Download Evidence Based Practice on Trial – YOU Be The Judge

Evidence Based Practice on Trial – YOU Be The Judge
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Cindy T. White, MA, RN, CNML is Manager of Nursing Education at John Muir
Medical Center, Walnut Creek, CA.
Evidence Based Practice on Trial – YOU Be The Judge
Abstract
Traditional teaching and training methodologies often present challenges to
learning. The mock trial method was designed as a dramatic, innovative, and engaging
courtroom drama where the nurse ‘defendant’ was challenged to substantiate practice
based on ‘evidence.’ Seminar ‘jury’ participants scrutinized testimony through
deliberation (learning) before delivery of the verdict.
Definitions
Evidence Based Practice: the deliberate use of clinical expertise and the integration of
current best evidence in making decisions about the care of patients.
Traditional teaching methods: teacher-centered, classroom lecture, discussion, note
taking, and memorization, learning packets.
Mock Trial: a simulated trial that involves active participation as in an actual courtroom
case.
Shared Governance: a decentralized system of management in which nurses make
decisions regarding practice and practice environment.
High Alert Medications: drugs that bear a heightened risk of causing significant patient
harm when they are used in error.
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Introduction
The value of evidence based practice and its impact on professional nursing
practice and patient care outcomes is garnering the attention of healthcare practice and
standards today. Evidence based practice is defined as the practice of nursing in which
the nurse makes clinical decisions on the basis of the best available current research
evidence, his or her own clinical expertise, and the needs and preferences of the patient.
(Mosby, 2009) Knowing and practicing to a set of standards impacts safe patient care
and legitimizes existing evidence through improved patient outcomes. Traditional
approaches to teaching and training methodologies such as educator centered lectures and
learner centered self-study learning modules often present a challenge to the educator, the
learner, and the learning. These methods can often make or break the learning process.
(Biddinger, 1999)
With the need to reinforce the initial, traditional self-learning module efforts for
an evidence based practice approach to opioid sedation and a new opioid sedation rating
and intervention scale, the shared governance education council (Council) was
challenged to design an effectual learning impact on the nurse and their nursing practice.
The Council took up the challenge to enhance the initial educational efforts through the
development of a mock trial approach designed as a dramatic, innovative, and engaging
courtroom drama where the nurse ‘defendant’ was challenged to substantiate their
practice based on the value of the best ‘evidence.’
Making the case for drama
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Literature informs us the best teaching methods for learners to acquire new
knowledge occur when the learner is actively involved in their own learning. (GMU,
2012) While traditional methods such as lectures and self-learning packets are tried and
true, they may not be the best approach for learning and retention of new knowledge.
Engagement in an active learning process through activities such as role-playing,
simulation, case studies, gaming, and problem solving, takes involvement on the part of
the learner. International research and concept papers agree that students are more likely
to retain learning when it falls close to and is grounded in clinical experiences and patient
cases rather than the more traditional teaching methods. (Persad, 2008) Empirical
support for the effectiveness of these learning methodologies is strong. Malcolm
Knowles’ theory of andragogy describes fundamental principles of how adults learn best:
by active involvement in the learning; utilizing personal experiences; creating relevance
to the learner, and fostering an environment where fun is used as a basis for learning
activities. (Knowles, 2005) These principles were used as the underlying framework for
the development of the mock trial and central to the goal of influencing learning.
Making the case for the ‘evidence’ in evidence based practice
Evidence-based practice is a systematic approach to problem solving for health
care providers and is characterized by the utilization of the best evidence currently
available for clinical decision making in order to provide a standard for delivery of
quality patient care. Although nurses frequently acknowledge the need for more
information regarding nursing practice, they feel much more confident asking colleagues
or peers than searching databases to find specific information themselves. Pravikoff noted
that the majority of nurses don’t understand or value research and have received little or
Evidence Based Practice on Trial – YOU Be The Judge
no training in the use of tools that would help them find evidence on which to base their
practice. (Pravikoff, 2005) This assertion was key to the development of the body of
evidence or fact basis for the expert witnesses in the trial. The dialogue throughout the
trial utilized the ‘experts’ to argue best current research evidence verses expert clinical
opinion and knowledge from pain research translated into practice.
Developing the case for trial
Pre-trial preparation began almost a year in advance of the scheduled event with
each month’s Council meeting devoting significant time to trial planning and
development. The Council worked on the selection of the patient’s medical condition,
hospital course, lab tests, physician orders, nurses notes, a literature search of the latest
and best evidence in the management of pain for a patient receiving an opioid infusion,
and familiarized themselves with the new sedation scale, policy and procedure. They
also selected their characters as well as crafted their profiles that guided their trial
‘performance.’ Other disciplines were recruited to fill vital roles of the bailiff – a retired
police officer, an expert pharmacist – director of the pharmacy director, and a nurse
attorney played the role of the judge.
The argument – the basis of the trial
As the case took form through each successive Council meeting, the particular
issues or ‘arguments’ of the case emerged and were scripted as fact to lead the jury into
and out of the actual truth. Through the course of treatment and care of the fictitious
patient, it was essential that the ‘facts’ in the script needed to address if the standard of
care was met or not. It was determined that issues to be highlighted and called into
question through persuasive attorney arguments and banter were: assessment of the
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opioid naïve patient, use of the opioid sedation scale, appropriate administration,
monitoring, and interventions for patients on high alert medications, hourly rounding,
handoff communication, emergency interventions, patient and family education, and
documentation. The script evolved around these issues as the fact patterns expanded and
employed standard legal rules with interposing attorney objections, irrelevant evidence,
leading questions, and hearsay to spice up the dialogue. Pro and con persuasive
controversy was also built in to compel participants to listen intently as fact patterns
evoked reflection and consideration for the jury. The script was reviewed, revised,
reviewed, revised, reviewed again, revised draft, final draft review, then revised a final
time before it was time for the dress rehearsal. After approximately ten months of
preparation, the team was at last ready for their drama debut.
Through pre-conference advertising and registration confirmation notices,
participants were informed they would transform into the role of juror, not just class
attendees on the day of the trial. The ‘buzz’ this created peaked the nurses interest in
anticipation of the all day event. The stage was set – lights, cameras, action – we will
now enter into the courtroom scene…..
The Trial – the ‘transformed’ classroom
The day of the trial unfolded to a packed auditorium of over 150 registered
nurses. Upon entry into the auditorium, participants were handed an electronic ‘clicker’
or audience response system (ARS) device which would be used to vote on pre and post
conference questions including demographics and participant knowledge of issues to be
covered in the trial such as the latest evidence in the assessment, plan, care, and
evaluation of patients who are at risk for respiratory depression and over sedation with
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opioid infusion. Additionally the clickers would be used to register the final verdict at
the end of the trial.
Initial ARS demographic responses queried disclosed ninety seven percent of the
participants were registered nurses working in an acute care setting representing inpatient
medical/surgical and specialty divisions as well as emergency services. Sixty three
percent had twenty years or greater nursing experience; fifty percent had obtained a
bachelor of science as their entry into practice degrees, thirty one percent associate
degree nurses, and sixty five percent held national certifications. The characteristics of
this population represented a well-educated and clinically experienced group of ‘jurors.’
Pre conference questions regarding the knowledge base of the topics included in the trial
revealed an overall average of fifty percent correct responses from all questions asked.
This was the baseline with which learning would be measured at the end of the day.
The day was carefully crafted to be front loaded throughout the morning with
subject matter experts providing a review of the nursing practice act, scope and standards
of practice, chain of command, evidence based practice, legal implications of
documentation and a brief presentation on the basics of what to expect during a trial.
This education was strategic to establishing the framework from which to evaluate
nursing practice, patient care, documentation, and all evidence to be presented throughout
the trial in the afternoon. The underlying premise is that it is difficult to evaluate the
nursing practice standard, roles and responsibilities to the patient, and evaluation of these
without clear definition. This organizing framework allowed for this role and practice
standards review to guide the reflections in the intentional learning environment and the
jury deliberation dialogue. To aide in this process, members of the jury were given a
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notebook with all the evidence presented in the trial and a deliberation worksheet to take
notes of their findings throughout the day.
The afternoon session became alive with judge, jury ‘box,’ bailiff, plaintiff and
defendant attorneys carefully arranged on stage and expert witnesses embedded within
the participant audience. Evidence was then presented in a dramatic role-play scripted
scenario equipped with the cast presenting in full dress and characterization. The judge
entered the courtroom in full black judicial robe attire to the booming voice of the
security guard clad bailiff bellowing out “ALL RISE”. The plaintiff’s attorney was pretty
in pink as the Elle Woods fashion icon character of the Legally Blonde movie fame –
complete with ‘yapping’ miniature dog in carrier which she positioned high on her desk
for all to see. The plaintiff was the wife of the deceased patient and she was fully
believable as a woman in her final trimester of pregnancy (belly pillow) and extremely
emotional with weeping outbursts and tossing hankies throughout the case. The
defendant’s attorney was dressed in serious minded business dress suit attire and was
poised for the debate. The defendant was believable as an authentic and caring
experienced nurse. One nurse expert witness was dress in full ‘brainiac’ fashion with
hair pulled back and glasses slightly tipped on her nose looking down condescendingly at
all who cared to gaze at her. Another nurse expert witness was a confident and abrupt
experienced nurse clinician who valued research but felt expert practice trumped research
any day of the week. The expert pharmacist stayed the course and stuck to ‘just the
facts,’ as it related to pharmacology science and the literature. All courtroom exhibits
were shown on the projection screen in the center of the stage so all participants could see
the evidence entered into testimony.
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The addition of humor, the courtroom scene with judges bench, jury box,
attorneys desks, a daunting bailiff swearing in each of the witnesses and calling out
directives from the judge for ‘‘order in the court,’’ along with elements of surprise and
uncertainty, all encouraged an appealing and fun learning atmosphere which had
participants fully captivated.
The deliberation and verdict
At trial conclusion, the judge gave instructions to the jury concerning
deliberation. The judge then exited the courtroom and the moderator gave further
instructions. Participants were asked to divide into twelve groups of 12-15 participants
each, and given 45 minutes to deliberate. Each group represented the vote of one juror,
and the majority vote within the group (50% plus 1 = majority) would be the final
decision to be registered via ARS. Groups engaged in active and lively discussions
regarding the content and context of the trial and its relevance to the ‘evidence’
presented. The auditorium was buzzing with dynamic, informative, and appealing
scholarly dialogue.
At the end of the deliberation period, the ‘judge’ re-entered the courtroom and
asked the jury ‘foreman’ for the final verdict. For dramatic effect, the jury foreman
handed a card representing the jury’s decision over to the judge around the same time the
votes were being registered electronically. Each group entered their final vote –one vote
per group. The final verdict reached was 10 to 2 in favor of NOT NEGLIGENT. Once
the verdict flashed upon the projection screen you could hear a collective exhalation from
the crowd with mixed emotions of surprise, sadness, and relief. It was clear that the
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audience was deep into the realism of the experience and the verdict represented each
participant’s personal resolution of the case.
An open microphone session ensued in order to give the jury an opportunity to
state the evidence that weighted their decision and tipped the scales of justice in one way
or another. Resulting dialogue was rich with enlightened acumens about the value and
legitimacy of the evidence presented from which sparked more debates. The auditorium
was once again buzzing with dynamic, informative, and appealing scholarly dialogue
within the larger, all-inclusive assemblage. During this final interchange, there was
overpowering agreement that there was not enough ‘evidence’ in the documentation to
reach a verdict of NEGLIGENT but the case was noticeably ‘convincing.’
As the final order of the day, post-test questions – the same as that for pre trial were then queried in order to substantiate if there was substantiation that there was a
significant impact on learning. Of the six questions asked, the majority of participants got
them 50% correct pre conference and the majority 100% correct post conference. The
two questions that were split down the middle in percentage correct were the two
questions intended for controversy and emphasized during the trial with not enough
‘evidence’ nor sample size in the literature study presented to yield convincing results.
As this was intentionally controversial, the participants apparently paid particular
attention to this argument that threaded throughout the trial as evidenced by their split
decision on those two post-conference questions – a very convincing case of the impact
of learning.
Standard written class evaluations were useful in capturing thoughts on the full
immersive experience of the day. A preponderance of affirming comments reflected the
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effectiveness of the learning for the learner such as, “the mock trial was thought
provoking,” and “the speakers were inspirational and validated nursing as a scientific
profession,” “the mock trial was a well planned and thought out presentation,” and “this
reminded me that practice can always be improved by utilizing my ideas or perspective
and moving further to research and implementation.” Further statements concentrated
on what was most valuable to the participants such as learning the relationship between
patient care, safety, quality, and the importance of connecting the documentation that
reflects the evidence of the care that was given.
Discussion
By laying the groundwork early in the day with the essential foundations of
practice, nurses felt better prepared to evaluate the unfolding courtroom drama in the
afternoon. Participant jurors summarily became involved in a fun, challenging, and
engaging way of learning to substantiate their practice through a tangible application of
complex and abstract principles of healthcare and the law. They also became more
knowledgeable about the new sedation scale and critical elements of assessment and
monitoring patients receiving high alert medications. These benefits were achieved in as
much of the deliberation as it was in the trial itself. There was unanimous agreement that
new learning took place with a level of understanding that could not have been achieved
apart from this lived experience.
Conclusion
Through a transformed classroom and utilization of relevant nursing practice
concerns along with a little fun and entertainment, initiative to learn changed from the
traditional teacher centered to participant centered in the acquisition, retention, and
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transfer of new knowledge. The mock trial approach successfully challenged nurses to
examine their practice and gather evidence to support changes to clinical practice. At the
end of the day, nurses left feeling “inspired” about their practice and challenged
themselves to examine it at a closer level.
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References
Biddinger, L. (1999). A mock trial at nursing grand rounds. Journal for Nurses in Staff
Development , 15 (3), 111-115.
GMU. (2012, January 31). Center for Teaching Excellence. Retrieved March 3, 2012,
from www.cte.gmu.edu:
http://cte.gmu.edu/Teaching/active&collaborative.html
Knowles, M. H. (2005). The adult learner: the definitive classic in adult education and
human resource development. Burlington, MA: Elsevier.
Mosby. (2009). Mosby's Dictionary of Medicine, Nursing, & Health Professions (8th
Edition ed.). Elsevier.
Persad, G. E. (2008). The current state of medical school education in bioethics,
health law, and health economics. Journal of Law & Medical Ethics , 89-94.
Pravikoff, D. T. (2005). Readiness of U.S. nurses for evidence-based practice: Many
don't understand or value research and have had little or no training to help
them find evidence on which to base your practice. American Journal of
Nursing , 105 (9), 40-51.
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