Highlighted Research Internship Abstracts

Patricia Bieck, RN, BSN, OCN (Radiation Oncology): Does the Timing of Application of Topical Agents (Lotion, Deodorants) Affect the Severity of Radiation Skin Reaction?

The purpose of this project was to determine whether or not the rationale for avoiding the use of lotions or topical agents for four hours prior to radiation therapy is supported by research evidence. A comprehensive literature review was conducted to determine the current standards of care and to identify research findings to support or refute the practice. Interviews with clinical experts, benchmarking with international cancer centers, and consultation with professional nursing organizations also was done.

Although limited, available research refutes the current practice of avoiding the use of lotions or topical agents prior to radiation therapy. Results of benchmarking revealed wide variations in practice, but clinical experts stated that patients may use lotions or topical agents prior to radiation therapy without risk of a “bolus” effect. Nonetheless, the Oncology Nursing Society (ONS) has no published guidelines specific to this issue, and the ONS Radiation Therapy Special Interest Group acknowledges that clinical practice varies across institutions and additional research is needed. Moreover, the public health educator at the National Cancer Institute (NCI) was unable to provide specific evidence-based references for their patient education material, but stated that the materials are drawn from existing NCI sources, nursing text books, and input from clinical experts.

The limited evidence in the literature and the absence of confirmation of evidence to support NCI standards suggests that further research is warranted. As a direct result of the questions raised during this project, our facility has developed standardized skin care guidelines and has revised patient education materials.

Brenda Carlson, RN (Operating Room): Recycling and Waste Minimization in the Hospital Setting

The purpose of this evidence-based activity was to reduce waste and increase recycling efforts in the hospital setting. The project was guided by two research questions: 1) How can staff facilitate the collection of recyclable materials on the inpatient units at Strong Memorial Hospital (SMH)? and 2) What are the strategies that can be implemented to reduce the amount of waste? A comprehensive review of the literature was conducted and other organizations that serve as benchmarks for implementing a strategic plan were contacted. Sixteen key informants within SMH and the county government were interviewed about current practices and plans for future implementation of sustainability practices. In addition, internal documents pertaining to waste management and recycling processes were reviewed. Interviews, documents and field notes were examined for themes.

Several staff expressed frustration over the inability to dispose of recyclable materials in the inpatient setting. A number of initiatives were identified as bringing the hospital in line with recommendations for waste management and recycling, however. Among these were the addition of containers for returnable and recyclable bottles in several areas and plans to hire a recycling coordinator to oversee compliance with sustainability initiatives and implement educational programs for staff. Key informants expressed a commitment to improving recycling and waste minimization efforts and progress was evident. Nonetheless, additional work is needed and compliance and vigilance will be necessary as new initiatives are implemented.

Robert Hance, RN, BS (Operating Room): Best Practice/Standard for Weighing Sponges to Estimate Blood Loss During a Surgical Procedure

The purposes of this study were: 1) to determine the rationale, in the absence of published policy, for current practice among operating room (OR) nurses’ weighing of blood-soaked sponges; and (2) to develop a standardized process for weighing blood-soaked sponges. A preliminary investigation of the dry weights pre-printed on the count sheets for two different types of sponges in the OR (12” x 12” and 18” x 18”) determined that the weights were incorrect.

A search of SMH OR and hospital policies found no policy pertaining to the recommended process or method for weighing bloody sponges. Furthermore, the Standards and Recommended Practices Manual of the Association of Peri-Operative Nurses (AORN) contained no information pertaining to the weighing of blood-soaked sponges. As a result, key nursing leadership staff and anesthesia providers in the OR were interviewed about the practice of weighing bloody sponges and estimating blood loss intra-operatively. None of these key leaders was aware of the existence of any evidence-based information. After interviewing several OR nurses from various hospitals in the area and finding that nurses did not weigh blood-soaked sponges at those institutions, a determination was made that the existing practice was for anesthesia providers to estimate and record the intra-operative blood loss. A thorough review of the literature failed to identify specific citations in support of the described method for weighing sponges.

OR nursing staff were surprised to learn that no policy existed for weighing blood-soaked sponges. Even though many OR nurses reported that they know how to weigh blood-soaked sponges to estimate blood loss, it appeared that several were not doing this accurately or in a standardized way. Because of this, a draft policy was developed for accurately weighing blood-soaked sponges and for calculating estimated blood loss (EBL) during a surgical procedure. This policy has been approved by the PI/QA staff and placed in the SMH OR Policy manual.

Beth MacVittie, RN, MS (Operating Room): Pressure Ulcer Risk Assessment Tool for the OR

The purpose of this study was to develop and test a tool that could be used the day of surgery to identify surgical patients at highest risk for developing pressure ulcers as a result of the intra operative experience. A literature search was performed to identify factors that lead to pressure ulcers in surgical patients. The investigator also attended several conferences concerning the prevention and management of pressure ulcers, collaborated with area researchers interested in pressure ulcer prevention, and conducted a focus group to better understand nurses’ perceptions of the factors that contribute to ulcer development.

Findings from this investigation are being used to: 1) develop a plan for identifying higher risk patients; 2) target resources (e.g., positioning aides, mattresses, OR beds); and 3) provide educational programs to assist staff with identifying patients at risk and using evidence-based interventions to prevent pressure ulcers.

Amy Murphy, RN, BSN (Pediatric Emergency Department): Determining a Best Practice Method for Temperature-taking in a Pediatric Emergency Triage

The purpose of this study was to determine the most accurate and efficient method of temperature measurement for patients presenting to triage in the Pediatric Emergency Department (Peds ED) of SMH. Because a comprehensive review of the literature revealed scant evidence pertaining to the precision of temporal artery thermometers, a study was carried out to compare the results of temporal artery thermometer measurement to other methods of temperature measurement available for patients presenting at triage.

Two temperature measurements were taken by triage nurses in the Peds ED on a randomly selected sample of patients (N = 101) of varying ages and with varying complaints. The first measurement was taken using the temporal artery thermometer; the second was taken with a digital thermometer via oral, axillary, or rectal routes, dependent on age, and via random assignment. Each temperature, along with the age of the patient, chief complaint, and initials of the nurse were recorded in a study log. The principal investigator reviewed proper usage of the temporal artery thermometer with each triage nurse to assure that the instrument was being used according to instrument specifications.

Temperature data were analyzed for the chief complaint of fever. Pearson’s product moment correlation was used to determine relationships between axillary temperatures and temporal artery temperatures, between rectal temperatures and temporal artery temperatures, and between oral temperatures and temporal artery temperatures. Sample distributions were characterized descriptively.

The temporal artery thermometer was found to be unreliable for recording the presence of fever in patients with an admitting diagnosis of fever. Axillary and rectal temperature measurements differed significantly (p< .001) from temporal artery temperature measurements. In patients with other admitting diagnoses, positive correlations were found between axillary and temporal artery temperature measurements (r = 0.793, p< .01) and between oral and temporal artery temperature measurements (r = 0.725, p< .01). No relationship was found between rectal and temporal artery temperature measurements in these patients.

Kylena Payne, RN, BSN (8-1600): The Effects of Outside Interests on Nursing Satisfaction and Retention

The purpose of this study was to determine the relationship between work/life balance and nursing satisfaction and retention. A comprehensive review of literature was conducted along with interviews of key stakeholders (Nurse Manager of the Medical Intensive Care Unit (MICU); Coordinator of Nurse Recruitment; a senior clinical nurse specialist from Nursing Support Operations) and a survey of nurses in the MICU.

Of 200 questionnaires disseminated, 52 were returned. No significant relationships were seen between satisfaction with work and satisfaction with personal life or outside activities. A positive correlation (r= .621, p< .01) was found, however, between “recommending Nursing as a career” and “feeling proud to share with others what I do at work”.

Cathy Van Houten, RN, BSN, CWON (Wound Care): The Wound and Ostomy Nurse as Part of the Critical Care Team: Impact on Pressure Ulcer Prevention and Prevalence

The purpose of this study was to determine whether weekly skin assessment rounds and bedside education by a Certified Wound Ostomy Nurse (CWON) has a measureable effect on the incidence of hospital-acquired pressure ulcers in the intensive care unit (ICU). A pre/post intervention evaluation was conducted to compare pressure ulcer prevention outcomes prior to and following the introduction of a CWON into the critical care areas.

Findings suggest that the presence of the CWON has resulted in a greater number of patients being placed on prevention surfaces sooner and that the accuracy associated with differentiating pressure ulcers from incontinence associated dermatitis, moisture lesions and skin tears has improved. In addition, the use of pads, pillows, breathable underpads to wick away moisture and other devices to relieve heel and occipital pressure has increased. ICU prevalence rates are declining, and the size and severity of the pressure ulcers that have developed have decreased.

Joanne Weinschreider, RN, MS (Ob/Gyn Nursing): Effects of an Interdisciplinary Team Training Simulation on Care Delivery Outcome

The purpose of this study was to determine the relationship between observed key team training behaviors and care delivery outcomes during a simulated interdisciplinary shoulder dystocia. A comprehensive literature search was completed during the initial phase of this project to determine the need and the focus. An interdisciplinary shoulder dystocia simulation scenario was created. Teams composed of at least 2 resident physicians or 1 attending physician and 2 RNs from the SMH OB Service were recruited for team training. Once the simulation session was competed and teams were excused, a small group of 3 simulation faculty members reviewed a video of the team training process and scored the team. The time from delivery of head to delivery of fetus and force applied was recorded.

An evaluation of the training program will focus on: a) the communication and teamwork of each interdisciplinary team observed; and b) the outcome of the delivery (time from delivery of head to delivery of neonate, force applied and maneuvers completed). Teams will be scored according to a tool adapted from Vermont Oxford Network.