: What is the purpose of this research study? A: The main purpose of this study is to understand the beliefs and values of ICU Resource Nurses towards an innovative ICU risk assessment application, I3. The beliefs and values of the ICU resource nurses will inform the development of the implementation phase of the I3 application.
Q: Who is conducting this research study? A: The researchers include: Jane Foley, RN, BSN, MHA, Susan Desanto-Madeya RN, PhD
Q: Who will be taking part in this research study? A: Approximately 12-16 ICU Resource Nurses at Beth Israel Deaconess Medical Center will participate in the study. We plan on conducting 2 focus groups with 6-8 Resource Nurses in each group.
Q: What will happen if I am interested in taking part in this research study? A: If you agree to take part in the study you will participate in a group discussion that will last between 45-60 minutes. Prior to the discussion you will receive a basic overview of the I3
application and how it interacts with both ICU environmental and patient data. We will ask you to provide some basic information about yourself and your experience as a Resource Nurse and overall nursing experience. We will ask the group a series of questions about your role as a Resource Nurse, how you assess for risk in your unit, and tools you use to make decisions. Additionally, we will ask what you see as the risk and benefits of implementing the I3 dashboard as a risk assessment application.
Q: What are the risks to taking part in this study? A: Generally, there is no risk to taking part in this study, there is no intent to evaluate the Resource Nurse role or the difference in how participants function in the role, no answer is wrong. The discussion groups will be facilitated by a non-bias RN whom you have no reporting relationship with. All of the information shared is to inform themes of benefits and challenges that may exist in the implementation of innovative technology. You may refuse to answer any of the questions or even decide to leave the study. We will audio record the sessions but then we will transcribe the recordings without recording your name. We will then destroy the audio recordings.
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 51
Q: What are the benefits to taking part in this study? A: There is no direct individual benefit to you from being in this study. However, in the Resource Nurse role you have direct influence on the culture and staff in the ICUs. The knowledge gained from your feedback, along with beliefs and values in the I3, will inform a successful implementation plan throughout all the ICUs.
Q: Will it cost me anything to take part in this research study? A: No, it will not cost you anything to be part of this study, except for your time, refreshments will be severed.
Q: What if I decide not to take part in this research study? A: Participation in this study is voluntary. You have the right to decide not to take part in the study. You will not be penalized if you decide that you do not want to participate in the study. We will not share your decision to participate or to not participate with anyone.
Q: Whom should I talk to or call if I have questions about this study? A: If you have any questions about this research, you should contact Jane Foley at 617-632-7176 or email [email protected]. I will follow up via email to see if you would like to participate. If you do not want to be contacted, please let me know and I will not contact you about the study. If you have questions about the study, or about your rights as a research subject and you wish to speak with someone independent of the research team, you may contact the Beth Israel Deaconess Human Subject Protection Office at 617-667-0469
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 52
Appendix G
ICU Resource Nurses Beliefs and Values towards Risk Assessment Application
Focus Group Categories Notable Quotes
Lack of trust in I3 Tool accuracy and validity of current state
" But there's really nothing to do by developing a tool that already tells me what I already know unless we're going to do something about that, I don't see it a s a huge improvement" "I just think there's too much potential for error when you run all these things together" "I think that's going to be problematic if it isn't able to capture what's really happening"
Assumption that gut, experience & intuition of ICU Nurse is better than an electronic tool
"So even though you don't use the word risk we're always taking the temperature of the unit, how's everyone doing" "All of these situation are very well known, so I don't know what the information being in a program format is going to change anything" "You use your experience and your instinct to know that a patient is in a certain state and they may not always be, we have some nurses who are afraid to say they need help" " A gut feeling, like you just know something bad is going to happen" "No system of pulling information is going to give you that judgement, the human judgement piece which I think should be a part of this"
Inconsistency in escalation process for needed resources (staff)
"So, when you are in trouble you can put out a call and say we are drowning but it's not typically responded to, there's no extra airs of hands around"
Lack of trust in standard approach to acuity assessment, unit specific & supervisors
"Supervisors only look at the numbers" "I think what every unit calls one-to- one might be different" "ED admit GI bleed, happens many times and it's all hands on deck and there's no way of staffing that up" " We look ahead at what is the acuity then it doesn't always work out""the ACS they don't come and spend time in our unit to know what's going on"
Perception that electronic documentation is not timely and therefore not reflective of current state of the ICU.
"Concern about the accuracy of the acuity tool all computer generated, no input from a human being saying what else might be going on" "Difficult for the documentation to show the accurate levels on the unit" "There's not a lot of time to be documenting everything" "So that patient might take up a lot of a nurse's time, but they're not on CRT and they're not traveling MRI and they're not on pressers" "Yah, but you can't leave the room, there's no place that you can document Code Purple in MetaVision""Am I going to spend the extra time with the patient doing patient care or charting?""You know if you are having a crazy day you're not going to think to check that box off that I went to CAT Scan or Angio or MRI""Does it kind of reflect rally what the day is like in the unit versus what is just being pulled"
Concern that the unmeasurable elements of the environment will not be captured (travel time with patient, family social support)
"There's still things that aren't going to be captured"
Hopelessness that the tool will not provide the needed value of additional resources, staffing
" So, it's nice to have a risk assessment tool so it is Red, what are we doing about that?" "There is no flex, there's no flexibility""Maybe it will help with the supervisors, I just honestly don't see them coming around that often anyway" "So no matter what this tool says it's not going to change anything, if there aren't the resources to address what the tool is indicating""It would help if you have the nurses to give us, other than that""I think it will hurt us and work against us, then it will create Riskier States."
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 53
Risk is identified at the specific unit level, not overall community of ICU
"Help with traveling, I think having someone that can be pulled that they can identify more risky states then it could be useful"" And then people don't feel like they want to help each other out they don't feel like there's any reciprocity"" Finard 4 in itself every day makes it a Risky State, if something happens you don't get people there as quickly as you necessarily would like them there"
Normalization of risk as acceptable "Everything is usually a perfect storm" "This is what it's going to be, I don't honestly think of it as risk, I just think it's just craziness." " I don't think of it as risk, just norm"
Current changes in the overall ICU environment
" I don't know if this has anything to do with the question, but I think when you have two patients it is busier than it has ever been" "You can't even take 5 minutes" " you have to be extremely organized" "We're not all super human, then you're like you've got to do this, do all these trips by 5 o'clock and that is risky" "It seems like every week or month there’s constantly new things, new initiatives starting, new things to document, new equipment, there's more and more." "Even from when I started nine years ago it is so different" " There's so much more to do now" "The big CAUTI-FOLEY initiatives, when a patient doesn't have a Foley, that takes more time" "Early mobility is a huge one, plus we're getting patients into a chair" "These are things that take more time, but their staffing numbers have not increased" "It seems like more and more and more there's all these new initiatives" "Everything's changing and it is more and more for nurses to do, I now when you have a two patient assignment, I mean you go , go ,go, you have to take a report on two patients, read up on your 2 patients and then get going" "We have huddles in the morning, we never used to have a huddle, a morning huddle with physical therapy" " All these things add on to our day, but nothing's been eliminated" " More with less" "It's not like they're increasing staffing numbers because now you're supposed to be getting your patient out of bed three times a day even though they're on the vent"" They're less sedated so they're on the call light"" It's a lot riskier, you can miss something, you know that"" And they were completely sedated so you didn't have to worry""Those were the good old days right?"" More good for the patient but a higher risky state"" Yeah you didn't have to worry about them pulling out their tube, everybody had a Foley, the second the tube went in, they got a Foley, that's just how it was it's much different now with all the new research and the different things going on" "Don't know if it is good or bad but sometimes newer staff come from the floor are used to having a four-five-six patient assignments, but they do better with the two patient because they're used to that"
Interchangeable perception of safety and risk
"I would say risk is potential harm" "Just new terminology that you want us to start thinking about" "Many things happening at one time for the amount of people you have to manage that situation"
Identified their own level of anxiety and stress / not patient level of safety or risk
"Rounds take so long so then all the traveling takes place in the afternoon 5-6 o'clock that is when people try and get things wrapped up to hand over" "All the line placements take place in the afternoon""We spend so much time just figuring out staffing and covering sick calls, acuity wise for what staff you have on""No matter if we're in the red I have my own problems""I can't be looking at the dashboard when I'm trying to put out all the fires in my unit, I'm not going to have time to""It would be nice if it was designed and it worked to help us, it's not going to be nice if it hurts us and sort of goes against what we say and what we know to be true"
Need for I3 tool validation by ICU resource nurse in real time
"There should validated by a resource nurse somewhere saying last 10 hours or 12 hours predicted to be in this state, it should have some sort of validation from
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 54
somebody in the unit""Hopefully it’s going to reflect what's going on in the unit and how we see it"
Resource Nurse identified components of risk
"Two people off the unit for a good chunk of the day really affects ability to admit patients - it really does put you in a bad place" "Because you're looking at staffing, you're not out on the unit looking at risky states, because you're actually looking at staffing level" "And it also depends on the age of the staff, like new staff it can be very chaotic whereas if you have older staff in that same situation????" "And in that out of controlness people are at risk" "Resident on the night get pummeled with five, seven admissions in a night that is unsafe" "We have to keep an eye on the residents too" "The fact that you have a border in another unit, that puts them at risk. It puts everybody at risk because you don't know if they're good or bad" "I think the unit can be very, very quiet and risky for patients there" " It's usually when it's quiet because people slow down, they're not in that state as when its's busy"" People are runny around like crazy, nobody sitting down, everyone's busy""The alarms""Traveling" "I think with all the initiatives that they want us to do, with all the added work and no more extra staff, I think that equals risk right there"
Methods Resource Nurse uses to gather data
"See it, hear it, talk about it" "Someone will let me know" "Just a constant upload of information about what's going on in the unit" "We know what the assignments are, who's in what room, what's going on in room, we don't have any written tools, but we do have an equation where we say well, we have --- in my unit""We don't follow tools, I think it's just getting a feel for the unit""What helps me is actually going to each room""You instinctively know, this person is going to be busy""There is no tool, it was passed down by being trained as a resource nurse or years of experience that if somebody meets certain criteria then that's who go 1 to 1"
Optimism in an ideal state "So, does this help level the playing field for staffing" "In an ideal world supervisors would look at this information""I think if it works well it might help us get more staffing""I think if we have a tool that actually works and shows, yes, we are at a very Risky State right now, it might give us extra time""What would be perfect is if the ACS said we can see from this that you are very busy, we're going to give you another nurse for the night shift""And I feel like I'm never going to prevent risky states, but if it's used well, you 're in the red, you need help, there's going to be some kind of help provided for you at that time"
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 55
Appendix H
Themes and Definitions
Theme Description Notable Quotes in that theme
Lack of trust in the accuracy of the tool and in the ability of the tool to capture the full range of factors influencing the risk/intensity level of the ICU.
An electronic risk assessment tool cannot reliably capture the real time activities of an ICU.
" But there's really nothing to do by developing a tool that already tells me what I already know unless we're going to do something about that, I don't see it a s a huge improvement" "I just think there's too much potential for error when you run all these things together"
"I think that's going to be problematic if it isn't able to capture what's really happening"
"Concern about the accuracy of the acuity tool all computer generated, no input from a human being saying what else might be going on"
"Difficult for the documentation to show the accurate levels on the unit"
"There's not a lot of time to be documenting everything"
"You know if you are having a crazy day you're not going to think to check that box off that I went to CAT Scan or Angio or MRI"
Clinical experience, and nursing intuition is more reliable than electronically pulled data
Experienced ICU Resource Nurses feel that they are able to rely on their past experiences to make assessment of potential risk in the ICU more accurately than an electronic tool.
"All of these situation are very well known, so I don't know what the information being in a program format is going to change anything"
"You use your experience and your instinct to know that a patient is in a certain state and they may not always be, we have some nurses who are afraid to say they need help"
" A gut feeling, like you just know something bad is going to happen"
"No system of pulling information is going to give you that judgement, the human judgement piece which I think should be a part of this"
Loss of control/autonomy of staffing decisions made by the resource nurse.
The solution to increased risk in an ICU is to increase the number of ICU nurses. Unless an acuity tool can support the justification for additional nursing staff the resource nurses do not see a lot of value in using the tool. Staffing resources are needed to mitigate risk in the ICU environment.
" So, it's nice to have a risk assessment tool so it is Red, what are we doing about that?" "There is no flex, there's no flexibility" "So, no matter what this tool says it's not going to change anything, if there aren't the resources to address what the tool is indicating"
"It would help if you have the nurses to give us, other than that"
"I think it will hurt us and work against us, and then it
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 56
will create Riskier States." Changing landscape of critical care environment and initiative overload.
The ICU nurses are experiencing a changed ICU environment. Increasing quality improvement initiatives have increased the workload for the nurse at the bedside. The improvement initiatives are seen as just more work for the bedside nurse i.e. (early mobility, decreased sedation for pt, decreasing catheter associated infections)
"It seems like every week or month there’s constantly new things, new initiatives starting, new things to document, new equipment, there's more and more."
"The big CAUTI-FOLEY initiatives, when a patient doesn't have a Foley, that takes more time"
"Early mobility is a huge one, plus we're getting patients into a chair"
"It seems like more and more and more there's all these new initiatives"
"Everything's changing, and it is more and more for nurses to do, now”
"We have huddles in the morning, we never used to have a huddle, a morning huddle with physical therapy"
" All these things add on to our day, but nothing's been eliminated"
"It's not like they're increasing staffing numbers because now you're supposed to be getting your patient out of bed three times a day even though they're on the vent"
" They're less sedated so they're on the call light"
" And they were completely sedated so you didn't have to worry"
"Those were the good old days, right?"
" More good for the patient but a higher risky state"
" Yeah you didn't have to worry about them pulling out their tube, everybody had a Foley, the second the tube went in, they got a Foley, that's just how it was it's much different now with all the new research and the different things going on"
Risk in an ICU is accepted as a normal work environment.
ICU nurses have normalized the burden of risk in an ICU as an expected condition.
"Everything is usually a perfect storm"
"This is what it's going to be, I don't honestly think of it as risk, I just think it's just craziness." " I don't think of it as risk, just norm"
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 57
Appendix I
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 58
ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 59
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