Evidence based nursing research
question needed answered:
You are a NP in a leadership role on an Inpatient Adult/Gero psychiatric unit. In the past 4 months you have noticed a pattern of elderly female patients falling and injuring themselves in the middle of the night. Using the 3 major components of Evidence Based Practice (Melnyk & Fineout-Overholt, 2011, page 4 figure 1.1) Discuss the following in relation to your decision to make a practice change on the Unit:
Identify the best type of evidence to use to solve this patient care issue
Name the level of the evidence,
Briefly discuss Why you would use that particular type of Research Evidence.
Name and describe how you would use the other 2 Components essential for Evidence-based Clinical decision making and describe what changes you might institute on this unit.
example of how the answer should look:
I am a PMHNP in a leadership role on an inpatient adult/gero psychiatric unit. In the past four months I have noticed a pattern of elderly female patients falling and injuring themselves in the middle of the night. This is unacceptable. My goal is to improve the falls rate on the unit and to accomplish this I will utilize evidenced based practice (EBP). Evidenced based practice is a problem-solving approach to the delivery of health care that integrates the best evidence from well-designed studies and patient care data, and combines it with patient preferences and values and nurse expertise (Melnyk et al., 2010). Evidenced based practice is aimed at hardwiring current knowledge into common care decisions to improve care processes and patient outcomes and holds great promise for producing the intended health outcome (Stevens, 2013).
The first step in integrating the best evidence and the patient data is to search for the best evidence (Fineout-Overholt et al., 2010). The search for evidence to inform clinical practice is tremendously streamlined when questions are asked in PICOT format. Inquiries in this format take into account the patient population of interest (P), intervention or area of interest (I), comparison intervention or group (C), outcome (O), and time (T). Once articles are selected for review, they must be rapidly appraised to determine which are most relevant, valid, reliable, and applicable to the clinical question. Rapid critical appraisal uses three important questions to evaluate a study’s worth: 1) are the results of the study valid (level of evidence), 2) what are the results and are they important (how well was the study conducted), and 3) will the results help me care for my patients (how useful it is to practice)?
The Hierarchy of Evidence for Intervention Studies
The Hierarchy of Evidence for Intervention Studies categorizes the validity of studies from Level I to VII (Petrisor & Bhandari 2007). Available therapeutic literature can be broadly categorized as those studies of an observational nature and those studies that have a randomized experimental design. The reason that studies are placed into a hierarchy is that those at the top are considered the “best evidence” . In the case of therapeutic trials, this is the randomized controlled trial (RCT) and meta-analyses of RCTs. In contrast to this, the lowest level on the hierarchy (aside from expert opinion) is the case report and case series. The best type of evidence to solve the issues of falls would be Level I which is a synthesis of evidence from all relevant randomized controlled trials. Blair and Waszynski (2013) utilized this level of evidence to reduce falls in their psychiatric unit. Their findings are relevant and I will follow their example and evidence to solve the issue on my adult/gero psychiatric unit.
Research evidence alone is not sufficient to justify a change in practice. Clinical expertise, based on patient assessments, laboratory data, and data from outcomes management programs, as well as patients’ preferences and values are important components of EBP. Fall prevention is a challenge in any healthcare facility. Falls have traditionally been recognized as an inherent risk for geriatric or elderly patients and patients in general on psychiatric units. Independent mobilization coupled with the side effects of medications given to these patients for their psychiatric conditions increases fall risk (Blair & Waszynski, 2013). From my clinical expertise, I know that many psychiatric medications can cause blood pressure changes, often resulting in dizziness or an unsteady gait. Blood sugar regulation, electrolyte balance and muscle strength are commonly altered by psychiatric medications, increasing the complexity of managing patients with co-existing medical conditions such as heart disease, hypertension and diabetes.
Environmental Improvements
After accounting for patient preferences where we are able, my facility will implement the following measures: We will install rubber non-skid mats and provide shower shoes for patients who come to the facility without them. We would encourage patients to bring in clothing, especially pajamas that fit and that are not too long. For patients that do not have them, “Capri” length pajama pants with a Velcro waist would be available to prevent tripping over too long pajamas. Though patients my prefer them, clogs, crocks, flip flops and other backless shoes would be discouraged. We would make available lids for cups, spill proof water pitchers, and water bottles to encourage drinking but minimizing spills. Housekeeping staff would be reminded to limit the amount of water used during floor maintenance. Nightlights will be installed in all patient rooms or if the patient prefers, in private rooms the patient can leave their bathroom light on instead (Blair & Waszynski, 2013).
Functional & Physiological Attributes of Patients
An occupational therapy or physical therapy consult will be performed on selected patients whose fall risk score identifies physical risk factors impacting safe mobilization. The therapist identifies and makes recommendations to improve the patient’s mobilization and engagement in activities of daily living in a safe manner based on the patient preferences. We will implement orthostatic blood pressure monitoring twice per day and notify the PMHNP immediately of systolic blood pressures below 100 (if this is different from patient’s baseline), pulse rates above 100 or positional blood pressure changes of 20 mm/Hg systolic or 10 MM/hg diastolic. Patients will be notified of their increased fall risk and be given a bright green laminated card reminding them to change position slowly, recognize the potential for dizziness or weakness and call for assistance with mobilization (Blair & Waszynski, 2013).
References
Blair, E & Waszynski,C. (2013) . Fall Prevention in Psychiatric Nursing. Advance for Nursing, Retrieved online at http://nursing.advanceweb.com/Features/Articles/Fall-Prevention-in-Psychiatric-Nursing.aspx
Fineout-Overholt, E., Melnyk,, B., Stillwell, S., & Williamson, K., (2010). Evidence-based practice step by step: Critical appraisal of the evidence: Part I. American Journal of Nursing, 110(7):47-52
Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: step by step: the seven steps of evidence-based practice. AJN The American Journal of Nursing, 110(1), 51-53.
Petrisor, B., & Bhandari, M. (2007). The hierarchy of evidence: Levels and grades of recommendation. Indian Journal of Orthopaedics, 41(1), 11–15. http://doi.org/10.4103/0019-5413.30519
Stevens, K. (2013). The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas. OJIN, 2, -4.
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