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Week 2: The Clinical Question

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Your capstone change project begins this week when you identify a practice issue that you believe needs to change. The practice issue must pertain to a systematic review that you must choose from a List of Approved Systematic Reviews (Links to an external site.)Links to an external site. for the capstone project.

· Choose a systematic review from the list of approved reviews based on your interests or your practice situation.

· Formulate a significant clinical question related to the topic of the systematic review that will be the basis for your capstone change project.

· Relate how you developed the question.

· Describe the importance of this question to your clinical practice previously, currently, or in the future.

· Describe what a research-practice gap is.

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Julie White

SundayOct 29 at 9:39am

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Opening Post_Julie

On a daily basis, healthcare providers are faced with an array of clinical decisions to be made in an efficient and timely manner. Translating evidence into best practices is one way to achieve this. Without current best evidence, practice is rapidly outdated, often to the detriment of the patient. Evidence based practice is the conscientious use of current best practice in making decisions about patient care (Sackett, Richardson, Rosenberg, & Hayes, 2000). It is important for health care professionals to ask questions about their current clinical practice. In this week’s threaded discussion you will ask that burning question that you ask in your daily care of your patients.

You’ll need to focus on asking the right questions, narrowing the questions to one that is nurse driven and the need for change is evident. The question that you formulate will be the question for your Capstone Project.

The process of reviewing scholarly articles for a change in practice is an important part of the development of any type of research project that can lead to a change in practice. As you are appraising the systematic review and other scholarly articles for your change project, think about areas of the article such as sample size, the population, type of study, discussion and limitations. Critiquing a research article will allow you to evaluate the scientific merit of the study and decide how the results may be useful in practice.

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Adele Allen

SundayOct 29 at 12:58pm

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Hello Professor and Classmates,

Nurses are called to rely on current research to guide evidence-based practice. The research on a topic can be vast and contradictory. Traditional reviews of the evidence are no longer appropriate. The information sifting called for with the wealth of information available is too great a task. The reviewer needs guidelines to ensure bias is minimized and the literature is reviewed in such a way that questions are answered reliably. It is easy to produce evidence to prove a point. Systematic reviews follow a framework with clear objectives, clear questions, criteria for inclusion , quality of evaluation, analysis of data for significance, and transparent reporting of the method used to conduct the review. The Cochrane Collaboration is a group which synthesizes data to answer questions related to interventions (Aromataris & Pearson, 2014).

The PICO format provides a framework to pose a question in a manner which assists in the search for evidence to answer that same question. Searchable key terms can be identified which lead to relevant evidence (CCON, 2016). I chose the systematic review: “Health-Associated Infections” (HAI) from the approved list. Using the PICO framework I broke down the study in the following manner:

P: surgical patients

I: preoperative bathing and showering with antiseptics of preventing hospital acquired surgical site infections.

C: preoperative bathing and showering with non-antiseptic preparations for preventing hospital acquired surgical site infections.

O: incidence of surgical site infections.

The decrease of HAIs from clinical practice is of the utmost importance. Elimination of HAIs is always a goal of care. HAIs increase the length of hospital stay and increases morbidity and mortality rates. Reimbursement of care is tied to ensuring patients do not become subject to these complications. There was a time in my practice when complications of hospitalization were not recorded, analyzed and reported to the general public. Currently transparency is expected by the public and hospitals are required to report infection rates. This has led to rigorous efforts to develop protocols and standards which eliminate the occurrences of HAIs. This benefits patients, reduces costs and ultimately drives nursing care in a positive direction which raises standards and calls for innovation.

The research practice gap occurs when there is a large body of knowledge and research pointing toward practice changes that are not implemented. Implementation of a new practice requires systematic review of the research. Many nurses are not adequately prepared to undertake EBP initiatives. The bedside nurse is in a key role to recognize where improvements need to occur but are often not supported in being change agents. Hospitals administrations need to provide the financial resources and academic support to assist staff nurses to the next level. Conner (2014), describes barriers to nurses using research such as lack of knowledge, lack of confidence in the process. Conner (2014), describes how the administration of Medical University Hospital in South Carolina noticed this problem and decided to tackle it. A shared governance model was initiated. The nurse’s knowledge was assessed, staff were educated, and a one year nurse fellowship program was developed where five nurses were mentored in conducting research.

References:

Aromataris, E. & Pearson, A. (2014). The systematic review: An overview. AJN, 114(3), 53-58. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00000446-201403000-00028&LSLINK=80&D=ovft (Links to an external site.)Links to an external site. (Links to an external site.)Links to an external site.

Chamberlain College of Nursing (2016). NR-439. RN Evidence Based Practice: Weekly Lessons 3. Downers Grove, IL: Online Publication.

Conner, B.T. (2014). Bridging the gap between academia and clinical practice How to build foundations for translating research and evidence-based practice to the bedside. American Nurse Today, 9(5), 40-43.

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Julie White

TuesdayOct 31 at 7:10pm

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Hi Adele.

Well done post; many things in healthcare have change over the years such as collecting and analyzing data related to infections. This had led to many improvements in care which we need to continue with to see quality outcomes. Your PICO question looks good with the appropriate elements in place; consider making your population more specific such as certain type of surgery and make your outcome measurable-what do you want to see with your intervention?

Julie

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Jessica Stuckert

MondayOct 30 at 3:59pm

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Professor and Class,

For this discussion post, I chose to read â€œSystematic Review and Meta-Analysis of Comprehensive Behavioral Family Lifestyle Interventions Addressing Pediatric Obesityâ€ (Janicke, et al., 2014). I am a bedside nurse in a large pediatric hospital, and I see many children who are clinically obese. Several of them are admitted for issues related to their weight, such as diabetes, but many are not. Additionally, many are admitted for tonsil and adenoid removal due to obstructive sleep apnea, but in talking with them and their families, it seems that the role their weight plays in their OSA has either not been discussed or barely discussed. Some of these hospitalized children are referred to our outpatient weight-management program, Center for Obesity and its Consequences in Health (COACH), but many are not. Currently, we have no way of knowing whether those who are referred ever follow up. After reading the systematic review and considering my current scope of practice, I developed the following question: can providing hospitalized, clinically obese pediatric patients and their parents with an information packet about the health risks of obesity and general information about our outpatient weight-loss program increase the likelihood that they will follow up in the COACH clinic? I developed this question by thinking about what I, as a nurse who only sees a patient for one or two shifts, can do to help obese patients to adopt a healthier lifestyle. Weight is a sensitive subject for patients and their families, and many nurses and physicians are uncomfortable discussing it, especially when the patient has been hospitalized for something unrelated. In my experience, in-patient physicians might mention the fact a childâ€™s weight is a risk factor for health issues and tell the parents they are referring them to the COACH clinic, but that is the extent of it. Â Once a patient is discharged and returns to their normal routine, it is easy to forget about the referral. This may be especially true for patients with overweight, sedentary parents, because the parents feel that the referral shines a negative light on their family. However, as healthcare providers, we know how detrimental obesity can be to physical and mental health. By not being proactive with our obese patients, we are complicit in their future negative health outcomes.

An article in Open Journal of Nursing (2014) posits that â€œapplying research findings in nursing practice is perhaps the greatest challenge facing the nursing profession todayâ€ (C. Agbedia, I. Okoronkwo, E. Onokayeigho,&Â M.A. Agbo). A research-practice gap occurs when there is peer-reviewed evidence for improved ways of doing things that are not adopted in nursing practice. Several factors can influence this phenomenon, including organizational culture, lack of technical support, and lack of education (C. Agbedia, I. Okoronkwo, E. Onokayeigho,&Â M.A. Agbo , 2014). To ensure that nurses adopt evidence-based practices, organizations must create a research culture where nurses are given the time to seek out new practices. They must also ensure that they provide adequate education of new processes, and after education nurse managers must follow up to ensure that these evidence-based practices are being consistently employed. Change can be frightening, especially when we are asked to change the way we have been doing something for a long time. For myself, I have come to see nursing as a constantly changing profession, and am therefore not bothered when I am asked to change my practice, so long as there is evidence to support that change. I think adopting this attitude helps me accept changes with less fear and annoyance.

References

Janicke, D. M., Steele, R. G., Gayes, L. A., Lim, C. S., Clifford, L. M., Schneider, E. M., & ... Westen, S. (2014). Systematic review and meta-analysis of comprehensive behavioral family lifestyle interventions addressing pediatric obesity. Journal of Pediatric Psychology, 39(8), 809-825.

Agbedia, C., Okoronkwo, I. , Agbo, M.A. (2014). Nursesâ€™ perspective of the research-practice gap in nursing. Open Journal of Nursing. 4(2). DOI:10.4236/ojn.2014.42013 (Links to an external site.)Links to an external site.

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Anna Campomanes

TuesdayOct 31 at 8:51pm

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Jessica,

You do have a very good understanding of childhood obesity and your patients’ and their families’ need for additional teaching about its significance. It’s when nurses can identify the reasons for their patient’s hesitance that we identify areas of concern others might have missed. I like how you made out your clinical question as it is very nursing-driven. You also explained how and when a research gap occurs. It’s enlightening to hear someone else say that nursing is constantly evolving and changing. I too try to keep an open-mind to new ideas our hospital’s education department might introduce. After all, I don’t know everything, and I can certainly benefit by learning from those who know more than me. I enjoyed your post, thanks for sharing.

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Erin Knevels

TuesdayOct 31 at 12:54pm

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Professor and class,

As nurses, it is our responsibility to advocate for our patients safety and well being. Sometimes as nurses we need to make decisions that will be better for our patients safety, even though it is not something they approve of or understand. We need to educate our patients on the reasons we do things a certain way and how it can better their outcome. Evidence based practice plays a large role in healthcare, with nurses being some who are most affected. We see practice changing almost daily as new research comes out showing that changing the way we practice can be more beneficial for our patients and ourselves.

The systematic review that most closely relates to what I do is that of health acquired infections. This speaks specifically to pre-op patients and how to decrease their risk of infection. One way to pose a question is to use the PICO template- population, intervention, comparison, outcome. In this case, we are monitoring surgical patients to see if using an antiseptic wash prior to surgery decreases the rate of infections. Decreasing the post op infection rate would tremendously improve patient outcomes, decrease death rates, decrease length of stay, and decrease cost for the hospital and the patient.

Research practice gap is what happens when research shows that a specific practice is what is best, but the clinical areas are not using that practice yet. This can be caused by a number of things including practicality and misunderstanding. According to jnd.org, sometimes clinicians believe that the research was too pristine and doesn't actual show a real world use.

Eventually practices change and health care providers must change, too. Getting stuck in your ways will inevitably cause poor outcomes for your patients.

https://guides.nyu.edu/c.php?g=276561&p=1847897 (Links to an external site.)Links to an external site.

Norman, D. (n.d.). The Reseach-Practice Gap. Retrieved October 31, 2017, from http://www.jnd.org/dn.mss/the_research-practic.html

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Lubomira Kotowska

TuesdayOct 31 at 5:57pm

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Professor, and Classmates,

For the past ten years of my nursing career, I have been employed in the sub-acute vent unit. It consists of a mixed population of patients with a common denominator. All of the patients have tracheostomies, some are dependent upon mechanical ventilator support, others rely on oxygen delivered via tracheostomy masks. In most cases, these patients are non-ambulatory and incontinent of bowel and bladder. In addition to their respiratory status being compromised, they also have neurological deficits, poor circulation, and other comorbidities such as diabetes. Some patients are admitted to our facility with multiple pressure ulcers at different stages and receiving treatment. Others come with skin intact. According to NPUAP (2001), 95% of pressure ulcers could be prevented. Bruno Costa the author of article “ Pressure Ulcers: assessment and Prevention in The Early Stages” supports the idea that prevention begins with assessment. Not only an assessment of the individual’s risk for development of pressure ulcers such as nutritional status, mobility, comorbidities but also skin assessment which should be performed Costa, B. (2013) “continuously from admission” (p.260). Our facility has a Pressure Ulcer Prevention Protocol, which includes a use of Low Air Loss Mattresses, nutritional support, turning and repositioning schedule and weekly skin assessment. Despite all efforts and interventions to prevent the occurrence of new pressure ulcers on weekly wound rounds lead by a Dr. K. wound specialist hired by our facility, new pressure ulcers are frequently identified. When does that happen? From intact skin, how does a patient develop a stage II, or DTI pressure ulcer? Apparently, our protocol is not carried out successfully.

Hence I would like to focus on systemic review on a subject pertinent to wound care. It would be great to have a designated wound care team, but since my intervention needs to be nurse-driven and show the need for change I will ask the following clinical question;

”Could increase in the frequency of skin assessment from weekly to every shift decrease the occurrence of new pressure ulcers?”

According to the (Moore, Z. E. H., Webster, J., & Samuriwo, J. (2015), the wound care team consists of healthcare professional who works closely to supervise prevention and manage wound care. As indicated by authors the team may have a simple strategy such as increased frequency of skin assessment, turning and repositioning schedule, or more complex including dietary interventions, mobilization, and education.

Increased incidence of new pressure ulcers indicates poor practice for nurses and healthcare facilities. In addition, treatment is more expensive than prevention. Most of all, pressure ulcers cause pain and decrease the quality of life for our patients. According to Lyder, CH.(2008) “Preventing pressure ulcers can be nursing intensive. The challenge is more difficult when there is nursing staff turnover and shortages. Studies have suggested that pressure ulcer development can be directly affected by the number of registered nurses and time spent at the bedside”.

The research-practice gap occurs when despite an accumulating body of knowledge about the effectiveness of some nursing interventions, the gap forms between what is known and what is practiced. According to (Thomson, M.A, 2015)’ “The problem of implementing valid research results in nursing practice is well known”, however, the problem involves many systems, and it is not merely the consequence of nurses failing to keep up to date.

References;

Closing the gap between nursing research and practice

Mary Ann Thomson, BHSc (PT), MHS,http://dx.doi.org/10.1136/ebn.1.1.7 (Links to an external site.)Links to an external site.

Costa, B. (2013). Pressure ulcers: assessment and prevention in the early stages. Nursing & Residential Care, 15(5), 258-262.

Moore, Z. E. H., Webster, J., & Samuriwo, J. (2015). Wound-care teams for preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD011011. doi:10.1002/14651858.CD011011.pub2. http://onlinelibrary.wiley.com.chamberlainuniversity.idm.oclc.org/doi/10.1002/14651858.CD011011.pub2/full (Links to an external site.)Links to an external site.

Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK2650/

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Anna Campomanes

TuesdayOct 31 at 9:04pm

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Lubomira,

I agree about how the prevention of pressure ulcers is less costly than its treatment. The medical-surgical units in our hospital employ similar interventions to yours. I work in NICU now, but my former colleagues from the medical units told me that there still is a high incidence of hospital acquired pressure ulcers. And it is a cause of concern because it significantly affects our reimbursement rates. This seems to be an example of a research gap. Your clinical question sounds valid and promising, I hope to hear more about what you find out.

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Jessica Stuckert

YesterdayNov 1 at 10:02am

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Lubomira,

I think this is a great idea. We learned in nursing school that pressure ulcers can form over a relatively short period of time, so having daily assessments could help prevent ulcers and help ensure that Stage I and II ulcers are properly treated so that they do not progress. Of course this a big patient safety and satisfaction issue, but it is also a financial one. When Stage III and greater pressure ulcers form during a patient's stay, they will require increased services and treatments. Also, I'm not sure insurance companies will reimburse facilities for those treatments if the ulcer forms during the patient's stay.

Jessica

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Melissa Kirk

TuesdayOct 31 at 9:35pm

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Professor and Class,

Nurses use research on a daily basis in their line of work. Nursing research is defined as “a systematic process of inquiry that uses rigorous guidelines to produce unbiased, trustworthy answers to questions about nursing practice” ( Houser, 2018). Nursing research creates new knowledge for the nursing practice. In order to conduct a systematic review, one must have the knowledge of developing questions and conduct literature searches (Houser,2018).

Based on the choices from the approved systematic reviews, I feel that the topic of hospital acquired infections best fits my current line of work. Being employed at a urology office, we see many patients that decide on elective surgeries, or may even need an urgent surgery. Occasionally, the patient will be readmitted to the hospital for an infection, or will need an urgent surgical procedure to clean up the infection (ex. I&D). By reducing the risk of hospital acquired infections after surgery increases patient satisfaction and allows the patient to heal in a timely manner. Hospitals and/or facilities lose money when a post-op patient returns with an infection. Initiating evidence-based practices revolving around the preparation of surgical patients could reduce the risk of HAIs.

A systematic review summarizes existing knowledge and answers specific questions related to a topic (Acromataris & Pearson, 2014). For the topic of hospital acquired infections, the question I have created is: Does the use of antiseptic cleansers for preoperative cleansing reduce the risk of hospital acquired infections or surgical site infections in urology patients?

P: Urology patients receiving surgical procedures

I: Use of antiseptics for pre-operative bathing

C: No use of antiseptics preoperatively

O: Decreased number of HAI of surgical sites of patient receiving urological procedures

“Research gaps prevent systematic reviewers from making conclusions and, ultimately, limit our ability to make informed health care decisions” (Robinson et al., 2013). A research gap indicates information is missing or incomplete; therefore, the key question has not been answered.

Melissa Kirk

Houser, J. (2018). Nursing research: Reading, using, and creating evidence (4th ed.). Sudbury, MA: Jones & Bartlett.

Robinson, K. A., Akinyeda, O., Dutta T., et al. (2013, February). Framework for determining research gaps during systematic review: Evaluation. Retrieved October 31, 2017, from https://www.ncbi.nlm.nih.gov/books/NBK126708/

Webster, J., & Osborne, S. (2015). Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database of Systematic Reviews2015, Issue 2. Art. No.: CD004985. doi:10.1002/14651858.CD004985.pub5.

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