Educating Parents on Gastrostomy Devices: Achieve Success
Necessary Components to
Lisa Kirk MSN, RN, CWOCN, Anita Shelley MSN, RN, CWOCN, CNS, Maureen Battles BSN, RN, Cynthia R. Latty BSN, RN PII: DOI: Reference:
S0882-5963(14)00138-9 doi: 10.1016/j.pedn.2014.05.002 YJPDN 1150
To appear in:
Journal of Pediatric Nursing
Received date: Revised date: Accepted date:
27 January 2014 26 April 2014 9 May 2014
Please cite this article as: Kirk, L., Shelley, A., Battles, M. & Latty, C.R., Educating Parents on Gastrostomy Devices: Necessary Components to Achieve Success, Journal of Pediatric Nursing (2014), doi: 10.1016/j.pedn.2014.05.002
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ACCEPTED MANUSCRIPT Educating Parents on Gastrostomy Devices: Necessary Components to Achieve Success
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Lisa Kirk, MSN, RN, CWOCN
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Anita Shelley, MSN, RN, CWOCN, CNS Maureen Battles, BSN, RN
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Cynthia R. Latty, BSN, RN
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Riley Hospital for Children at Indiana University Health
Author Note
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Lisa Kirk, Surgery Medical Service Area, Riley Hospital for Children at Indiana University Health; Anita Shelley, Surgery Medical Service Area, Riley Hospital for Children at Indiana University Health; Maureen Battles, Nursing Administration, Riley Hospital for Children at Indiana University Health; Cynthia R. Latty, Nursing Administration, Riley Hospital for Children at Indiana University Health.
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Correspondence concerning this article should be addressed to Lisa Kirk, Wound, Ostomy and Continence Nurse, Riley Outpatient Center, Room 4390, 705 Riley Hospital Drive Indianapolis, IN 46202. Telephone: 317-944-5018; Fax: 317-948-0439 E-mail:
[email protected] Introduction
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Parents of children with various medical conditions are often faced with tough healthcare
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decisions, such as the best way to provide adequate nutrition. Failure to thrive, aspiration, intestinal malabsorption and swallowing disorders often cause children to have altered nutrition.
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Surgical intervention may be needed. One method of treatment is to place a gastrostomy device. A gastrostomy device is a flexible, polyurethane or silicone tube placed in the stomach through
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an opening in the abdominal wall. This device provides access to administer nutrition in children who are unable to eat or take in adequate nutrition orally.
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Giving up all chances of feeding their child normally can produce feelings of fear,
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frustration and anxiety. Guerriere’s (2003) study of mother’s uncertainty concerning gastrostomy device insertion in their children found many mothers experienced a sense of failure
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as a parent by accepting the gastrostomy device. If professionals empower parents to make the decision they believe to be in the best interest of their child, it will improve the quality of life for the whole family. It is imperative that families are given the most complete and accurate information about gastrostomy devices. Nurses report parents are overwhelmed with the large amount of technical information given (Todd, Van Rosendaal, Durgeon & Verhoff, 2005). Variation in practice by nurses and physicians can lead to confusion for the families which usually results in a lack of trust in their providers. Todd et al. (2005) studied nurses’ involvement in gastrostomy device placement and found they perceive their role in the decision-making process to be important.
ACCEPTED MANUSCRIPT The purpose of this project was to standardize education of gastrostomy devices to improve the nurses’ skills to prepare families for discharge and reduce their self doubt at home.
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The processes in this paper are based on the authors’ experiences with families of medically
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Background
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fragile children cared for in a large Midwestern Children’s Hospital.
Children with certain medical conditions require gastrostomy devices to maintain
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adequate nutrition, hydration and to administer medications. In most situations, the child was
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fed via a nasogastric (NG) tube, nasojejunal (NJ) tube or received Total Parenteral Nutrition (TPN) prior to the gastrostomy device placement. When it is anticipated a child will require
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long-term nutritional support, a gastrostomy device is recommended (Soscia and Friedman, 2011). Lord (2011) noted more than 245,000 gastrostomy devices are placed annually in the
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United States.
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Knowledge and confidence of nursing staff is important when teaching parents how to
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care for a gastrostomy device at home. Limited knowledge of the subject for which a nurse is responsible for teaching a parent of a medically fragile child increases the potential for inconsistent care, according to Edwards, Walsh, Courtney, Monaghan, Wilson and Young (2010). As noted by Sarro, Anthony, Magtoto and Jauceri (2010), standardizing care of devices will increase the comfort level and self-confidence of the nurse, which will in turn increase the self-confidence of the parent. Gozdzialski, Schlutow and Pittgilo (2012) claimed that non-emergent use of Emergency Departments has increased over the past 10 years. They suggested the increase is due to lack of knowledge and resources. Improved discharge teaching is one way to reduce the misuse of the
ACCEPTED MANUSCRIPT Emergency Department. Comprehensive parent education is integral to ensuring parents feel comfortable and confident enough to safely care for their child’s needs at home. A study by
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Lerret (2009) found that one of the biggest predictors of parent readiness for discharge was the
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quality of education provided by the bedside nurse.
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Sanford (2010) recommended the provision of continued training of nursing staff in order to encourage accountability and empowerment. Decreasing variance in nursing practice will in
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turn increase parent satisfaction. The current healthcare environment necessitates the
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development and utilization of better methods to educate parents to improve patient outcomes and reduce readmission rates.
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Background of the Problem
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At this Midwestern Children’s Hospital, a trend showed parents had increasing questions
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and concerns regarding gastrostomy device care. The Emergency Department (ED) also noted increased non-emergent visits related to leakage, granulation tissue or the accidental
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dislodgement of the gastrostomy device. In addition, the nursing staff verbalized confusion regarding the different devices and what to teach families due to multiple physician preferences. Three different medical services place gastrostomy devices at this Midwestern Children’s Hospital: Pediatric Surgery, Gastroenterology and Interventional Radiology. Approximately 365 children of all ages receive gastrostomy devices each year. The majority are placed by the pediatric surgery service. Seven surgeons place a variety of gastrostomy devices both surgically and percutaneously. Each physician had their own plan of care for each device placed. Manufacturers develop new products that surgeons may bring into the system at any time. All of these elements elicited staff confusion and an inability to keep up with the nuances
ACCEPTED MANUSCRIPT of these devices when teaching parents care. Follow up with parents after device placement consisted of return appointments to the outpatient clinic in 4-12 weeks, depending on physician
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preference. The Wound, Ostomy and Continence (WOC) nurses are available if parents have
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questions. The WOC nurses log the phone calls they receive. An increase in calls with questions about gastrostomy devices was noted. Over a six month time frame, the phone calls
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increased approximately 20%. The calls revealed parents were not sure what type of device their
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child had, what to do if the device came out, when to return for their follow-up appointment and
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if their child could bathe or swim.
Bedside nurses were often inconsistent when teaching parents about a new gastrostomy
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device. The education nurses received regarding gastrostomy devices appeared inadequate to help them identify the type and confidently teach parents how to care for their child’s
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gastrostomy device or what to do if it prematurely came out. A standard education plan
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regarding what to teach parents had not been developed. Additionally these children were admitted to a variety of units, resulting in some nurses who were very familiar with the devices
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and others who were not. This made it a challenge for nurses to keep current with the varying recommendations for practice. During new hire orientation, pediatric staff nurses receive a 45 minute lecture about various gastrostomy devices and how they are placed. The short lecture also includes how to troubleshoot complications that may occur with different devices, such as skin irritation and leakage. Online resources regarding the devices are available on the hospital intranet system, but many staff did not access them because they either did not have time or did not know how to easily find them.
ACCEPTED MANUSCRIPT If a patient’s gastrostomy device accidentally came out at home, the child was often brought to the Emergency Department (ED), sometimes via ambulance, because parents did not
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have the education or resources to replace it. Follow up with ED nurses revealed they were not
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comfortable identifying the various gastrostomy devices and how to best meet the needs of this
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type of patient.
Unnecessary trips to the Emergency Department for gastrostomy replacement, an
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increase in phone calls and questions at follow-up appointments and frequent consults to the
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WOC nurses brought this problem to the forefront. How could staff best standardize their approach to educating parents whose child received a gastrostomy device? What needs to
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happen to ensure these parents are able to confidently care for their child after discharge?
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Problem Identification
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Two WOC nurses and two Patient Education Coordinators formed the primary team. It was decided that one reasonable approach would be to teach the parents in a structured class.
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They began meeting to discuss content for a gastrostomy device class, which would be offered in the Family Education Center. During content development, the primary team speculated how often the class would need to be offered. Originally, the plan was to offer a class once or twice a week. They soon realized this would not be adequate to meet the needs of the families served due to some patients’ short length of stay. So the primary team investigated other options. They established clear and action-oriented goals through an AIM Statement which is a written, measurable and time-sensitive description of the accomplishments the team expects to make from its’ improvement efforts. The AIM Statement answers the question: “What are we trying to
ACCEPTED MANUSCRIPT accomplish?” (Tennessee Center for Patient Safety 2008). The AIM Statement for this process improvement project was “Caregiver(s) (and child when appropriate) will be prepared for
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continued care of the child’s gastrostomy device upon discharge. Nursing staff will have the
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Study, Act (PDSA) model to determine the best solution.
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knowledge and resources to provide this education.” Ultimately, they turned to the Plan, Do,
The PDSA Cycle is a trial-and-learning method to discover an effective and efficient
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way to change a process. The "study" part of the cycle is key to learning what change leads
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to improvement. Study compels the team to learn from the data collected, to look at effects on other parts of the system and on patients and staff, and under different conditions, such as
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different practice teams or different sites. Most importantly, the study phase is an ideal time to think through how the Chronic Disease Model helps generate new ideas and approaches to
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positive change. PDSA cycles are short and quick. Typically, they need only hours, days or
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at most, a few weeks to complete. All improvement requires making changes, but not all changes result in improvement. Therefore, the team must identify the changes that are most
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likely to result in improvement (Langley et al., 2009). Data Collection
To determine what improvements were needed, nursing staff were interviewed to assess their knowledge about gastrostomy devices and resources. The information collected was used to improve care in the hospital so IRB approval was not sought. Approximately ten staff nurses were instructed on how to conduct the interviews. They assisted the primary team. One hundred nurses from units throughout the hospital were randomly chosen to participate in face-to-face interviews over a two week period. The primary team believed that, no matter the shift or unit, it
ACCEPTED MANUSCRIPT was important all nurses had the ability to educate a parent about gastrostomy devices. Therefore, a minimum of two nurses from each unit, any shift were interviewed. Nurses were
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asked to identify seven different kinds of gastrostomy devices that were placed at this
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Midwestern Children’s Hospital. They were also asked to locate resources (staff and tools) which could aid in patient education. In addition, they were asked who was responsible to
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educate parents and what supplies should be sent home at discharge.
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The findings revealed many nurses lacked knowledge and confidence to teach parents
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about gastrostomy devices. Overall, 42% of nurses could not correctly identify the seven different gastrostomy devices and 70% did not know the resources available to them.
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Documentation audits were also conducted to check for evidence of gastrostomy device education, including learner response. The primary team obtained the names of patients who
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received a gastrostomy device during the months of May and June, 2009. A sample size of at
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least 25% of the maximum number of patients on a unit with greater than ten patients or all
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patients for units with less than or equal to ten patients was used in the audit. Thirty retrospective documentation audits were completed. The primary team reviewed the medical records to find documentation of the following:
Gastrostomy education
Learner’s response
Appropriate gastrostomy device booklet was given
What to do if the gastrostomy device fell out
ACCEPTED MANUSCRIPT In addition to the staff interviews and documentation audits, parents received a survey when they returned for a follow-up clinic visit. The survey consisted of 12 questions related to
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the education they received about their child’s gastrostomy device. Two of the questions were: 1. Did you receive information about what to do if your child’s tube or button falls out?
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2. Did you receive supplies including a replacement/emergency tube when your child was discharged?
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Twelve surveys were collected over a three month time frame.
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The Plan
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The primary team reviewed the results of the staff knowledge interviews, documentation audits and parent clinic surveys. Key stakeholders were consulted throughout the process.
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Stakeholders included: staff nurses who often cared for children with new gastrostomy devices,
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pediatric surgeons, the Clinical Service Coordinator for Pediatric General Surgery, clinical educators and case managers. These key stakeholders provided valuable input. Sullivan et al.
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(2005) say a predictor of success is ensuring that those who are affected by the change participate in its’ transformation. Based on the results and discussion with stakeholders, the primary team developed a plan. Changes the primary team wanted to accomplish:
Create a culture in which nurses understand they are responsible to provide timely, appropriate, complete gastrostomy device education.
Create gastrostomy device toolkits for staff. Determine how many each unit will need. Toolkits will include everything staff need to educate parents before discharge.
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Revise the gastrostomy patient education record as a supplement to the Pediatric Generic Patient Education Record. Educate staff about how to use the toolkit and other available resources, such as the
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gastrostomy supplemental patient education record (how to document on form). Inform staff of location of all resources.
Ensure staff know which gastrostomy device supplies are available on their units.
Identify unit champions. Hold gastrostomy device education sessions for champions so
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they will become resources for other staff.
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Develop and Revise Resources / Standardize Process
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The primary team started by revising existing resources and developing new ones. The WOC nurses consulted with the surgeons to gain consensus on standardizing gastrostomy device
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care and follow-up. In order for the nurse to provide consistent, accurate information, a grid
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outlining each surgeon’s preferences was developed (see Table 1 for the list of resources the primary team revised or developed). They then refined and standardized the education process. Two studies reviewed by the team supported the use of process standardization to improve the adoption of change. A study by McMurray, Chaboyer, Wallis and Fetherston (2009) found linking the project to standardization initiatives was one emerging theme in their study that looked at factors influencing change in two hospitals that moved from taped and verbal nursing handover to bedside handover. As well, the global body of nursing research indicates nurses are generally supportive of quality improvement initiatives, particularly those aimed at standardizing care to enhance effectiveness of patient care (Hinshaw, 2000). The primary team then created a
ACCEPTED MANUSCRIPT toolkit for nurses to use when educating parents (see Table 2 for the list of items found in each unit’s toolkit).
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Staff Education
Educating staff was a key component to improve and standardize parent education
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regarding gastrostomy devices. The primary team developed a standardized staff education
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program. Content was based on pre data results and input from key stakeholders. The Education Specialist for Pediatrics and unit clinical educators were consulted to determine methodology
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and timeline. Edwards et al. (2010) describe the success of a peer education program used to develop nurse’s knowledge and attitudes and sustain change. As part of the PDSA cycle, the
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primary team’s plan included training staff members to educate and support their peers. They first trialed the process, resources and methodology on two units before the education was rolled
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out to the remaining units. Pilot units were chosen based on quantity of patients with new
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gastrostomy devices and their length of stay.
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The first pilot was conducted on the Infant Unit, which admitted patients less than two years of age with varied medical and surgical diagnoses. This unit received the most patients with new gastrostomy devices. The primary team members conducted eight educational sessions over a two week period in February 2010. The sessions were one hour in length. Education included:
Rationale and goals for the training
Review of each gastrostomy device with opportunity for hands-on learning
Outline of the nurse’s responsibilities throughout the hospital stay of a patient who had a new gastrostomy device placed, including:
ACCEPTED MANUSCRIPT o receiving a patient from the operating room o caring for the device
o preparing parents for discharge
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o documenting the education
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replacing a gastrostomy device on a doll
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o teaching parents to care for and use the device, including a demonstration of
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o location and use of all available resources, including the gastrostomy device toolkit
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Approximately 90% of Infant Unit staff attended a session. After the education, staff immediately started using the new resources and toolkit. An evaluation tool was completed by
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staff when they utilized the new process and resources. Questions revolved around the
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resources, the amount and quality of education provided and nurses’ confidence to provide discharge education to parents. The pilot lasted one month. Eight of the 43 nurses who attended
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training completed evaluations. Those who responded shared positive feedback regarding the
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tools and instruction. Anecdotal feedback, including conversations with several staff nurses and unit shift coordinators, also indicated staff used and liked the new process and tools. Due to their high volume of patients admitted with new gastrostomy devices, the unit requested an additional toolkit to provide timely education. Two staff members asked for additional space to document on the patient education record. One nurse requested a picture of a foley catheter be added to the gastrostomy education booklet (the replacement tube used for some patients). The primary team discussed the feedback. No changes were made to the patient education record. Nurses were instructed to use the comment form (supplemental documentation form) when additional space
ACCEPTED MANUSCRIPT was needed for documentation. Pictures of a foley catheter were added to the gastrostomy education booklet. Ultimately, the Infant Unit received a second toolkit.
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Train the Trainer
The second pilot was conducted on the 4B Unit, which admitted children with complex
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medical needs. This time, a Train-the-Trainer model was used to educate staff for the pilot. The
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primary reason for the second pilot was to test the training method in anticipation it could be utilized to successfully train the remaining staff nurses (Pearce et al., 2012). With the large
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number of staff to train throughout the hospital, this methodology would be more efficient. The 4B unit clinical manager identified key staff who would become “G-Tube Experts”
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and train their peers. Members of the primary team educated the trainers to use the same training
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method as in the first pilot. Trainers were given all of the resources and tools they needed. These included a packet of information containing a script to use during education and talking
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points for each gastrostomy device. All other supplies and a toolkit were also provided. The
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primary team reviewed each resource and how to use it. Then they conducted an actual training session with the G-Tube Experts so they would know how to educate their peers. Trainers worked with their respective clinical educators and managers to develop a training schedule. A primary team member partnered with each trainer when they taught their first educational session. As with the Infant Unit, 4B staff began to use the new resources and toolkit immediately after education. Staff were asked to complete the same evaluation tool with the addition of one question which evaluated the training methodology. Despite encouragement from the primary team and unit trainers, no evaluations were completed. Anecdotal discussions
ACCEPTED MANUSCRIPT with trainers revealed positive feedback on the process, toolkit, other resources and training methodology.
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Rollout
Clinical managers were contacted to discuss the rollout plan and gain their support prior
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to educating the remaining hospital staff. Their support was important. They mandated staff
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attend an educational session. Training all nursing staff was imperative because a patient with a new gastrostomy device could be admitted to any hospital unit. Hispanic nurse educators, who
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teach Spanish-speaking parents, were also included due to the volume of Hispanic families served at this Midwestern Children’s Hospital. Thus, all needed the knowledge and resources to
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teach parents.
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Each clinical manager was asked to identify at least two staff members to help train their unit staff and become G-Tube Experts. The remaining hospital staff were educated in three
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phases. Timing was based on competing initiatives (such as other hospital or unit-based
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education) and a planned move to a new structure within the facility for several units. Example of unit rollout Week 1:
The primary team conducted training sessions for selected unit staff trainers. Toolkits were given to unit trainers during the training sessions. Each unit received one toolkit with the following exceptions: one unit received two toolkits because they received a large number of patients with new gastrostomy devices; two units shared a toolkit
ACCEPTED MANUSCRIPT because the units were in close proximity to each other and they received very few patients with new gastrostomy devices. Unit trainers partnered with their manager and educator to develop a schedule for staff
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training sessions. Weeks 2-4:
Unit training sessions were conducted. A primary team member partnered with each
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Staff began to utilize the new educational resources, toolkit and process immediately after receiving their training.
The primary team was available to answer questions or assist with issues as they arose.
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trainer during their first session. 4B trainers assisted with sessions as able.
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Fifteen months passed from the initial pilot (February 2010) until all inpatient unit staff were educated (May 2011). Four units were located in two other hospitals which were also a
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part of the hospital system. Some units took more than one month to complete the training.
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Eighteen of 19 units completed staff training as outlined. One unit used a different methodology. Six staff members from this unit were trained to be G-Tube Experts. They received the same information and instruction as all others regarding how to conduct training for their staff. Instead, they chose to place information on a tri-fold poster board along with other education. This information was reviewed during their unit education fair rather than conducting instructor-led training sessions. This method was not endorsed by the primary team. The unit’s manager and educator approved the alternative methodology. The primary team was not consulted and only discovered this through conversation with staff.
ACCEPTED MANUSCRIPT The primary team met with four ED nurses to discuss a training plan for gastrostomy education for their area. On several occasions the ED nurses voiced concerns about the current
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methodology and content. They felt their focus was different. Initial education about
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gastrostomy device care and feeding was not their responsibility. Their main responsibilities revolved around handling emergent situations and troubleshooting problems. A distinctive
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approach, which included revised resources, was developed to help staff identify and treat
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concerns such as granulation tissue, cellulitis and leakage. Instead of conducting educational sessions, these ED nurses observed the WOC team during Pediatric Surgery Clinic. Each nurse
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spent four hours with the WOC team. The nurses received hands-on education regarding each gastrostomy device. They also observed family education in the clinic setting, including
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troubleshooting tips and techniques as well as how families get needed supplies at home.
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The four ED nurses educated their peers using a different methodology. They made a
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poster with each device type and key points. They placed this poster in their report room. They also featured a “device of the week.” Staff on each shift was verbally taught how to troubleshoot
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this particular device. The select ED nurses who observed the WOC team worked in the triage area of the ED. They were the first to assess gastrostomy issues and emergent gastrostomy problems. The knowledge they gained from partnering with the WOC team was put to use in their practice. Not only did this experience change nursing practice, it also influenced how ED staff physicians managed the care of patients with gastrostomy devices Near the end of the rollout, the primary team consulted with the Education Specialist for Pediatrics and unit clinical educators to determine how to incorporate this education into the orientation of nursing staff. Additional time was not available for inclusion in the new hire
ACCEPTED MANUSCRIPT orientation lecture, so the clinical educators incorporated the training at the unit level. The
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Program Evaluation
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assigned preceptor was responsible for the instruction.
The primary team did not include a staff competency with this education rollout. Their
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AIM Statement (Nursing staff will have the knowledge and resources to provide this education.)
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lead them to measure staff knowledge rather than have staff do a skills validation.
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To determine the global effectiveness of the educational intervention, a random sampling of staff were interviewed using the same technique and questionnaire. At the time of the post
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data collection (July/August 2011), a student pursuing a Masters degree in Public Health was working with two members of the primary team. She conducted the interviews after being
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instructed on the process. One hundred and fifteen nurses were interviewed (Schowe, 2011). No
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attempt was made to interview the same staff who participated in the pre data collection. The ED nursing staff were exempt from this interview. Analysis of the data showed staff recognition
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of the gastrostomy devices did improve, even though it was not statistically significant (p > .05; mean increased from 4.19 to 4.43). Staff ability to locate the resources needed for education also improved and was statistically significant (p = 0.00; mean increased from 1.98 to 3.10). The primary team obtained the names of patients who received a new gastrostomy device between the months of January and June 2011. Thirty medical records were retrospectively reviewed for evidence of appropriate and accurate documentation. The same four items evaluated prior to implementation were examined. The results of the pre and post documentation audits were analyzed. The percentage of yes responses for each of the four questions was determined (see Table 3 for a graph of the
ACCEPTED MANUSCRIPT documentation audit questions and percentage of yes responses). Each question was then evaluated individually. Chi-square analysis was done, comparing pre to post results.
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The number of times gastrostomy parent education was documented before versus after
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the standardized training (question 1) was statistically significant in the Pearson test (χ2 = 5.455; p = 0.0196), showing there was a positive association between the use of the standardized
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gastrostomy education and the amount of parent gastrostomy education documented by the
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bedside nurse.
The amount of documentation that included the learner’s response to gastrostomy
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education between pre and post training (question 2) was also statistically significant in the Pearson test (χ2 = 6.648; p = 0.0099), showing there was a positive association between the use
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of the standardized gastrostomy education and the likeliness a bedside nurse would document
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learner response after parent gastrostomy device education. Whether parents received the correct gastrostomy device parent education booklet
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(question 3) was not statistically significant pre versus post standardized training. This suggests
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the standardized gastrostomy education had no effect on the likeliness that the correct parent education booklet would be given to parents. However, given the frequency data for chi-square analysis (χ2 = 3.270; p = 0.0705), the results would trend toward significance with an increase in sample size. Finally, the frequency with which parents received education on what to do if the device came out (question 4) was statistically significant with chi-square analysis results (χ2 = 4.267; p = 0.039). Table 3
ACCEPTED MANUSCRIPT Documentation Audit Questions: Percentage of Yes Responses 100
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90
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80 70 60
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50 40 30 10 0 Learner's response documented
Appropriate G- Information given Tube booklet on what to do if given G-Tube falls out
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Education given
Post Education
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20
Pre Education
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Parent surveys were conducted again after the educational rollout. During a child’s
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follow-up appointment for their gastrostomy device, parents were asked to complete the same 12 question survey about the education they received when their child had a new gastrostomy
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device placed. The pre survey results (n = 12) with a mean of 3.83 showed families received
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varying degrees of information. The results of the post survey (n = 16) with mean of 8.12 revealed families received more comprehensive education to care for their child at home. This particular information was not analyzed; however, based on the significant rise of the post survey mean value, a correlation can be made that standardizing education gave families what they needed to care for their child safely at home. Responses to two questions in particular were significantly different from pre survey to post survey. Prior to the educational rollout, only 55% of the parents who completed the survey knew what to do if their child’s gastrostomy device fell out. And, 45% went home without supplies to replace it. After the educational rollout, 100% of
ACCEPTED MANUSCRIPT the parents who completed the survey knew how to replace the gastrostomy device and had the supplies (emergency replacement kit) to do it.
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Discussion
The implementation of the standardized gastrostomy education was successful as the data
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results indicate. A culture was created in which nurses knew their responsibilities. They could
timely and accurate education to families.
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identify the various kinds of gastrostomy devices and locate the resources needed to provide
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The G-Tube toolkit became a valuable teaching tool. Staff quickly realized its’ importance. When a child with a new gastrostomy device was expected from the recovery room,
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the toolkit was often found in the patient’s room for timely education. Hispanic nurse educators
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(hospital-employed nurses responsible for teaching Spanish-speaking parents in preparation for
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discharge) also utilized the toolkit. This toolkit offered these parents the same opportunity for practice and skills validation. For follow-up, limited English proficient parents were given the
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Language Services Department phone number to call with questions and concerns after discharge. An interpreter could connect them with the appropriate staff member and would stay on the line to assist with communication. The Language Services Department provided services for all other interpretation needs. The bedside nurse was responsible for the education of parents who spoke a language other than Spanish. Nurses partnered with a medical interpreter to educate the parents. Due to the language barrier and need to use an interpreter, there was an increased chance for misinterpretation. Having Hispanic nurse educators, eliminated the need for a “middle man” for Spanish-speaking parents, therefore, decreasing the possibility of misunderstanding.
ACCEPTED MANUSCRIPT The WOC nurses from the primary team were not able to provide the same level of support to the four units located elsewhere in the system. However, those units rarely received
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children with newly placed gastrostomy devices. When they did, the unit clinical educators
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assisted as needed.
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Although the rollout took longer than anticipated, the methodology was effective. However, the inability to make direct comparisons pre and post implementation was a limitation
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of the evaluation. During the implementation, five units relocated to a newly completed
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structure within the hospital. Some unit staff changed in composition as units transitioned from age-based to service-based. Thus, it was not possible to compare pre and post data for those
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units.
Despite the change in composition, move to the new structure and the offsite location of
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some of the units, the educational content was consistent. However, one unit chose to use a
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different methodology to educate their staff. They displayed information on a tri-fold board,
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along with other education. Instead of holding instructor-led training sessions, each staff nurse learned independently at their annual unit education fair. When comparing their pre and post data for the nurse knowledge interviews, the mean for correct answers increased from 4.36 to 6.33. This data indicates using a different methodology may have been effective even though it was not the suggested approach of the primary team. A request to offer another training session so they could videotape and use it as an education tool was later made by this unit’s staff and clinical educator. This request to repeat the education casts doubt on the success of their methodology. Of note, this was the only unit who made such a request.
ACCEPTED MANUSCRIPT Though the number of staff interviewed was not large enough to compare most units’ specific results, the unit having the second largest number of staff participating had an even more
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significant change, pre (n = 11), post (n = 10). Their mean for correct answers increased from
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4.64 to 9.30. Although both units had an increase, these results could imply using the suggested methodology had a greater impact. Research has shown the more involved a learner is with the
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education the more the learner will remember (Dwyer, 2010). For example, if staff learned about
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this change in education through an exhibit, in two weeks they only remember 10% of what they read. However, if they watch a demonstration and participate in a discussion, they will retain 50-
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70% of what they learn. This research influenced the methodology chosen by the primary team
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(Dwyer, 2010).
Only sixteen parent surveys were collected after the rollout. Several factors contributed
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to the low numbers. Though approximately 90 gastrostomy devices were placed over three
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months, not all patients returned for the post op visit. Some may have been seen at an offsite clinic. Other patients were still hospitalized at the time the surveys were conducted. For those
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who did return to the clinic, surveys were given to the family when they entered the exam room. Some parents completed the survey immediately and returned it to the nurse. If the survey was not completed by the end of the visit, some families did not return it. Though the percentage of surveys completed was disappointing, the results were encouraging. The ED nurses acknowledged the value of knowing what education families were given regarding gastrostomy devices. They utilized a different approach to educate their peers according to the typical care they give. The knowledge gained by the ED nurses during their experience with the WOC team strengthened the collaboration between all the ED staff (nurses and physicians) in troubleshooting concerns they encountered. It also helped them understand
ACCEPTED MANUSCRIPT when and why follow up in clinic was necessary after an ED visit. The nurses have standardized their practice as well as what they communicate to families who come to the ED. The families
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are directed to the Pediatric Surgery Clinic during open clinic hours or given the phone number
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for appropriate follow-up for non-emergent care.
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Recognizing the importance of this education, new nursing staff now receive standardized gastrostomy education during orientation. Nurses receive an introduction to some
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of the content during a lecture and obtain the “hands-on” portion on the unit. As noted by
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Sanford (2010), in order to encourage staff accountability and empowerment, continued training is needed. The primary team is challenged to keep all nurses updated about new products,
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procedures and other changes. Nurses must have current information in order to continue to provide complete and accurate education to parents regarding gastrostomy placement and care.
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As technology advances, new products and techniques are developed. During the rollout,
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a new gastrostomy device was brought in to replace a product that had been discontinued. One
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of the surgeons began using a new surgical technique. Information about these changes was communicated by the primary team. Pictures and detailed explanations were sent via email to unit trainers with the expectation they would share the information with their peers. It is uncertain if this happened on every unit.
Limitations The post nurse knowledge interviews were conducted two to three months after the final phase of the rollout. Thus, the timing of this post data collection was not consistent from unit to unit and could have affected the results. Staff who received the education closer to the interviews may have correctly answered more items.
ACCEPTED MANUSCRIPT No pre or post data for nurse knowledge was obtained for the Emergency Department. The primary team spent considerable time deliberating with ED staff nurses about the changes
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that would be needed due to their different focus. Data collection was not in the forefront of the
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primary team’s thoughts.
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Other limitations surrounding the nurse knowledge interviews could have affected the results. First of all, there was no effort to interview the same staff for the pre and post data
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collection. The use of a random sample of staff could limit the validity and reliability of the
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study results. Second, the n per unit was not large enough to compare most units’ specific results. The number of staff interviewed was determined based on the total number of units
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(including a mix of day and night shift) instead of the total number of staff on each unit. Thus, the number of staff who participated from each unit was disproportionate. Third, the number of
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staff interviewed based on years of experience was different pre compared to post data
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collection. For example, in the group of nurses with one year or less experience, n = 3 (pre data) and n = 19 (post data). Finally, the data collectors were not the same for the pre and post
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interviews. Ten staff nurses conducted the pre data interviews. It is thought some of the nurses may have led staff by saying “Use your resources.” One MD (MPH student) conducted the post data interviews. The primary team was unable to extract accurate data regarding number of visits to the Emergency Department related to gastrostomy device issues. Patients presented to the ED with varying concerns. Many times, they had gastrostomy device problems but they were not the main issue. Due to the current ICD-9 coding system and lack of supporting documentation, accurate data was difficult to obtain.
ACCEPTED MANUSCRIPT Other limitations include the low number of parent surveys completed. The clinic nurse was responsible for giving the survey to the parent during the visit. On busy clinic days,
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sometimes the survey was inadvertently not given. Other times the parents did not complete or
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return the survey. A better process may have helped increase the number of surveys returned
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and strengthen the data.
New nurses who were hired during the rollout received the general gastric device
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education during their new hire orientation. This lecture did not include the standardized parent
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education. Responsibility for this education was not added to the preceptor duties until after the roll out was complete. Therefore, it is possible some new nurses did not receive the updated
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education.
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Conclusion
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Overall, the primary team considered the performance improvement project to be a success. The standardized gastrostomy education plan and Train-the-Trainer methodology
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proved to be effective. The toolkit was very well-received by staff. Documentation of parent education improved significantly as evidenced by the documentation audits. Post-op clinic surveys revealed families received the emergency gastrostomy tube replacement supplies and practiced placing a gastrostomy tube on a doll prior to discharge. Practicing placement appeared to give parents the confidence to replace a gastrostomy device at home rather than bring their child to the ED if the device came out. In addition, the WOC nurses reported a decrease in the number of phone calls from parents related to basic gastrostomy care.
ACCEPTED MANUSCRIPT A standardized education plan and Train-the-Trainer methodology could be used in other educational endeavors. Empowering staff nurses with knowledge and tools to confidently
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educate parents has shown to improve overall outcomes.
Future Considerations
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Currently, there is no annual competency for gastrostomy education. The WOC nurses
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continue to educate new staff during orientation. Preceptors offer hands-on training on the unit.
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If staff have questions, they contact a primary team member for guidance. The primary team has discussed reconvening the G-Tube experts on an annual basis to discuss new products and techniques and any issues that have occurred. The educational
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resources have been updated with plans for placement on the staff’s intranet site so nurses have
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up-to-date and accurate resources.
References
Dwyer, Francis (2010, September 22). Edgar Dale’s Cone of Experience: A Quasi Experimental Analysis. International Journal of Instructional Media. 37(4), 431-437.
ACCEPTED MANUSCRIPT Edwards, H., Walsh, A., Courtney, M., Monaghan, S., Wilson, J., & Young, J. (2007, January 12). Improving paediatric nurses’ knowledge and attitudes in childhood fever management. Journal of
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Advanced Nursing 57(3), 257-269.
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Gozdzialski, A., Schlutow, M., & Pittgilo, L. (2012, May). Patient and family education in the
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emergency department: how nurses can help. Journal of Emergency Nursing 38(3), 293-295. Guerriere, D. (2003, July). Mothers’ decisions about gastrostomy tube insertion in children: factors
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contributing to uncertainty. Developmental Medicine & Child Neurology 45(7), 470-476.
Nursing Scholarship, 32(2), 117-123.
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Hinshaw, A. (2000). Nursing Knowledge for the 21st century: opportunities and challenges. Journal of
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Lerrett, S. (2009). Discharge readiness: an integrative review focusing on discharge following pediatric
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hospitalization. Journal for Specialists in Pediatric Nursing, 14(4), 245-255. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., Provost, L. (2009) Using the Model for
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Improvement. (Ed.). The improvement guide: A practical approach to enhancing organizational
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performance (pp. 97-100). San Francisco, CA: Jossey-Bass. Lord, L. (2011) Maintaining hydration and tube patency in enteral tube feedings. Safe Practices in Patient Care 5(2), 1-11.
McMurray, A., Chaboyer, W., Wallis, M., & Fetherston, C. (2009). Implementing bedside handover: strategies for change management. Journal of Clinical Nursing, 19, 2580-2589. Pearce, J., Mann, M., Jones, C., van Buschbach, S., Olff, M., & Bisson, J. (2012). The most effective way of delivering a train-the-trainer program: a systematic review. Journal of Continuing Education in the Health Professions, 32(3), 215-226.
ACCEPTED MANUSCRIPT Sanford, K. (2010). Reducing variance in nursing practice. Healthcare Financial Management, 64(11),
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40-45.
ACCEPTED MANUSCRIPT Table 1. Staff Resources (New or Revised)
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Resources
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1. Worksheet: Completed by the OR nurse and placed in the medical chart; describes the patient’s specific device type and size and the surgeon who placed it.
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2. G-Tube card: 3 ½ x 5 card attached to the worksheet; to be completed by staff and given to families prior to discharge; includes the patient’s gastrostomy device type, size, date of placement, home care company and surgeon contact information.
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3. G-Tube parent education booklets: Existing resources used to educate parents on specific device types (include care, use and troubleshooting information).
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4. Resources on the hospital intranet: Information for staff on how to care for each device; patient education resources.
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5. Supply lists: Supplies the patient needs at home; lists include each type/size of gastrostomy device.
6. Doctor grid: Each surgeon’s specific care instructions for bathing, swimming and follow up appointments.
7. Patient education record: Paper form which includes key objectives of family education; easy to use tool to help ensure appropriate documentation.
ACCEPTED MANUSCRIPT Table 2. Gastrostomy Device Toolkit Contents
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Items
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1. Samples of seven different gastrostomy devices
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2. Quick reference sheet with information about each gastrostomy device
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3. Supplies needed to demonstrate replacing a gastrostomy device
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4. Samples of five G-Tube parent education booklets
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5. Supply lists and doctor grid (laminated) on a ring