Running head: PATIENT-FOCUSED EDUCATION IN AESTHETICS 1
PATIENT-FOCUSED EDUCATION TO IMPROVE AWARENESS OF ADVERSE
REACTIONS IN THE AESTHETIC INDUSTRY
by
Alonna Wannamaker
Capstone Paper submitted in partial fulfillment of the requirements for the degree of
Doctor of Nursing Practice
Chatham University
November 19, 2017
Signature Faculty Reader Date
Signature Program Director Date
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 2
Acknowledgments
I would like to first give all the praise and glory to God, for without Him I could not complete this milestone in life. Philippians 4:13 states that “I can do all things through Christ which strengtheneth me.”.
I would first like to thank my fiancé for being understanding and supportive through the extended days and nights of me complaining and for pushing me to never give up. Next, I would like to thank my sister for the inspirational quotes and for always believing in me. It has always been my goal to set a pristine example for you, Akena. I would like to thank my parents for setting the bar so high that I have no choice but continue to push to be just as great as them; and my grandparents for their continual prayers and words of uplift; and my future in-laws for the prayers and love. Thank you, Dr. Popovich, and Dr. Hopkins for pushing me past my own comfort to discover deeper aspects of my intellect. I would like to thank my preceptor Devin
Bailey for the motivation and words of encouragement throughout this program. Lastly, I would like to thank my friends and my linesisters for seeing something in me that I never saw within myself!
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 3
Dedication
I dedicate my capstone to my sister, Akena Wannamaker. Let this allow you to see that
ALL THINGS ARE POSSIBLE.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 4
Abstract
Over the past decade, the number of aesthetic/cosmetic treatments has rapidly increased. An estimated 6.6 million Americans have underwent some form of medical aesthetic treatment
(Sarwer & Crerand, 2003). The purpose of this paper is to present findings of an evidence-based practice (EBP) project designed to discuss the process of implementing an educational intervention focusing on patient knowledge in aesthetic medicine. Literature review established that current misconceptions and lack of knowledge of established and potential aesthetic patients must be addressed. Patient teaching provides information on behaviors that can assist in increasing patient knowledge and reducing the incidence of adverse reactions. The goal of this
EBP project was to increase patient knowledge in the aesthetic/cosmetic industry focused on laser hair removal. The Aesthetic Knowledge Survey was used to assess patient knowledge prior to the educational intervention, and four to six weeks after the educational intervention. The mean pre-test score was 89% in comparison to a mean posttest score of 97%. The findings of this project indicated a decrease in adverse reactions from 29% to 4%.
Key words: Laser hair removal, lasers, aesthetics, cosmetics, adverse reactions in aesthetics PATIENT-FOCUSED EDUCATION IN AESTHETICS 5
Table of Contents
Acknowledgments...... 2
Dedication ...... 3
Abstract ...... 4
Chapter One: Overview of the Problem of Interest ...... 10
Background Information ...... 11
Significance of Clinical Problem ...... 12
Question Guiding Inquiry (PICO) ...... 14
Variables of the PICO question ...... 14
Population ...... 14
Intervention ...... 14
Comparison ...... 15
Outcome ...... 15
Summary ...... 15
Chapter Two: Review of the Literature ...... 17
Methodology ...... 17
Sampling strategies ...... 17
Inclusion/Exclusion criteria ...... 18
Literature Review Findings...... 18
Patient Education Aesthetic Industry ...... 19
Patient Education Important in LHR ...... 21
Nursing Discipline ...... 22
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 6
Discussion ...... 23
Limitation of literature review...... 23
Conclusions of findings ...... 23
Potential practice change ...... 24
Summary ...... 25
Chapter Three: Theory and Model for Evidence-based Practice ...... 26
Concept ...... 27
Theory ...... 27
Application to practice change...... 28
Stetler Model ...... 29
Application to practice change...... 29
Summary ...... 30
Chapter Four: Pre-implementation Plan ...... 32
Project Purpose ...... 32
Project Management ...... 33
Organizational readiness for change ...... 33
Inter-professional collaboration ...... 33
Risk management assessment ...... 34
Organizational approval process ...... 36
Use of information technology ...... 36
Materials Needed for Project ...... 37
Plans for Institutional Review Board Approval ...... 38
Plan for Project Evaluation ...... 38 PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 7
Plan for demographic data collection ...... 38
Plan for outcome data collection and measurement ...... 39
Increase in Patient Awareness ...... 39
Decrease in Adverse Reactions ...... 40
Plan for data management ...... 40
Summary ...... 41
Chapter Five: Implementation Process ...... 42
Setting ...... 42
Target Population ...... 42
Recruitment ...... 43
Implementation Process ...... 44
Phase I ...... 44
Phase II...... 45
Phase III ...... 46
Plan Variation ...... 46
Summary ...... 47
Chapter Six: Evaluation and Outcomes of the Practice Change ...... 48
Participant Demographics ...... 48
Figure 6.1. Gender of Participants ...... 49
Figure 6.2. Ethnicity of Participants ...... 50
Outcome Findings ...... 50
Increase in Knowledge ...... 50
Table 6.1 Comparison of Mean Test Scores ...... 51 PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 8
Table 6.2 Correct Answers ...... 51
Reduction of Adverse Reactions ...... 52
Figure 6.3 Laser Hair Removal Reactions ...... 52
Summary ...... 52
Chapter Seven: Discussion ...... 54
Recommendations for Site ...... 54
Plans to sustain change at site ...... 55
Implications for Policy ...... 56
Links to Health Promotion ...... 57
Role of DNP-prepared nurse ...... 57
Next Steps for Evidence-based Practice ...... 58
Plans for Dissemination ...... 58
Summary ...... 59
Chapter Eight: Conclusion ...... 60
Clinical Problem ...... 60
Evidence Base ...... 61
Theory and Model for Evidence-based Practice ...... 61
Project Management ...... 63
Project Implementation ...... 63
Outcome Findings ...... 64
Discussion Summary ...... 65
Final Conclusions...... 66
References ...... 67 PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 9
Appendix A: Participant Cover Letter ...... 71
Appendix B: Aesthetic Knowledge Pre-Test ...... 72
Appendix C: Aesthetic Knowledge Post-Test ...... 73
Appendix D: Brochure ...... 74
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 10
Chapter One: Overview of the Problem of Interest
Within the past ten years, the number of cosmetic treatments has increased drastically.
This rise can be related to several factors such as the evolution of safer, minimally invasive procedures, an increase in mass media attention, and the greater willingness of individuals to undergo cosmetic procedures in order to enhance their physical appearance (Sarwer & Crerand,
2003). In 2002, the top five cosmetic procedures were non-surgical. These procedures included
Botox injections, chemical peels, microdermabrasion, laser hair removal (LHR), and sclerotherapy. It is estimated that approximately 6.6 million Americans have underwent some form of cosmetic medical treatment (Sarwer & Crerand, 2003). With there being a growing demand of non-surgical procedures, there is also a need for the expansion of individuals and locations that will provide these services.
More specifically, advances in laser technology have rapidly progressed. This includes successful treatments of vascular and pigmented lesions, tattoos, scars, and unwanted hair
(Tanzi, Lupton, & Alster, 2003). Advancements in laser technology and technique have provided practitioners and patients with alternative therapeutic choices as well as improved clinical outcomes (Tanzi et et al., 2003). As the number of individuals seeking cosmetic services increases, the possibility of adverse reactions continues to increase as well, particularly in patients of darker skin types. In a clinical practice, an internal chart review indicated that there was a difference in reactions such as micro crusting/burns and hypo or hyperpigmentation between Fitzpatrick skin type I-III, or fair skinned individuals, versus individuals with darker pigments, or skin type IV-VI undergoing LHR. It was found that darker skinned individuals were more susceptible to pigmentary changes (Alexis, 2013). Freedman, Earley, and Balakrishnan
(2006) established that patient education in aesthetic medicine was necessary for patient PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 11 knowledge and safety. The purpose of this paper is to introduce an evidence-based project that focused on increasing patient knowledge of aesthetic/cosmetic treatments related to LHR. Patient education will allow knowledge attainment, which will promote patients to become more accountable for their pre-/post treatment regimes. In turn, this will indirectly lead to the reduction of adverse reactions such as micro-crusting and hyper-/hypopigmentation with the use of laser treatments in skin types IV-IV.
Background Information
As stated by Tanzi et al., (2003), the term laser is an acronym for light amplification by the stimulated emission of radiation, and the light that the laser uses is monochromatic. When the light reaches certain wavelengths, the laser energy can absorb certain chromophores such as melanin, hemoglobin, or tattoo ink. In 1996, the Food and Drug Administration (FDA) approved laser and light-based technology for safe and long-term hair reduction (Tanzi et al., 2003). There are specific types of lasers that emit energy pertaining to the type of treatment. Treatments can be performed on all skin types and ethnicities due to the variety of wavelengths used by the lasers (Tanzi et al., 2003)
In order to provide safe and effective laser treatments, most clinicians use the Fitzpatrick skin type scale. Per Oakley (2012), the Fitzpatrick scale assists with determining the amount of melanin pigment in the skin. This scale provides guidance with instructions on how to properly assign skin types I-VI. This will then determine the plan of care for the patient. Although there are ways in which clinicians can provide laser safety, some side effects can occur with these treatments. A survey administered by Vachiramon and McMichael (2011) demonstrated that of the 221 African American subjects (patients), only 122 subjects (55.2%) knew that dark-skinned individuals could be treated with LHR. Only 44.3% of subjects believed that dark-skinned PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 12 people were more prone to develop hyperpigmentation from LHR (Vachiramon and Mc Michael,
2011).
The most common complication of LHR is pigmentary alteration, including hyper- and hypo-pigmentation (Ibrahimi, Avram, Hankes, Kilmer, & Anderson, 2011). As noted in the study, Burning, Paradoxical Hypertrichosis, Leukotrichia and Folliculitis are Four Major
Complications of Intense Pulsed Light Hair Removal Therapy (2008), out of the first series of
1,000 patients, 75 participants received post inflammatory hyperpigmentation, and in the second series of 1,541 patients, 25 participants had indications of post inflammatory hyperpigmentation.
This evidence was merely a portion of the number of adverse reactions that are occurring within clinics that perform LHR.
Due to the lack of knowledge in patients seeking aesthetic treatments, educational interventions were employed to address misinformation and misconceptions. Although there is minimal evidence on patient education in aesthetics and cosmetics, literature suggests that this lack of knowledge and education is indeed a clinical problem. Freedman, Earley, and
Balakrishnan (2006) found that educating patients about their treatment options and any issues that they may experience leads to greater patient satisfaction with their consultation; a better understanding of the treatment options, greater confidence in their choices, and a higher number of scheduled procedures. Focusing on patient education in aesthetics rather than provider education was necessary to increase patient knowledge, and assist in the reduction of adverse reactions such as micro-crusting and hyper-/hypopigmentation. Greater patient knowledge can lead to overall positive clinical outcomes and enriched patient-provider relationships.
Significance of Clinical Problem PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 13
Based upon a chart review at the clinical site over the past three months, there is a 17% difference in the adverse reactions that occur in those of skin type I-III versus those in skin type
IV-VI. Of the one-hundred and twelve adverse reactions that occurred in the current practice setting, 41% were skin type I-III, and 58% were skin type IV-VI (LaserAway, 2016). Ultimately, adverse reactions such as hyperpigmentation have been noted to negatively affect social interactions as well as the quality of life of the affected individual (Wang et al., 2014). In turn, increased knowledge through education would serve as an effective solution to provide patients with information on the advantages and disadvantages of the available treatment options.
The average cost of laser hair removal ranges from $150-$500 per session, although some larger areas may cost up to $900 (Lim, 2015). Patients are typically paying out-of-pocket for cosmetic procedures. If an adverse reaction occurs, the patient may need to seek medical attention from a dermatologist. Their visit could potentially cost between $100-$200 without health insurance (The Law Dictionary, n.d.).
Of the 10,105,164 surgical and nonsurgical aesthetic procedures reported in 2012, approximately 21% were performed on nonwhite racial/ethnic groups (Hispanics, 8%; African-
Americans, 7%; Asians, 5%; and other non-Caucasians, 2%) (Alexis, 2013). In regard to the
Fitzpatrick skin typing scale, these ethnicities would fall within skin types IV-VI. Currently, there are trends in clinical practice that support the need to educate patients based upon the incidence of burns/micro-crusting and hyper- and hypopigmentation in darker skinned individuals. Although skin hypopigmentation or hyperpigmentation usually resolves within 6 to
8 weeks (Liew, 2002), increasing patient safety was the primary reason for the reinforcement of laser treatment education. In turn, patient education will positively affect treatment outcomes as well as patient attitudes about adverse events. The clinical problem guiding this evidence-based PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 14 practice (EBP) project is the lack of patient knowledge in aesthetics related to laser hair removal and incidence of burns/micro-crusting and hypo- and hyperpigmentation in laser hair removal in the aesthetic and cosmetic medical environment.
Question Guiding Inquiry (PICO)
Variables of the PICO question. Evidence-based practice is necessary for the highest quality of care to be provided to achieve optimal patient outcomes (Melnyk & Fineout-Overholt,
2015). A systematic approach to formulating a clinical question of inquiry which is asked in a specific PICO format. This format includes the patient population (P), intervention or issue of interest (I), comparison intervention or group (C), and the outcome (O). Furthermore, considering the aesthetic industry, the PICO question guiding this project was as follows: In the adult population receiving aesthetic/cosmetic treatments related to LHR, does patient education improve knowledge and reduction of micro crusting/burns and hypo or hyperpigmentation?
Population. The population of interest was male and female adults aged 18 through 75 with a Fitzpatrick skin type between IV-VI, currently receiving laser treatments and those initiating laser treatments. Specifically, ethnicities included in skin types IV-VI were Hispanic,
Asian, Middle Eastern, and African-American, as these are the skin types that are more prone to experiencing hyper-/hypo- pigmentation and micro-crusting (Alexis, 2013). Patient exclusions included medical conditions that do not warrant laser treatments, pregnant women, and skin type
I-III.
Intervention. The intervention for the EBP project was an educational intervention that that was directed to the patient and provided information needed to increase knowledge of aesthetic treatments and the potential of micro-crusting/burns and hypo- and hyperpigmentation.
Eapen (2009) developed a tool to simulate LHR. This tool was found to be sensitive in providing PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 15 a method to demonstrate the LHR process. The simulation tool was presented in a manner that patients could understand the educational information for LHR. Freedman, Earley, and
Balakrishnan (2006) found that an educational intervention led to improved patient satisfaction, increased knowledge of treatment options, and the increased the overall confidence in the treatments.
Comparison. There was no comparison group. Patient knowledge was tested prior to and after the educational intervention. A pre-test was administered before the patients received the educational material. A post-test was given at the follow-up visit between 4-6 weeks after the pre-test. A follow-up call was made if the patient could not make the follow-up appointment. At this time, a question was asked if any adverse reaction occurred after their previous treatment.
Outcome. The outcomes of the EBP project included the following: (1) increased patient knowledge on the potential of burns/micro-crusting and hyper-and hypopigmentation and (2) reduction of adverse reactions including micro-crusting and hyper-/hypopigmentation.
Summary
As non-invasive laser treatment technology continues to advance, there is a need for ongoing patient education. Since patients who are classified within Fitzpatrick IV-VI are more prone to adverse reactions, it is imperative that they are aware of the interventions that need to be implemented in order to prevent these reactions from occurring. Although studies have proven the safety and efficacy with lasers in theses skin types, education can have a positive effect on increasing patient knowledge and understanding of common reactions that occur related to laser treatments. The educational intervention will also allow patients to become more active in their treatment process. Due to the implementation of the educational intervention, the patients will be able to fully understand the purpose behind sun avoidance, reporting changes in medical PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 16 history, and avoidance of specific activities post treatment. The next chapter of this paper will discuss the results of the literature reviewed in support of an educational intervention to reduce or prevent adverse events related to LHR in the aesthetic industry. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 17
Chapter Two: Review of the Literature
The aesthetic industry has grown tremendously within the past few years. Our society has made receiving surgical and non-surgical cosmetic enhancements more acceptable and attainable. In an industry that is quickly advancing, healthcare professionals must stay abreast of current best practices in the clinical practice setting. Evidence-based practice (EBP) is imperative to maintaining quality patient outcomes as well as providing the highest quality of patient care
(Melnyk and Fineout-Overholt, 2015). One benefit of EBP involves reviewing multiple sources of evidence and studies that will incorporate provider experience and patient values and preferences (Melnyk & Fineout-Overholt, 2015). Evidence-based practice assists in addressing the clinical problem of the patient’s lack of knowledge of aesthetic treatments as well as any potential adverse reactions associated with these treatments.
Unfortunately, patients of darker skin lack knowledge and possess negative beliefs about aesthetic treatments including laser hair removal (LHR) (Vachiramon and McMichael, 2011). In order to address these issues, an EBP intervention was identified. The purpose of this literature review evaluates evidence used to support an educational intervention aimed at increased awareness to knowledge regarding adverse reactions associated with LHR. The intervention was aimed at increasing patient knowledge and assisting in the prevention of micro-crusting, hyper- and/ or hypopigmentation in aesthetic/cosmetic treatments for patients who are identified in category IV-VI using the Fitzpatrick scale. This review focused on research that has evaluated the effectiveness of patient education in the aesthetic industry.
Methodology
Sampling strategies. Studies that primarily focused on patient education in the aesthetic industry were sought. PubMed, Science Direct, JAMA Network, and Google scholar are search PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 18 engines that were used to search evidence related to an educational intervention. The Jennie King
Mellon Library at Chatham University was used to access the following databases: Cumulative
Index to Nursing and Allied Health Literature (CINAHL) with full text, MEDLINE, The Journal of Cosmetic Dermatology, and Cochrane Central Register of Controlled Trials. The Chatham
University Discovery search was also used for a broader search of evidence. Specific terms used to search evidence included the following: patient education laser hair removal, laser hair removal education, laser hair removal side effects, photosensitive patient education, cosmetic patient teaching, laser and esthetics, laser safety education, skin type IV-VI laser safety, increase patient satisfaction, non-surgical cosmetic procedures, laser hair removal dark skin, laser hair removal patient education, and non-surgical aesthetic patient teaching.
Inclusion/Exclusion criteria
Inclusion and exclusion criteria for this literature review were based upon literature relevant to the focus of the EBP project. The literature search was narrowed from 1990 to 2017.
This large gap in years was due to the lack of evidence directly related to the clinical problem.
The literature search also included items that focused on patient education for cosmetic treatments. The focus included both surgical and non-surgical interventions. The need for education within the aesthetic industry was the overall concern. Literature greater than 30 years was excluded from the search. Any literature that focused on provider knowledge and education was excluded as well.
Literature Review Findings
There was parity in literature related to an intervention to educating patients in the aesthetic and cosmetic industry. Smedra et al. (2015) mentioned that discussing and providing educational material on contraindications, possible side effects and post-treatment care will PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 19 decrease complications. The literature review distinguished studies that focused on educating patients on aesthetic treatments, including laser hair removal. Through this literature search, it was revealed that education provided patients with a sense of empowerment and it showed greater improvement in their understanding of aesthetic treatments (Williams et al., 2011).
Adverse reactions and aesthetic knowledge can be distributed to both health care providers and patients. Rather than focusing on provider knowledge and education, the literature review distinguished interventions that focused on patient education to assist in improving patient outcomes.
Patient education in aesthetic/cosmetic industry
Freedman, Earley, and Balakrishnan (2006) performed a randomized study of 100 patients, comprised of 78 women and 22 men. The patients were divided into two groups in which their concerns and treatment options were identified. Group A was provided with a teaching module while group B did not receive the educational intervention and visual outline.
The patients were then surveyed on their understanding of the information discussed, and their satisfaction with the consultation (Freedman et al., 2006). Results indicate that group A had a higher level of satisfaction and a better understanding of available treatment options when compared to group B (p<0.05). In group A, 73% of the patients scheduled procedures in comparison to the 43% of patients in group B. Members of group A who received procedures were more satisfied than patients of group B (p<0.05). The authors indicate that the increase of patient education led to higher patient satisfaction, better understanding of the treatment options, and a greater number of scheduled procedures.
Williams et al. (2011) used a prospective, randomized, controlled, multicenter study to compare the Home of Younger Skin (HOYS) education program to a standardized patient PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 20 education program on age-related skin changes. After the educational intervention, patients completed an evaluation questionnaire based on a five-point Likert scale. Questions were answered in yes/no format. Out of 95 participants, 84% of the HOYS group and 50% of the standard group had increased knowledge of skin aging features. Ninety-one of the HOYS group were satisfied with their educational program, and 61% of the standard group was satisfied
(p<0.0001). Overall the HOYS group scored higher than the standard group. Scales noted that patients felt a sense of empowerment, knowledge of age-related skin changes, and their amount of participation in the selection of potential treatments (Williams et al., 2011). The study indicates that HOYS education showed significant improvement in patients’ understanding of age-related skin changes.
In a prospective, randomized study of 120 patients, Makdessian, Ellis, and Irish (2004) sought to evaluate the recall and effectiveness of oral communication in cosmetic procedures verses oral and written communication. Patients were placed in two groups. A group of 63 patients received pamphlets that included risks of the procedures, and the other group of 57 patients did not receive pamphlets. The study indicated that printed materials had a significant recall and retention rate in patients undergoing non-surgical and surgical cosmetic procedures.
An average follow-up from the time of consultation was 15 days. An increase in risk recall from
1.5 to 2.5 out of 5 was noted in patients after receiving printed education material. Patients that did not receive pamphlets, had an overall recall of 1.97 out of 5 risks. The authors mentioned that a more informed patient will be aware of the advantages and disadvantages of the procedures
(Makdessian et al., 2004), which can reduce the lack of informed consent on a procedure.
Overall, education in the printed form had a positive impact on the retention and recall rate in patients. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 21
Patient education is important in LHR
Huang et al. (2013) evaluated the effectiveness of sun protection education with 128 patients that were randomly assigned to a control group or an intervention group. Patients in both groups were instructed to use a broad-spectrum sun screen and to avoid sunlight. Patients in the intervention group were given an intensive sun protection module with an educational manual containing all content from the module. Each patient was interviewed at baseline and at 12 months using the Dermatology Life Quality Index (DLQI) questionnaire. The intervention group was evaluated after 1 month of the educational module (Huang et al., 2013). In comparison to the baseline, the intervention group showed improvement in sun protection practices after both 1 month and 1 year (p<0.01). The control group did not show any significant changes from baseline. The score of the modified DLQI score decreased significantly in the intervention group in comparison to the scores at baseline. There was no change found with the DLQI scores in the control group. The study indicated that before education, 72% of patients did not avoid artificial light and never applied sunscreen. The authors found that formal sun protection education in combination with written materials improved quality of life, sun exposure habits, and sun protection behaviors.
Eapen (2009) created and evaluated a tool, using NetLogo, for patient education and simulation of laser hair removal. The simulation sought to be simple enough to use for patient education, yet sensitive enough to predict the effects of LHR. A formula was used to determine the probability of hair and skin injury. Factors including pigmentation, laser fluence, pulse duration, spot size, wavelength, and pulse width were taken into consideration. Although the study did not perform a detailed statistical analysis, improvement data during simulation days was depicted (Eapen, 2009). The simulation showed information on skin types IV and V that PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 22 were treated on different wavelengths with either 4-week or 8-week gaps between sessions. The simulation was found to be simple and useful for health care providers and patients. This tool proved to be a reliable form of patient education and depiction of treatment optimization. Despite the lack of actual data of patients using this simulation, the findings of the study are relevant as a method to educate patients on the process of laser hair removal which will aide in increasing their knowledge and understanding.
The literature provided support for patient education as an effective intervention in the aesthetic/ cosmetic industry, and more specifically education on laser hair removal (LHR). This education improved patient knowledge and decreased adverse reactions (Makdessian, Ellis,
&Irish 2004). All findings support and coincide together about the positive effect of patient education. Studies reveal that when patients felt a sense of empowerment, patients were more comfortable with the procedures and they had a better understanding of their treatment options.
Although Huang et al. (2013) focused on sun protection practices. These practices are essential for patient teaching because sun exposure could potentially cause adverse reactions from LHR and other treatments offered in aesthetics. Furthermore, the treatment optimization tool evaluated by Eapen (2009) provided patients with a better understanding of the process of LHR and safety habits that they can abide by to prevent adverse reactions and obtain optimal hair reduction.
Nursing Discipline
The information found during the literature search did not originate from the discipline of nursing. There was no nursing literature that was found to support the intervention of patient education in aesthetics and LHR. Due to the lack of literature available from the nursing discipline related to educating patients in aesthetics, studies were sought and found within the discipline of medicine. Although studies did not derive from the discipline of nursing, all PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 23 literature was necessary to support patient education in aesthetics. Most of the literature was derived from journals of dermatology and plastic surgery. Many adverse reactions were noted with LHR and the field of aesthetics relate to the skin. The dermatologic journals provided information about the potential reactions and how to reduce or prevent these reactions.
Furthermore, the discipline of medicine reported that the attitudes and patient satisfaction were related to detailed explanations of treatments through an educational intervention. The next section will explore limitations identified as a result of the literature review.
Discussion
Limitations of literature review
A limitation of the literature found a lack of studies that were directly related to the effectiveness of patient education on LHR and aesthetic treatments. However, literature was found on educating providers on the proper treatment settings to use and remaining up-to-date in aesthetic advances. There were also studies comparing the techniques and methods used by physicians versus nurse practitioners. More literature was located on the safety and efficacy of the different types of lasers on skin types IV-VI. Studies were also discovered referencing patient education on lasers in the field of dentistry and optometry.
Non-empirical studies were used because each provided substantial information necessary to support patient education with LHR and aesthetics. Two studies elicited information related to potential adverse reactions because of aesthetic treatments. Overall, the limitations were considered for the EBP change project and the remaining evidence supports the need for patient education to increase knowledge and prevent adverse reactions in aesthetics treatments.
Conclusion of findings PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 24
The studies revealed that patient education is a key part of aesthetic medicine. Education can alter patient perceptions and attitudes towards receiving treatments. The findings indicate that patient education is an effective way to increase patient knowledge in LHR and aesthetics.
Patients should be made aware of any adverse reactions that could occur from aesthetics procedures. Education should also include information on methods to reduce and prevent adverse reactions as well as to identify what to do if a reaction occurs (Makdessian, Ellis, &Irish 2004).
The evidence discovered through the literature review supported different forms of education.
Oral communication, in addition to written material, proves to be an effective form of education to support patient knowledge and recall (Makdessian, Ellis, &Irish 2004). Education allows for the patient to take an active role in the reduction of adverse reactions such as hyper-
/hypopigmentation and micro-crusting (Freedman, Earley, and Balakrishnan, 2006).
Potential Practice Change
The literature reviewed supported the education of patients as effective intervention on treatments and procedures offered in aesthetic medicine. Current misconceptions and lack of knowledge of established and potential patients must be addressed. Patient education will provide information on behaviors that can assist in preventing adverse reactions. Education will increase knowledge and awareness of the positive and potential negative outcomes of aesthetic treatments, thus allowing them to make an informed decision regarding cosmetic procedures with confidence. Once knowledge and comfort is increased, there will be a reduction of adverse events such as micro-crusting, and/or hyper-/hypopigmentation. Ongoing patient education will reinforce and enhance prior knowledge of LHR and treatments sought within the aesthetic/cosmetic industry.
Summary PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 25
In our current society, aesthetic practice is more accessible and acceptable, thus increasing the desire to enhance or correct a cosmetic deformity. Each year, there is a rise in the number of individuals seeking aesthetic treatments including: LHR, Botox, dermal fillers, tattoo removal, laser facials, and body contouring. With each year, there are updated versions of current treatments as well as up-and-coming treatments that are approved by the Food and Drug
Administration (FDA). All patients should be educated on any services sought. This will ensure that patients are comfortable and confident enough to make an informed decision to proceed with a service. The goal of patient education in aesthetics is to increase knowledge and to prevent or reduce the incidence of adverse reactions. Evidence-based practice supported the notion that patient education as an intervention is important in aesthetic medicine. The next chapter will discuss the theoretical framework and the EBP model utilized for the development of this EBP project. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 26
Chapter Three: Theory and Model for Evidence-based Practice
Through the development of the body of nursing knowledge, literature has supported the need to incorporate theoretical frameworks and models into project design. There are many ways in which structure is sought. For the purpose of this project, the Concept-Theoretical-Empirical
(C-T-E) structure was used. By incorporating conceptual models and theories during the design phase, implementation of project can progress effectively.
Applying a conceptual framework requires clinical reasoning, critical thinking, and use of processes based on evidence which are ethically sound (Fawcett & DeSanto-Madeya, 2013). The
C-T-E structure requires the doctoral prepared nurse to integrate people, environment, and health into one entity to elicit greater practice experiences and improve patient outcomes. For the purpose of this EBP project, the concept of patient education was explored and synthesized. The theories chosen to support the concept of patient education were the Social Cognitive Theory
(SCT) and Nola Pender’s Health Promotion Model. The empirical indicator used in the project was the Aesthetic Knowledge Test. The C-T-E conceptual framework was used as a guide for this EBP project. This chapter will discuss the integration of the concept patient education and
SCT, and the EBP model of Pender’s Health Promotion as they relate to the EBP project aimed to increase patient knowledge on LHR and reduce complications associated with LHR. These theories and concepts will be used to support development of the EBP project asking the question of: In the adult population receiving aesthetic/cosmetic treatments related to LHR, does patient education improve knowledge and reduction of micro crusting/burns and hypo or hyperpigmentation?
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 27
Concept
The concept of patient education will be explored for this EBP project. Patient education must be provided to allow patients to understand their diagnoses, treatment options, and prognosis. Education that is sufficient and effective can aid in positively impacting the quality of care and overall safety of the patient (Tamura-Lis, 2013). The concept of patient education is defined in the Medical Dictionary (2012) as health information and instruction provided so that the patient will understand and learn about medical diseases. The Medical Dictionary for the
Health professions and Nursing (2012) elaborates on patient education as providing or assisting with the acquirement of patient knowledge and skills. This medical dictionary also places values on health promotion and specific health problems. In a simplified manner, patient education is providing patients information and lessons on diseases, treatments, or health promotion. This
EBP project showed that the area of most concern is within the aesthetic/cosmetic industry is the lack of patient education. Evidence from Vachiramon and McMichael (2011) proves this lack of patient education in aesthetic medicine.
Theory
The C-T-E conceptual framework incorporates theories to provide a foundation to support the EBP project. The basis of the SCT proved to be an essential link between theory and evidence-based practice. This theory provided organization and structure throughout the practice of nursing and education conducted in this field of study (Chinn and Kramer, 2015). There are two theories that supported the concept patient education. Both theories addressed the question:
In the adult population receiving aesthetic/cosmetic treatments, does education improve knowledge and reduction of micro crusting/burns and hypo or hyperpigmentation? PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 28
The Health Promotion Model (HPM) was developed by Nola Pender in 1982. The HPM focuses on predicting health-promoting lifestyles, and behaviors that will assist in designing this
EBP project. Individual characteristics and experiences, prior behavior and frequency of past behaviors are all major concepts of the HPM. This model evaluates cognitive and perceptual factors that will determine the extent of the health-promoting behavior (Aligood, 2010). In relation to patient education, it is imperative to assess patients’ cognitive ability. This will assist in tailoring the education to allow for the best retention of the information by the patient.
According to the model, effective education could lead to initiating behaviors that are preventative and health promoting. Understanding the concepts of this model led to the development of the educational intervention to increase patient knowledge of LHR.
The Social Cognitive Theory (SCT), a non-nursing theory, originates from the theorist
Albert Bandura. SCT is comparable to HPM such that they both evaluate the importance of cognition in altering behaviors. The purpose of SCT is to understand and predict individual and group behavior, and identify methods to change behavior. Bandura theorized that an individual’s behavior is based upon personal factors, and the environment (Social Cognitive Theory, n.d.).
With providing any education, it is crucial to incorporate specific content that will aide in the retention and understandability of the material. In conjunction with the noted clinical problem, effective patient education was necessary to ensure the advancement of patient knowledge of adverse reactions of LHR including hypo/hyperpigmentation and microcrusting. Both theories supported the development of this EBP project by including the need to focus on specific educational material specific to adverse reactions specific to LHR.
Application to practice change. Prior to the initiation of the EBP project, an observation of the clinic population was conducted. It was understood that the educational PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 29 intervention needed to be tailored to fit the population. The HPM provides insight on methods to ensure optimal retention of the educational material. It was important to create educational materials that could be understood by the patient population. Once the patient understood the information they could apply the knowledge gained to improve their knowledge of LHR in the aesthetic industry. Methods derived from the SCT were considered to ensure patient retention and understanding of the provided educational material. Since most of the clinic population sought treatments based on social media influencers, the educational material included a video found on YouTube, which was a common site used for promotion of laser hair removal.
Stetler Model
The Stetler Model of Evidence Based Practice will be used as the guiding EBP model for this project. The Stetler Model uses a series of steps to evaluate and research findings necessary to ensure safe implementation of EBP (Melnyk and Fineout-Overholt, 2015). This model has been known for its focus on practitioners with a concentration on critical thinking and use of findings by the practitioner. It can also be considered to incorporate other groups of clinicians
(Melnyk and Fineout-Overholt, 2015).
Application to practice change. The Stetler Model was utilized to address the presented clinical problem. The Stetler Model uses five phases that will assist in the EBP change process.
These steps include: (1) preparation, which involves finding the purpose, context, and sources of evidence; (2) validation, which critiques and gathers essential components and details of evidence and eliminates non-credible sources; (3) comparative evaluation and decision-making, which synthesizes findings and determines which evidence to use; (4) translation and application, which confirms the operational definition of use and action for change; and (5) PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 30 evaluation, which determines and identifies if the outcomes were obtained (Melnyk and Fineout-
Overholt, 2015).
During the preparation phase, an intense search for evidence was conducted through several research databases. This phase was prolonged due to the lack of published evidence related to adverse reactions in aesthetic medicine with a focus on laser hair removal. Once valuable literature was obtained, an intensive literature review was initiated. This review provided a summary of all relevant evidence which was incorporated in the validation phase. The research provided support for the intervention of patient education. Within the comparative evaluation and decision-making phase, five significant pieces of evidence were obtained to provide substance and sustenance. The translation phase included comprising an educational intervention for patient education, and constructing a pre- and post-test. Implementation and evaluation of the educational material occurred with individualized sessions. The evaluation phase provided data and feedback of the educational material. These results confirmed that the outcomes of increased patient knowledge, and the reduction of micro crusting/burns and hypo or hyperpigmentation were achieved.
Summary
To address the lack of patient knowledge in the aesthetic/ cosmetic industry, an EBP project was developed and implemented. A systematic approach, inclusive of the C-T-E conceptual framework was integrated to efficiently and successfully implement this practice change. Concrete structure and framework were essential in initiating the EBP project.
Components involved in this formal structure include the concept of patient education, and the
Social Cognitive Theory and Health Promotion Model. The use of the Stetler Model provided a step by step outline from initiation to implementation of the EBP project. The C-T-E conceptual PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 31 framework assisted in addressing the clinical problem of: In the adult population receiving aesthetic/cosmetic treatments related to LHR, does patient education improve knowledge and reduction of micro crusting/burns and hypo or hyperpigmentation? By incorporating these theories and models, a foundation was designed for the implementation of an educational intervention for this EBP project. Overall, each step assisted the project manager with understanding, predicting, and evaluating data associated with the EBP project outcomes of (1) increased patient knowledge and (2) reduction of adverse reactions including micro-crusting and hyper-/hypopigmentation. The next chapter will discuss the pre-implementation steps of the EBP project.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 32
Chapter Four: Pre-implementation Plan
Evidence has shown that EBP is essential to ensuring both the highest quality of healthcare and improving patient outcomes (Melnyk and Fineout-Overholt, 2015). The previous chapters have provided supporting evidence and recognition of the lack of patient knowledge in the aesthetic industry. The ability to translate evidence into clinical practice through the utilization of a conceptual framework, guiding theory and an EBP model assisted in the development of the EBP project with an end goal of providing a higher-standard of patient care.
The purpose of the chapter is to discuss the planning, implementation, and evaluation of the educational material given to aesthetic patients receiving laser hair removal (LHR).
Project Purpose
In the United States, the American Society of Aesthetic Plastic Surgery found that
2,271,818 aesthetic/cosmetic procedures were performed in 2012 (Alexis, 2013). This EBP project was implemented to increase patient knowledge in the aesthetic/cosmetic industry, and provide attention to laser hair removal. Prior to initiating LHR, patients were provided with a pre-test to assess their knowledge of adverse reactions that are associated with treatments. A short video/PowerPoint was viewed. This included information on the process of LHR, potential adverse reactions associated with aesthetic treatments, and post-treatment care. An information sheet was given to the patient after their treatment. A follow-up phone call was conducted for patients unavailable for their second treatment at 4 or 6 weeks. For those available for the next appointment, a post-test was given to assess their knowledge and to evaluate if any adverse reactions occurred. The desired outcomes of the EBP project included the following: (1) increase patient knowledge on the potential of burns/micro-crusting and hyper-and hypopigmentation (2) reduction of adverse reactions including micro-crusting and hyper-/hypopigmentation. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 33
Project Management
Organizational readiness for change
Discussions amongst healthcare providers, medical directors, and regional directors, proved that the organization accepts change willingly as this project was readily considered. The organization seeks to provide optimal and safe treatments within the aesthetic/cosmetic industry.
The organization’s regional director and national medical director are always seeking more effective ways to enhance policies and procedures. Within the organization, there are methods to send up-to-date information, regarding treatments, to the operations review team for consideration in the latest policy and protocols. Organizational change requires a “fundamental shift in its mindset, behavior, culture, principles, and infrastructure” (Harris et al., 2016, p.7).
Healthcare providers understood that to increase patient knowledge and decrease the incidence of adverse reactions, a focus on patient education was necessary. Change does occur abruptly.
Environmental change can occur in small doses. For this to ensue, critical elements such as leadership and values is essential in correlation to change (Harris et al, 2016). Both leadership and values of this organization are focused on providing the best treatments and having esteemed patient satisfaction. Employing educational material can assist in increasing overall outcomes.
Inter-professional collaboration
An improvement team was comprised of individuals with knowledge, skills, and experience. The focus of this team was to interact dynamically to make good decisions and find effective solutions (Ogrinc et al., 2012). The inter-professional team involved in implementing this evidence-based practice project included two nurses (RN), one nurse practitioner (NP), one physician assistant (PA), one regional director, and patient care coordinators. The sales staff/patient care coordinator had initial patient contact. At this point, they provided a brief PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 34 overview of their desired treatment and the treatment consent form. To assist in the process, these clinicians obtained consent for patient participation in the EBP project, and administered a pre-test and educational material. After the treatment, the clinician provided each patient with an educational sheet to review at home. The regional director and PA assisted in reviewing content for validity. The project leader administered the pre- and posttest, the educational tool, and conducted necessary follow-up phone calls. As the project leader, it is imperative to understand the implications of change, and coordination between team members. This will allow for congruency amongst members and a healthy project environment.
Risk management assessment
In implementing an EBP project, the SWOT (strengths, weaknesses, opportunities, and threats) analysis was a necessary risk management assessment. Of this analysis, strengths and weaknesses are internal factors while opportunities and threats are external forces (Harris
Roussel, Dearmna, and Thomas 2016). Strengths and opportunities were used to efficiently implement the EBP project while weaknesses and threats could potentially harm the outcomes if they were not addressed (Harris et al., 2016). Strengths included prior evidence to support the
EBP project and willingness of the company to implement new protocols. Evidence has shown that educating aesthetic patients have led to an increase in patient satisfaction and knowledge of treatments. Currently, medical directors and regional staff welcome feedback regarding policies and procedures. Clinicians can submit potential clinical changes and adaptions.
Some weaknesses included the time allotted for education of patients, and resistance from sales staff. Since the clinic was busy, patient care coordinators often double book or schedule treatments with no down time between patients. This had the potential to bring conflict between the clinicians and patient care coordinators. Opportunities from this EBP include more educated PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 35 patients, increased patient satisfaction, and an increase in number of aesthetic procedures performed. The company has expanded largely due to social media marketing. Many patients seek treatments with this company over others because the standard of care is detailed and thorough, including educational material for LHR which enhance the credibility of the company.
Some threats included push back from the medical staff and unavailability of patients for follow- up phone calls. Although patient follow-up appointments were scheduled directly after the current treatment, patients have the option to cancel. Once the patient leaves the clinic, the patient may or may not be available for the follow-up posttest.
One of the largest barriers to overcome was the time allotted with each patient. In practice, the scheduled times are made based upon the patient’s treatment areas. In some cases, time allows for immediate same-day treatments of patients who purchase aesthetic services.
Unfortunately, these times were not sufficient for maximum patient education. To address this barrier, collaboration with medical and sales staff was essential. A team meeting was held to discuss the amount of time needed for the educational material, pre-test, and treatment. Harris et al. (2016) found that effective and efficient communication is a face-to-face interaction. This meeting also addressed the needs of the sales staff due to time requirements. A detailed timeline provided structure and guidance to both clinicians and sales. Cooperation and patience were key factors in successful implementation of this EBP project.
To overcome a decrease in participation post-treatment, patients were advised that a posttest will be given at their next visit. If the visit was missed, a follow-up phone call occurred to assess knowledge. Visits were scheduled before leaving the clinic. If the patient decided to cancel the appointment, a notification was placed on the chart to call and reschedule the PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 36 appointment. At that time, the posttest was provided during the call. Patients were asked if any adverse reactions were experienced, and if the information sheet proved effective.
Organizational Approval Process
Since the organization focuses highly on patient safety and satisfaction, approval was granted for this EBP project. The medical directors are continuously seeking evidence that will promote a positive change, and they support the advancement of education. A meeting was initiated with the regional director to assess the needs of the organization. Upon a collection of responses from clinicians and the regional director, increasing patient awareness and knowledge was identified as a need for LHR patients. After clearance from the regional director was obtained, support and cooperation was sought from clinicians and patient care coordinators. All disciplines were prepared to introduce this EBP project. A formal organizational approval was granted by August 07, 2017
Use of Information Technology
Processing and managing information through electronic devices such as computers and handheld devices is known as information technology (IT) (Hebda and Czar, 2013). In current practice, clinicians use IPads to take photos, retrieve patient health information and review previous treatment records, and document treatments or any adverse reactions. The use of electronic medical records (EMR) is the primary method of retrieval and documentation in at this practice site. Prior to treatment, patients create profiles that contain medical history questions, and consent forms. For this EBP project, IT aided in providing the educational material. If there is a RN in clinic with no NP or PA available, telehealth was utilized. Telehealth is the delivery of health information to both consumers and health care providers. Nurses can FaceTime the on-call
NP or PA to complete a good faith exam. The NP or PA will directly review the patients’ PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 37 medical history with the patient and provide either treatment clearance or defer the patient to obtain a primary care clearance letter. The educational materials were viewed on an IPad. The presentation consisted of PowerPoint slides, pictures, and narration. The pre- and posttest were constructed using Microsoft Word. Analysis and data collection was entered and evaluated through Microsoft Excel.
Materials Needed for Project
Prior to the implementation of the EBP project, brochures were given to recruit patients for participation. Approximately 120 copies of the brochure were printed. The printed brochure was folded into three sections to ensure ease of reading information. For implementation of this EBP project, participants were provided with a cover letter that includes details (Appendix A).
Participants were also provided with a letter of consent. For the EBP project, the Aesthetic
Knowledge Survey served as the pre- and posttest. Each letter was printed on 8x10 sheets of paper. There were approximately 90 copies of the cover letter, survey, and the consent made.
After receiving the cover letter and consent, participants were provided with the Aesthetic
Knowledge Survey. There were two boxes of ball point pens provided to fill out the survey.
After receiving the Aesthetic Knowledge Survey, each participant was provided with an IPad to view the educational materials. The educational material consisted of a short YouTube video and a PowerPoint presentation. After the educational material was reviewed, each participant was provided with a summary of the information provided via printed educational material. This required 90 8x10 printed sheets of paper. Microsoft PowerPoint and a YouTube video were used for the educational material. A laptop computer was used to create all written and digital materials. Microsoft Excel was used to input and organize data collected, formulate graphs and charts to depict the data collected. Black and color ink cartridges were purchased to print all PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 38 necessary materials. An external hard drive was used as a backup for all data collected and information created for the change project. All participant information was stored in a locked cabinet at the clinic site.
Plans for Institutional Review Board Approval
The Institutional Review Board (IRB) approval was an exempt plan submitted through
Chatham University. An exempt review shows that there is minimal risk to patients. Approval was sought during summer 2017. IRB was exempted August 16, 2017. Please refer to IRB
(Appendix A).
Plan for Project Evaluation
For successful implementation of the EBP project, a detailed project plan was created and continuously monitored (Harris et al., 2016). For this EBP project, participants included those of skin type IV-VI. Individuals of darker pigmented skin were included in this category. Both male and female participants were included. All participants were between the ages of 18 to 75 years of age. This demographic data was depicted using a Microsoft or MS Excel spreadsheet table.
After the demographic data was presented, project outcomes were reviewed. This EBP project evaluated and measured an increase in patient awareness and the reduction in incidence of adverse reactions.
Plan for Demographic Data Collection
Demographic information was obtained from each participant. This data included: age, gender, ethnicity, and if the patient had received LHR prior to the educational material. If a participant had LHR in the past, they were instructed to indicate if they had experienced any adverse reaction with a treatment. This collection of information provided a clear depiction of PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 39 the participant population. These demographics were displayed in percentage format located on
Microsoft Excel spreadsheet.
Plan for Outcome Data Collection and Measurement
Increase in Patient Awareness. The first outcome evaluated was the increase in patient awareness of adverse reactions in aesthetic treatments with a focus on laser hair removal.
Educational material was presented to assist in increasing patient awareness. The survey used to evaluate the outcome was the Aesthetic Knowledge Survey (see Appendix B & C). The same survey was used for both pre- and post-testing. This survey was self-developed and was evaluated by an expert panel of two experienced aesthetic nurses and the organization’s regional director. By doing so, this established content validity. The survey consisted of 10 questions addressing adverse reaction knowledge and methods to prevent these reactions. Each question was worth 10 points each. The total amount of points possible was 100. The higher the score concluded that there was a higher chance of an achieved benchmark.
Data analysis was completed using a paired t-test. The paired t-test was used to evaluate the differences between two groups (Salkind, 2017). The comparison data evaluated the results of the pre-test survey, and the results of the posttest survey. The posttest was not given until the follow-up appointment, or the follow-up phone call. Analyzing this data showed that the educational material resulted in an increase of patient awareness in aesthetic medicine.
Establishing a benchmark provided insight on the effectiveness of the educational material. For this EBP project, participants should score 80% or better on the post test. All scores were recorded for both pre- and posttest. The goal of 80% or better for at least 90% of the participants was the identified benchmark. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 40
Decrease in Adverse Reactions. The second outcome of this EBP project was to observe a decrease in the number of adverse reactions in participants with skin types IV-VI. It was expected that after the participants received the educational material, they were more informed of the actions they could take to prevent reactions from occurring. A chart review was conducted with three months of data relating to adverse reactions within those of darker pigmented skin.
The adverse reactions that were considered included hyper-/hypopigmentation, micro-crusting
(burns), hives, and itching.
To evaluate the effectiveness of the educational material, during the follow-up, each participant was questioned to determine whether or not an adverse reaction occurred. This data was documented on an MS Excel spreadsheet. At the completion of the participant follow-up, the intended data was expected to reflect minimal adverse reaction occurrences. The data will be displayed in a percentage format. The total number of adverse reactions was divided by the number of participants then multiplied by 100. The total number of non-reactions was divided by the number of participants multiplied by 100. An initial chart review was completed from
December 1, 2016 to February 28, 2017 and revealed that 58% of skin types IV-VI experienced reactions. Those reactions included micro crusting/burns and hypo or hyperpigmentation. Based upon these findings, an internal benchmark was established to reduce the reactions from 58% to
30% amongst skin types IV-VI.
Plan for Data Management
Data management was important for the organization of information, and accessibility when necessary. For both outcomes, the gathered data was collected and stored in folders. Each folder was labeled for the data it contained. Folders names included pre-test, posttest, and reaction occurrence sheet. All folders were kept in a locked cabinet located in the clinic. The PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 41 project manager (PM) had key access to these files. After the written materials were collected and stored appropriately, this data was entered electronically into an MS Excel spreadsheet. All electronic information was stored under and encrypted and locked laptop computer. The files were backed-up on an external hard drive, which was kept in a locked safe. At the completion of the EBP project, the data is intended to be stored for approximately five years in the locked cabinet. At the five-year mark, all written materials will be shredded.
Summary
Based upon recent years in aesthetics, two major concerns of patients include: (1) is the laser safe for their skin type and (2) are they going to develop a burn. As aesthetic procedures increase, patients need up-to-date information in order to provide consent for their treatment. It was found that the growing popularity of aesthetic treatments did not include substantial patient education necessary to understand the potential risks associated with LHR. The intent of this
EBP project was to provide patient education in an effort to increase patient knowledge and reduce reactions such as micro crusting/burns and hypo or hyperpigmentation of aesthetic patients. In any medical specialty, patient safety is necessary. Experienced and well-educated treatment providers are essential, but an educated and knowledgeable patient will ensure optimal safety. As this industry continues to grow, patient knowledge must grow as well. Patients should be aware of the potential risks and benefits, necessary precautions, and management associated with the sought-after treatments. The greatest outcomes of patient education are safety, clinician rapport, and confidence of their choices. The next chapter will discuss the implementation of the
EBP project.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 42
Chapter Five: Implementation Process
Literature has brought to attention that there is a need to educate patients in the aesthetic industry, specifically regarding laser hair removal (LHR). The purpose of this evidence-based practice (EBP) project was to provide patient education on adverse reactions, such as hyper-
/hypopigmentation, micro-crusting (burns), hives, and itching, that can occur from LHR. The target audience of darker individuals was based on evidence that dark skinned individuals were concerned about the side effects of LHR on their skin (Vachiramon and McMichael, 2011) and found to be a higher risk during a chart review at the implementation site. Melnyk and Fineout-
Overholt (2015) states that “it is not enough to have knowledge of the best-evidence to guide clinical practice” (p. 202); this knowledge must be translated into clinical practice. This chapter will discuss the setting, population, recruitment methods, and implementation process of the EBP project.
Setting
The setting utilized for this EBP project occurred in an aesthetic dermatology clinic located in Orange County, California. Since the clinic’s beginning slightly over a decade ago, there are now 37 locations found within California, Nevada, Texas, New York, and Arizona.
Typically, the clinic serves about 30-40 patients per day. This organization has been the leading provider of non-surgical aesthetic procedures in California. Some services that are offered at the clinic include, Botox, fillers, cool sculpting, laser hair removal, laser tattoo removal, and laser facials.
Target Population
The population of interest for this EBP project were male and female adults ages 18 through 75 with skin types IV-VI who were currently receiving laser treatments and those PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 43 initiating laser treatments. Patient exclusions included medical conditions that do not warrant laser treatments, pregnant women, and skin type I-III. Individuals with ivory and cream-colored skin tones were excluded from participation.
Recruitment
Brochures were created by the project manager (PM) stating that aesthetic treatments are safe and effective for those of darker pigmented skin. These brochures were intended to prompt participant interest. Recruitment was directed towards those indicated in the target population of male and female adults ages 18 through 75 with skin types IV-VI, currently receiving laser treatments and those initiating laser treatments. This recruitment was focused solely on individuals seeking aesthetic treatments at the implementation clinic site. The patient care coordinators and clinical staff were aware of the recruitment process. The recruitment process involved brochures in the waiting area that stated LHR use is safe with darker pigments. All patients that are skin type IV-IV were asked by the patient care coordinators if they would like to voluntarily be involved in an EBP project focused on providing education on adverse reactions with LHR such as hypo-/hyperpigmentation and microcrusting. As new patients had their scheduled consultation, any current patients were asked by the patient care coordinators if they were interested in participating in the EBP project. After being taken back to the treatment room, the patient care coordinators informed the PM if the patient chose to participate. If a new patient registered for treatment and stated that they would participate, the patient care coordinators informed the PM. The PM took the patient to the treatment room and presented each participant with a cover letter and consent form. The cover letter explained the purpose of the EBP project, and any benefits or risks associated with their participation. Each participant was informed that their involvement in the project was completely voluntary. Once all questions were answered, PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 44 and the individual decided to move forward with participation, they signed an informed consent letter. They were also informed that the project was voluntary and they could resign at any point of the EBP project without it affecting their care. Recruitment of the EBP project continued for the first three weeks of implementation of the EBP project until the desired number of 90 participants was reached.
Implementation Process
Harris et al. (2016) mentions that as an organization undertakes an EBP project, it should be aligned with its mission and aims. The aim of the implementation site is to provide outstanding and optimal patient care. This clinic site seeks to provide the most up-to-date aesthetic dermatology treatments, and promote positive patient outcomes. By the implementation of this EBP project, these standards were met. This EBP project used evidence-based literature to ensure quality patient care (Harris et. al., 2016).
Implementation began August 28, 2017 and continued through November 30, 2017. The
EBP project was divided into three phases. Phase I included a timeline for initiation of the consent form, cover letter, educational tool, and pre-test. Phase II of the project included a follow-up visit or phone call from each participant to complete the posttest survey and report if any adverse reactions occurred. Lastly, phase III involved analyzing and synthesizing data. This phase included a week of peer and faculty review of the EBP project and its results. This review also provides dissemination of findings throughout the organizational clinical staff
Phase I. During weeks one through three, 90 participants were recruited. After recruitment, each participant was provided with a cover letter and consent form (Appendix A).
Recruits obtained a detailed description of the project, explanation of all risks and benefits, intended project outcomes, and contact information for the project manager. There was an PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 45 additional 10 minutes allotted for any questions or concerns about their elective participation.
Once all questions were addressed, the participant signed the consent. This consent form also included a contact phone number if there was a need to conduct the Aesthetic Knowledge Post-
Test (Appendix C) via follow-up phone call. The consent forms were then placed in a folder designated for consent only. This folder was only accessed by the PM and secured in a locked file cabinet. Next, each participant was presented with the Aesthetic Knowledge Pre-Test
(Appendix B). This one-page survey consisted of 10-items. These items addressed their knowledge of aesthetic treatments, potential adverse reactions, and home care instructions. After the survey was completed each was placed in its designated folder. Next, a brief Power Point presentation was viewed by the participant using an Apple iPad. The video took about 15 minutes for each participant to complete. The beginning of the video contained a PowerPoint addressing the most common potential adverse reactions that occurred from LHR. The last page of the PowerPoint contained a link to a YouTube video of an aesthetic medicine clinician discussing the importance of sun avoidance during treatments and the potential negative effects if sun exposure was present during a LHR session. At the completion of the video, the PM addressed any further questions. After the questions and concerns were addressed, the PM conducted the treatment. At the completion of the treatment, each participant was given a printed copy of the Power Point presentation. The PM ensured that all participants understood that there was a post test administered at the next appointment. If they were unable to adhere to the scheduled appointment time, then the patient was prepared for a follow-up phone call. During the phone call, the posttest was administered, along with a question asking if any adverse reaction occurred. This call took approximately 20 minutes to complete. The posttest and adverse reaction form was placed in a folder until evaluation. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 46
Phase II. The next phase of the EBP project was to conduct a follow-up on the educational intervention. This phase occurred during weeks four through eight. This included conducting the Aesthetic Knowledge Post-Test. Typically, participants were scheduled for their next treatment at either four or eight weeks. As part of facility practice and protocol, a reminder text was sent 24 hours prior to the scheduled appointment. Once the participant arrived to the clinic, they were guided to the treatment room. They were asked if they experienced any adverse reactions from their last treatment. A yes or no response was documented on the adverse reaction form. They were then presented with the posttest. A maximum time of 10-minutes was allotted to complete the survey; more time was granted if needed. If a participant did not show up to their next treatment, they were given a phone call to complete the posttest and any adverse reactions were discussed. Responses to the posttest were placed in its respective folder and placed in a locked file cabinet. During this phase, the PM conducted a chart review of adverse reactions that occurred between September and October of 2016.
Phase III. During this phase, all collected data was analyzed via Excel Spreadsheets and placed into charts and graphs. A t-test analysis was conducted to compare the results of the pre- and posttest. The data supported the intended outcomes of increased patient awareness of aesthetic treatments and a reduction in occurrence of adverse reactions. After the data was compiled and organized, a peer and faulty review was conducted to establish reliability and validity. The regional director conducted a review for content validity. These reviews further validated the importance of patient education in the aesthetic industry.
Plan Variation
Two challenges were faced with the implementation of this EBP project. The first was expected by the PM. Attendance to a mandatory residency program by the PM was required. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 47
Although this occurred, a plan was set that included the PM being present more time throughout alternative weeks. Another challenge that was faced with the EBP project implementation was the amount of time provided for a sufficient patient educational intervention. Prior to initiation of the EBP project, an email was sent to have additional time placed in the schedule for potential participants. This did not occur. The educational intervention was rushed because the next patient and clinician were waiting for the treatment room. Fortunately, an additional room was provided so that patients could complete the pre-test and educational PowerPoint after their laser hair removal treatment.
Summary
Based upon recent years in aesthetics, the two top concerns of patients included the safety of using the laser for their skin type and the potential of getting burned. It was found that the growing popularity of aesthetic treatments did not include effective patient education. The intent of this EBP project was to provide comfort, knowledge and reassurance to current and potential patients. In any medical specialty, patient safety is necessary. This chapter demonstrated the target population of skin types IV-VI who were between the ages of 18-75 that received or sought to receive LHR in a Southern California aesthetic dermatology practice. The implementation steps were broken down into three phases to ensure structure and organization.
Using a pre-/post-test along with an educational PowerPoint and video allowed for patient retention of information and an increase in knowledge. Although there was an unexpected obstacle, due to scheduling, implementation of the EBP project was successful. The following chapter will discuss the evaluation process and methods used to formulate outcome measurements for this EBP change.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 48
Chapter Six: Evaluation and Outcomes of the Practice Change
To discover the effectiveness of an evidence-based practice (EBP) project, evaluation and analysis of outcomes must occur. Reviewing the overall outcomes, and performance of the project team is termed evaluation (Harris et al., 2016). This phase reflects that project objectives and timelines were met, and the evidence supported the intervention. According Melnyk and
Fineout-Overholt (2015), outcomes research uses a scientific process to produce new knowledge.
Once outcomes are recognized, project members can disseminate findings for others to review and use as evidence for clinical practice change. The chapter addresses the evaluation and outcomes for the PICO question: In the adult population receiving aesthetic/cosmetic treatments related to LHR, does patient education improve knowledge and reduction of micro crusting/burns and hypo or hyperpigmentation?
Participant Demographics
There was a total of ninety participants for the EBP project. Demographics for participants included age, ethnicity, and gender. In order to participate, each participant had to be scheduled for laser hair removal (LHR), have an age between 18-75 years, and be of skin types
IV-VI which includes Hispanic, African-American, Asian, and American Indian. The criteria did not exclude the male gender. The percentage of female participants was 94% (n=85) and male participants consisted of 6% (n=5). More participants were of the 18-25 age range. The age ranges of the participants were as follows: (1) 31% were 18-25 years, (2) 29% were 26-30, (3)
26% were 31-40, (4) 13% were 41-50, and (5) 1% were > 50 years. All age groups were represented within the EBP project (see Figure 6.1.)
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 49
Participant Gender
6%
Male
Female
94%
Figure 6.1. Participant gender.
Of the ninety participants, the Hispanics were the predominate population with 48%
(n=43) followed by the Asian population at 17% (n=15). Other ethnic groups included African-
Americans at 10% (n=9), and American Indian with no participation. All ethnic groups are represented below (see Figure 6.2). From the ninety participants, only 4% (n=4) experienced an adverse reaction such as hyper-/hypopigmentation, micro-crusting (burns), hives, and itching, that can occur from LHR. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 50
Ethnicity
14% Hispanic 11% African-American 48% Asian Middle Eastern 17% Other 10%
Figure 6.2. Participant ethnicity.
Outcome Findings
The intended outcomes of the EBP project included the following: (1) increased patient knowledge on the potential of burns/micro-crusting and hyper-and hypopigmentation and (2) reduction of adverse reactions including micro-crusting and hyper-/hypopigmentation. The
Aesthetic Knowledge Survey was used to measure knowledge of aesthetic patients on the adverse reactions that can occur from LHR. The Adverse Reaction log was used to determine the number of adverse reactions that occurred during the implementation period. Evaluating an EBP initiative determines how it affected patient outcomes and how effective it was to clinical practice (Melnyk and Fineout-Overholt, 2015).
Increased knowledge. An increase in knowledge was determined by comparing the total pre-test scores with the post-test scores. There was an 8% increase from the overall pre-test scores versus the post-test scores (see Table 6.1). This increase indicates that the educational intervention proved effective at increasing knowledge for patients receiving LHR. The average PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 51 score of the Aesthetic Knowledge pre-test was 89%. The lowest pre-test score was a 60% with the highest score achieved being a 100%.
Comparison of Mean Test Scores
Average Score on Pre-Test Average Score Post Test 89% 97%
Table 6.1. Scores proved significant with a p-value of 0.000 by t-test analysis.
For this EBP project, participants were projected to score 80% or better on the post test.
A t-test analysis was conducted and proved significant with a p-value of 0.000, using a p-value of .05. The goal was for at least 90% of the participants to achieve this benchmark. After reviewing the post-test scores, the average scores achieved was a 97% with only one participant scoring a 70% which was under the 80% benchmark. Overall, the benchmark was achieved to have at least 90% of participants achieve an 80% or higher on the post-test. Individual test questions were reviewed below (see Table 6.2).
Participants with Correct Answers
Pre-Test Questions Answered Correctly Post-Test Questions Answered Correctly Question 1 87 90 Question 2 86 90 Question 3 48 81 Question 4 87 89 Question 5 90 90 Question 6 78 85 Question 7 89 90 Question 8 77 84 Question 9 76 84 Question 10 84 89
Table 6.2. Number of participants that answered each question correctly for the pre-test and post-test. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 52
Reduction of adverse reactions. In the process of increasing patient knowledge, it was the intent to see a reduction in the amount of adverse reactions including micro-crusting and hyper-/hypopigmentation. A more knowledgeable patient will be more equipped to complete necessary actions to prevent a reaction from occurring. A chart review was completed from
December 1, 2016 to February 28, 2017 revealed that 58% of skin types IV-VI experienced reactions. Those reactions included micro crusting/burns and hypo or hyperpigmentation. Based upon these findings, an internal benchmark was established to reduce the reactions from 58% to
30% amongst skin types IV-VI. Of the ninety participants, only 4% (n=4) experienced micro- crusting and hyperpigmentation as a result of LHR. This percentage is less than the reactions experienced from September 2016- October 2016 which was 25% (n=35) (see Figure 6.3). This reduction further emphasizes that the educational intervention proved effective.
LHR Adverse Reactions 0.3
0.25 0.25 0.2
0.15
0.1
0.05 0.04 0 Post-Intervention Reactions Pre-Intervention Reactions
Figure 6.3 Percentage of LHR reactions post-intervention 4% (n=4) and pre-intervention 25% (n=35)
Summary
Through a comprehensive literature review, two outcomes were established to provide education and safety for patients seeking aesthetic procedures such as LHR. A visual educational PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 53 intervention proved to be successful in increasing patient knowledge of (1) the potential of burns/micro-crusting and hyper-and hypopigmentation and (2) reducing the incidence of adverse reactions including micro-crusting and hyper-/hypopigmentation. Makdessian et al., (2004) states that “written disclosure of risks of cosmetic procedures enables patient to retain and understand more clearly those potential risks” (p 26). This educational intervention demonstrated an 8% increase in the average scores of a pre-test to the average scores of a post-test. There was an average score of 97% for the post-test. This proved that more than 90% of participants scored higher than the established 80% benchmark. The scores proved to be significant based on the results of the t-test analysis. Overall, there were 4% (n=4) adverse reactions of micro crusting and hyperpigmentation. This number was below the internal benchmark of 58% and below the goal set for this project. Participants indicated that the educational PowerPoint and video provided them with new knowledge and understanding of the potential reactions associated with
LHR. The next chapter will discuss key elements such as DNP essentials linked to the EBP project, plans for dissemination, and policy implications.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 54
Chapter Seven: Discussion
Evidence-based practice (EBP) is the integration of available evidence, and the use of nursing expertise to deliver care that ensures that quality patient outcomes are achieved (Chism,
2016). When promoting EBP, the doctor of nursing practice (DNP) clinician must reduce the potential of barriers at the clinical site. To reduce the potential of barriers, the DNP clinician must ensure the importance of EBP to clinical practice (Chism, 2016). The purpose of this EBP project was to provide patient education on adverse reactions of laser hair removal (LHR) such as hyer-/hypopigmentation, and microcrusting. The outcomes of this EBP project included increasing patient knowledge, and reducing the incidence of occurrence of reactions in patients of darker skin. After the implementation of the EBP project, data analysis revealed that the educational intervention was successful. The purpose of this chapter is to discuss further recommendations for the implementation site, plans to sustain this EBP project, implications for policy, links to health promotion related to the EBP project, the DNP role, steps for EBP, and plans disseminate project results.
Recommendations for Site
Although this EBP project focused on educating LHR patients of skin types IV-VI, it is recommended that all patients receive standardized education regarding the aesthetic treatments.
Vachiramon and McMichael (2011) found that further exploration of patients’ attitudes is necessary to diminish negative attitudes associated with LHR. Based upon feedback of this EBP project, clinician discussion has concentrated on the inclusion of this education for additional services such as Botox, fillers, laser facials, and tattoo removal. Integrating a standardized, formal patient education across all locations will improve continuity of care. Patients will understand that aesthetic procedures are being performed with safety as the main priority. With PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 55 the use of technology, educational videos can be easily accessed prior to the initiation of treatment. To further reinforce this education, patients should be provided with written materials as well.
Another recommendation for the clinic site includes providing care that is safe, timely, effective, efficient, and patient-centered, by using collaboration amongst healthcare teams
(American Association of Colleges of Nursing [AACN], 2006). These teams must include constructive collaboration and communication. DNP graduates can employ leadership skills that are needed to successfully analyze organizational issues and develop practice models and guidelines (AACN 2006). The clinical implication proves that inter-professional collaboration will provide the patient education necessary to produce positive outcomes. Working in teams allows patients to see cohesiveness amongst various healthcare teams and ensures that patient well-being is priority.
The last recommendation for this clinic site includes providing sufficient time to ensure adequate patient education, treatment time, and post-treatment education. During the implementation of the EBP project, there were instances when the treatment schedule ran behind because there was not adequate allotted time to implement the educational intervention. At the completion of the EBP project, there was a challenge with receiving patient completion of the post-test. One recommendation is to decrease the amount of follow-up time between the educational intervention and the distribution of the post-test.
Plans to Sustain Change at Site. In order to sustain this EBP project at the clinic site, information must first be submitted to the human resources department and legal team to develop an official policy change. Prior to this submission, clinicians must ensure that all patients benefit from this change. Collaboration amongst the regional directors, medical director, and medical PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 56 staff must occur to ensure the education is tailored to all patients, rather than specifically to skin types IV-VI. This EBP project should not only be considered at the practice site, but should be initiated at all locations of the organization. Rather than incorporating the education at once, to all sites, the education should be implemented in phases over the time span of six months to a year. This will allow for an easier transition into practice.
Implications for Policy
Organizational or intuitional policies have the potential to either enhance or impede the delivery of healthcare services. DNP graduates are prepared to advocate for health policy and engage in political action (AACN, 2006). It is imperative for DNP leaders to be informed of policies at local, state, and national levels. This will provide an opportunity to for the DNP leader to advocate for current and future status of healthcare. A policy implication is to ensure that state and organizational support better patient outcomes through patient education. In the state of
California, the California Code of Regulation provides a detailed description of the duties and outlines the requirement ofdelegation performed by Physicians, Nurse Practitioners, Physician
Assistants, Medical Assistants (California Law Relating to Medical Spas, n.d.).
Currently, there is legislation in effect related to the aesthetic industry. The primary stakeholder most affected includes women, since they make up about 86 percent of those seeking cosmetic treatments (Kobrin, Hindery, & Lieberman, 2005). Other stakeholders would include healthcare providers and those who are directly related to the operation of the clinical setting that provides these types of cosmetic procedures. The role of the DNP prepared nurse advocating for policy change occurs at different levels including (1) professional organizations; (2) workplace involvement; (3) involvement through research; (4) volunteering; and (5) though supporting a political party (Chism, 2016). It is said that DNP nurses can be influential political candidates, PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 57 because of the ability to gain visibility, and educate politicians and the public about the DNP role and field of nursing (Chism, 2016).
Links to Health Promotion
According to American Association of Colleges of Nursing (AACN) (2006), clinical prevention is risk reduction, prevention of illness, and health promotion. Nationally, it is recognized that the health and safety of the nation’s citizens is a priority and interventions are in place to ensure the overall well-being of the population. Although interventions are in place, current literature reports these interventions are underutilized. With the foundation of clinical prevention and population health, the DNP graduate can actively implement and evaluate evidence-based recommendations. The clinical implication involves using evidence-based research to guide activities that will address health promotion, disease prevention, and improved health status.
Role of DNP-prepared Nurse. The Doctor of Nursing Practice (DNP) nurse has acquired the knowledge necessary to successfully demonstrate the integration of human behavior with the environment through the use of nursing theories and conceptual frameworks to improve health (AACN, 2006). The Health Promotion and Social Cognitive Theory were used to guide steps of the EBP project. Prior to initiation of the EBP project, the aesthetic practice sought methods to improve patient outcomes. Although policies were in place to decrease adverse reactions, the results of this EBP project implies that patient education was an essential factor in addressing the lack of patient education of laser hair removal.
The DNP graduate is prepared to serve as a mentor by educating and guiding individuals and groups through different transitions (AACN, 2006). Evaluating evidence-based care and exhibiting advanced levels of clinical judgement are a couple qualities of a DNP prepared nurse PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 58
(AACN, 2006). These are some qualities achieved through advanced nursing practice. A direct implication is the role of the DNP nurse through initiating, implementing, and evaluating an EBP project. The Advance Practice Registered Nurse (APRN) applies mentorship, analytical skills, and guidance through complex health and situational transitions through an organizational change to educate aesthetic patients.
Next Steps related for Evidence-Based Practice
An essential component of preparation at the DNP level is to be able to transform evidence-based research into practice with the intent to improve healthcare practice and outcomes (AACN, 2006). DNP graduates are expected to be innovators and advocators of evidenced-based research. Graduates are expected to “apply relevant findings to develop practice guidelines and improve practice and the practice environment” (AACN, 2009, p. 12).
Implications found within this EBP project is the need for further investigation on methods to improve patient knowledge of aesthetic treatments, and reduce the incidence of adverse reactions related to laser hair removal using evidence-based research. It is important for a DNP nurse to promote EBP research in the clinic setting. Methods to assist in the transition of EBP include formulating questions, conducting literature reviews, starting a journal club, promoting communication amongst other health care professionals, and identifying any unmet healthcare and societal needs.
Plans for Dissemination
The dissemination of EBP project findings is essential to the sustainability of the clinic change (Harris et. al., 2016). These findings, despite being positive or negative, are imperative.
The organization and outside parties will be able to understand the impact or lack thereof regarding the projects outcomes. Harris et. al (2016) mentions that dissemination of results it not PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 59 solely for replication, yet it is meant for others to use the project as a sample or plan on how it should be completed. There are two methods that the project manager (PM) will use to disseminate findings. The first will be through manuscript publication. The medical director of the organization provided support by offering assistance with the publication process. He has experience and has had several articles published. The second means of dissemination will be through creating a short presentation for other locations and the human resource department, of the organization, about the purpose and implementation of the EBP project. The ultimate goal is to update the current protocol to include this new method of educating patients on their aesthetic treatments.
Summary
The AACN (2006) mentions that the DNP nurse must be equipped and skilled to work within organizational and system leaderships to improve patient and healthcare outcomes. The implication of this EBP project shows that optimal patient outcomes and satisfaction are based on a knowledgeable patient. The organization should add evidence-based methods into its policy to address the lack of patient education and the amount of adverse reactions that occur. This EBP proved to be successful through data analysis. The PM provided suggestions of providing enough time to effectively educate patients and create an efficient method to follow-up with patient education. DNP leaders can affect policy within the organization, at local and state levels, through their involvement. This EBP project proved that evidence-based research is essential to reduce risks and promote health. The results of this EBP project concluded that patient education is an effective intervention for improving knowledge and reducing procedure complications. The next chapter will provide discussions on the final conclusions for this EBP project.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 60
Chapter Eight: Conclusion
The evidence-based practice (EBP) project that was discussed in this paper was the implementation of an intervention directed towards increasing patient education and reducing procedural specific complications in the patient receiving LHR treatment. The educational intervention was designed to increase patient knowledge of the adverse reactions such as hyper-
/hypopigmentation and microcrusting, with the intent to reduce the incidence of these reactions in a Southern California aesthetic dermatology clinic. The EBP project provided patients with a pretest, educational PowerPoint/video, and a posttest. The results of the intervention proved that there was an increase in patient knowledge and a reduction in the occurrence of hyper-
/hypopigmentation, and microcrusting through patient education. The purpose of this chapter is to highlight the clinical problem, evidence base, theory and model used to guide the process, an outline of the project management and implementation, outcomes, and final conclusions of the
EBP project.
Clinical Problem
Approximately 6.6 million Americans received cosmetic/ aesthetic medical treatments within the past decade (Sarwer & Crerand, 2003). One treatment that has become popular recently is laser hair removal (LHR). Although the results are desirable, many individuals are unaware of the adverse reactions caused by lasers. Since the Food and Drug Administration
(FDA) approval of laser and light-based technology for hair reduction for all skin types,
Vachiramon and McMichael (2011) found that the population was still unaware of the potential reactions produced by the lasers. Currently, the financial cost of treating a LHR reaction consists of a visit to the Dermatologist, and application of a topical medication. The monetary expense can range anywhere from $100-$200 per visit (The Law Dictionary, n.d). Also, patients’ self- PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 61 esteem can be affected if there are noticeable pigmentary changes that can at times resolve over time.
A literature review and chart review of the clinic site proved that lack of knowledge and education was a true clinical problem. This review demonstrated that the education should be focused amongst individuals of skin types IV-VI who have a darker pigment. This clinical problem guided the EBP project to introduce an educational intervention to address the lack of patient knowledge in the aesthetic industry.
Evidence Base
Current literature distinguished studies that support educating patients on aesthetic treatments, including laser hair removal to improve patient satisfaction and treatment outcomes.
This EBP project’s educational intervention addressed the lack of patient knowledge and assisted in the reduction of microcrusting, hyper- and/ or hypopigmentation in aesthetic/cosmetic treatments. Smedra et al. (2015) mentioned that discussing and providing educational material on contraindications, possible side effects and post-treatment care will decrease complications.
Freedman, Earley, and Balakrishnan (2006) and Williams et al. (2011) suggested that increased patient knowledge led to higher patient satisfaction, better understanding of treatment options, and greater number of scheduled procedures. In a prospective, randomized study,
Makdessian, Ellis, and Irish, (2004) noted that a more informed patient was aware of the advantages and disadvantages of the procedures. Since sun exposure was a large cause of adverse reactions; Huang et al. (2013) found that formal sun protection education in combination with written materials improved quality of life, sun exposure habits, and sun protection behaviors. Lastly, Eapen (2009) used a simulation tool that proved to be a reliable form of patient education and representation of treatment optimization. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 62
Theory and Model for Evidence-Based Practice
This EBP project was supported by the Health Promotion Model (HPM) and the Social
Cognitive Theory (SCT). The HPM focuses on health-promoting lifestyle and behaviors. This behavior and lifestyle adaptions were needed for patients to make the right decisions for post-
LHR care. The educational intervention suggested ways for patients to ensure an active role in reducing risks of hyper-/hypopigmentation, and microcrusting post treatment for LHR. The SCT helps to understand and predict individual and group behavior and to identify methods to change behavior. Behavior is based upon personal factors and environment (Social Cognitive Theory,
(n.d.). These theories together assisted the project manager (PM) in tailoring the educational intervention to be specific and easily understood by the population at this aesthetic dermatology clinic. Since the clinic population of social media influencers and their followers, the educational material included a video found on YouTube, which was a common site used for promotion of laser hair removal.
The Stetler Model served as a guide for this EBP project. The Stetler Model uses five phases that will assist in the EBP change process. These steps include:
(1) Preparation- an intense search for evidence was conducted through several research
databases.
(2) Validation- research provided support for the intervention of patient education; it
eliminated non-credible sources.
(3) Comparative Evaluation and Decision-making - which synthesizes findings and
determines which evidence to use; five significant pieces of evidence were obtained to
provide substance and sustenance. PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 63
(4) Translation and Application- comprised an educational intervention for patient
education, and constructing a pre- and post-test.
(5) Evaluation- results confirmed that the outcomes of increased patient knowledge and
the reduction of micro crusting/burns and hypo or hyperpigmentation were achieved
(Melnyk and Fineout-Overholt, 2015).
Project Management
The EBP project occurred in an aesthetic dermatology clinic that serves individuals of all ethnic backgrounds. Purposeful and logical planning was used prior to beginning this EBP project. This clinic has a reputation for providing high quality aesthetic treatments while maintaining the safety of its patients. Prior to initiation of the EBP project, risks and benefits were identified through a detailed risk assessment. Inter-professional collaboration was noted amongst two nurses (RN), one nurse practitioner (NP), one physician assistant (PA), one regional director, and patient care coordinators. Before Institutional Review Board (IRB) submission, the
Human Resources Director and National Medical Director of the clinic granted approval of the project to ensure that patient safety and confidentiality was procured. On August 16, 2017, IRB was exempted.
Project Implementation
Implementation of the EBP project began on August 28, 2017. The implementation process was divided into three phases. During the first phase, participants were recruited from weeks one through three. After the participants were recruited, they were provided with a detailed description of the project, explanation of all risks and benefits, intended project outcomes, and contact information for the project manager. After the PM answered all questions, each participant was given a consent form followed by the Aesthetic Knowledge Pre-Test. After PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 64 completion of the pre-test, participants were provided with the education intervention. A
PowerPoint followed by a YouTube video discussing adverse reactions was viewed by each participant. At the completion of their treatment, each participant understood that the follow-up
Aesthetic Knowledge Post-Test will be given at their next appointment in four to six weeks. If their appointment was missed, they were informed that they would receive a phone call to complete the posttest.
Phase two of implementation occurred from weeks four through eight of the EBP project.
During this phase, the posttest was given in-person or via phone-call. Participants were also asked if they experienced any hyper-/hypopigmentation or microcrusting after their last treatment. This information was documented on the adverse reaction log (Appendix xx). A chart review from September and October of 2016 was also conducted during this phase.
The third and final phase consisted of data collection and analysis. This information was documented using Microsoft Excel. Data was then placed in tables and graphs for visual presentation of the data in preparation for dissemination. A peer and faculty review of the written document was conducted at the completion of implementation.
Outcome Findings
The outcomes of (1) increasing patient knowledge on the potential of burns/micro- crusting and hyper-and hypopigmentation and (2) reducing the incidence of adverse reactions including micro-crusting and hyper-/hypopigmentation were achieved. Analysis of the Aesthetic
Knowledge Pre-Test and posttest scores of 90 participants revealed an 8% increase in scores. T- test analysis showed statistical significance with a p-value of 0.000, using a p-value of .05. The mean pre-test score was 89% in comparison to a mean posttest score of 97%. An established benchmark was achieved. At least 90% of participants achieved an 80% or higher on the post- PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 65 test. In regards to reaction reduction, of 90 participants only, 4% (n=4) experienced microcrusting and hyperpigmentation from LHR. The overall findings of the EBP project showed a positive impact from the educational intervention.
Discussion Summary
LHR is a rapidly increasing treatment option being performed within the aesthetic/cosmetic industry. A survey administered by Vachiramon and McMichael (2011) demonstrated that it was unclear that dark-skinned individuals could be treated with LHR.
Through the completion of an EBP project, it was proven that patients benefited from an educational intervention. This EBP project began with identification of a clinical problem. Once this problem was identified, literature was reviewed in support of the need to employ an educational tool to assist in disputing misinformation and misconceptions of LHR. This intervention aided by increasing patient knowledge of adverse reactions such microcrusting and hyper-/hypopigmentation. The SCT, HPM, and Stetler Model guided the implementation of the
EBP project. Findings of the project indicate that an educational intervention is beneficial for patients seeking aesthetic/cosmetic treatments. A future recommendation would be to include a more effective method for follow-up assessment. The EBP project showed difficulty in reaching its participants for the follow-up assessment. One suggestion would include an incentive for completion of the posttest, such as one free session of LHR. For this EBP project, it was unclear if the amount of time between the pre-test and posttest served as a slight barrier to obtain participant completion of the Aesthetic Knowledge Post-Test. Despite the effort placed behind obtaining the posttest, both benchmarks were exceeded and the educational interventions proved as successful in alleviating the identified clinical problem.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 66
Final Conclusions
To embody successful leadership, a DNP prepared nurse must be a facilitator, role model, visionary and most importantly a professional (Chism, 2016). These qualities were necessary to successfully search for literature and to design, implement, and evaluate and EBP project. This
EBP project was implemented to educate patients on adverse reactions such as hyper-
/hypopigmentation and microcrusting resulting from LHR, and to reduce the reaction occurrence through an educational intervention. Due to the increasing rate of aesthetic/cosmetic procedures, patients must be educated to combat the misinformation and negative perceptions found regarding LHR treatment on individuals of darker skin. Education was found to be an effective intervention in increasing patient knowledge and reducing the incidence rate of adverse reactions. It is imperative that EBP continues to be implemented in the practice setting to increase patient safety and improve patient outcomes.
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 67
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Appendix A
Participant Cover Letter
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Appendix B
Aesthetic Knowledge Pre-Test
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 73
Appendix C
Aesthetic Knowledge Post Test
PATIENT-FOCUSED EDUCATIONAL TOOL IN AESTHETICS 74
Appendix D
Brochure