Making an Impact

Jul 16, 2018

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Innovation in critical care is important … You don’t have to begin with rigorous research. Start with a quality improvement or an evidence-based-practice project, a simple test of change.

Joyce Pittman

A key part of the AACN mission is to empower direct-care nurses as bedside leaders, innovators and catalysts for change. Clinician and researcher Joyce Pittman received a 2015 AACN Impact Research Grant to study an all-too-common acute care condition that is among the most complex and costliest. Now, her study, “Unavoidable Hospital-Acquired Pressure Injuries in Critical Care and Progressive Care” — an innovative bedside instrument — helps monitor and prevent pressure injuries.

Where do you work?

I’m coordinator for the wound/ostomy/continence (WOC) program at Indiana University Health-Academic Health Center and Indiana University School of Nursing. I’ve been a nurse for over 38 years — 18 as a WOC nurse, 14 as a nurse practitioner.

What drew you to nursing?

I wanted to become a nurse after I met nurses. I just looked up to them. They were very cool. I had an interest in health and medicine, and nursing just clicked for me. It offered flexibility, a stable occupation, a professional career and growth opportunities. I was young, in a community college pre-vet program. I switched after meeting them! These two young women played a very instrumental role in my career path.

What set you on the WOC nursing path?

An opportunity came to me to earn my WOC certificate and return to the critical care setting. In nursing, you often have that fork-in-the-road choice to decide whether it’s administrative leadership nursing roles or clinical. Unfortunately, to move forward in the nursing world, very often you have to move further away from the patients. I wanted to stay clinical and connected to the patients at the bedside, so I went back for advanced practice nursing with my nurse practitioner degree.

And what do you like to do outside of work?

I love to garden. I love to get my hands in the dirt. This winter was hard. We had a late, extended cold spell. I’m going to get my vegetable garden in — my tomatoes, lettuce, cucumbers, kale and shallots. I also have some strawberries that I fight my bunnies over. Yesterday, I cleaned out my raised garden beds with my yellow Lab running around stealing weeds. She was a mess. So that’s one of the joys — playing with my dog. My daffodils are coming. I’m watching for my forsythia, irises and lilac. I think it’s relaxing to plan for the whole season, watching things bloom and then bringing your garden inside with some cut flowers.

What motivated you to join AACN?

I’d always been involved with patients in critical care, but I didn’t feel like I was a critical care nurse because I wasn’t employed on a critical care unit. I go across the whole hospital system, but a large majority of my patients are in critical care, and I’m taking care of their complex wound/ostomy needs. But the critical care nurse is at the bedside and taking care of those critical care patients. So I didn’t feel like I was a critical care nurse until joining AACN and seeing all the opportunities and all the resources offered. It was amazing.

Why did you decide to focus on pressure injuries?

I’m also adjunct faculty at Indiana University’s School of Nursing, and as I continued my doctoral work, pressure injuries were a passion of mine and a priority for healthcare organizations. In the critical care population, pressure injuries are more common because of the complexity and acuity of patients. I wanted to research unavoidable pressure injuries. We know they happen, sometimes in spite of the excellent care our nurses provide.

What else motivated this research?

In our healthcare organizations we collect data on pressure injury rates, prevalence and incidence. We report to different benchmarking regulatory groups, and it’s hard and frustrating for nurses. These patients are on death’s door. They have every organ failing; they’re on pressors, vented. They survive awful traumas, but a deep-tissue pressure injury appears that wasn’t there yesterday. Regulatory-wise, we’re held responsible and it’s cited as a patient harm event, like we did something wrong — but we didn’t. So we explored and learned why it happens even when we do everything right. We did preliminary work and developed an evidence-based instrument — the pressure ulcer prevention inventory — for looking at those pressure injuries. We piloted it in a small group.

How did the AACN grant help you broaden the scope of your initial work?

We wanted to expand testing for this instrument to provide an objective measure of unavoidable pressure injuries. That’s not well-defined in the evidence or literature. The funding enabled us to study a larger sample size. After testing and validating the instrument, it’s now used across the country at medical centers from Nebraska to Miami, from east to west. It’s a one-page instrument with instructions. We use i retrospectively. Our top leaders — physicians, administration, nursing and bedside — review the medical record to confirm that, prior to the pressure injury, all was done appropriately and consistently using our tool. We still report it. But it’s reassuring to bedside nursing and leadership. It’s a great tool. It provides real-time reassurances of best practices and helps in their work environment knowing they’re doing the best evidence-based care.

In what other ways was AACN funding important for your work?

I worked closely with colleagues on the grant — critical care nurses and clinical nurse specialists. We saw this problem and sought funding. But, how could we do this? We’re primarily clinical nurses, and it’s difficult to do the research because we’ve got patient care and all of our other responsibilities. AACN provided the resources for research assistants and a project manager to help complete this study. Also, we were very thrifty and efficient and did not spend all of the funding. AACN allowed us to use the remainder on a secondary analysis to strengthen our findings.

What advice do you have for AACN members applying for research funding?

The best piece of advice is to gather a team of colleagues and mentors (specifically doctoral-prepared mentors) to ensure that the design of their research is appropriate and rigorous enough, and the protocol formatted and organized. Involve a biostatistician from the beginning, so the collected data is meaningful and going to result in important, useful findings. It’s all in the details, and the planning upfront is crucial to a successful study. It takes time from beginning to end, so think of it more in phases or you’ll become overwhelmed.

What do you say to researchers who are nervous about presenting their findings?

Presenting at NTI was a fabulous experience. To minimize our nerves we presented as a team. It always gives you reassurance when you have your colleagues right beside you. AACN and NTI provide templates for your slides and helpful instructions and guidance in preparing. I am in awe of what our critical care nurses do; they save lives every day. If you can save lives, for goodness sake, you can stand up in front of an audience of your colleagues and peers.

What inspiration can you offer front-line nurses to take the evidence they see and innovate?

Innovation in critical care is important, and I’m lucky to work in an organization where we really encourage that. And, of course, AACN does too. Nurses are thinking outside the box all the time. Look for simple things or even raise the question, “Why are we doing it this way?” Or, “Could we modify it some way?” Nurses are really good at that, but to spread the word they must do a project. Start with something as simple as a poster at NTI. You don’t have to begin with rigorous research. Start with a quality improvement or an evidence-based-practice project, a simple test of change.