Reading Research

Literature

Running head: RRL #5

Reading Research Literature - Number Five

NR 449ON - Evidenced Based Practice

1

Reading Research

Literature

Reading Research Literature - Number Five

Clinical Significance

a. Table

# Remaining Oriented # Experiencing Confusion

Treatment Group (Pt) 270 30

Control Group (Pc) 240 60

(Significantly different results: p < 0.01)

b./c. Calculations and Explanations

AR = Absolute Risk = Events/n = 30/300 = 0.1, indicating the risk of ICU patients

developing confusion.

ARR = Absolute Risk Reduction = Pc – Pt = 60 – 30 = 30, indicating how much lower

the probability of confusion is in the treatment group.

RR = Relative Risk = Pt/pc = 30/60 = 0.5, indicating the percentage of treatment-group

patients having an outcome divided by the percentage of control-group patients having an

outcome.

RRR = Relative Risk Reduction = 1 – RR = 1 – 0.5 = 0.5, indicating the proportional

difference in the rates of outcomes between the treatment group and the control group.

Odds = 30/60, indicating how many treated patients out of a group of untreated patients

experiencing confusion would also experience confusion.

OR = Odds Ratio = (30/270)/ (60/240) = 0.4444, indicating the odds of confusion in the

treatment group divided by the odds of confusion in the control group.

2

Reading Research

Literature

NNT = Number Needed to Treat = 1/ARR = 1/30, indicating the number of patients

needed to treat, explains how effective the treatment was (Manriquez, Villouta, &

Williams, 2007, p. 665).

d. The clinical significance of these findings is that ICU patients are less likely to become

disoriented if warm ambient lighting is used in the ICU in a 16-hour on/8-hour off cycle.

e. The clinical significance is consistent with the statistical significance, as the statistics

demonstrate its veracity.

Qualitative Studies

a. In the Bond et al. study, the participants were appropriate to provide data relevant to the

purpose of the study. First of all, since it was a qualitative study, qualitative results were being

sought, not quantitative results. Second, the data needed related to how the family members of

ICU patients presenting with traumatic brain injury felt about their loved one’s care; since all of

the participants were indeed family members of ICU patients presenting with traumatic brain

injury, they were fully qualified to provide information on how they felt about the patient’s care.

b. Based on the description of phenomenology given in the article, this is a

phenomenological study by virtue of the fact that it not only examines what the experience of

being a family member of an ICU patient with a traumatic brain injury is like, it also attempts to

elucidate the meaning of the family members’ experience in that context (Bond, Draeger,

Mandleco, & Donnelly, 2003, p. 66). The article includes “direct quotes that relate to a

particular theme the researcher has identified,” which is also consistent with a phenomenological

study (Bond, Draeger, Mandleco, & Donnelly, 2003, p. 66).

3

Reading Research

Literature

c. The theme of “need to know” signifies the family members’ need to know the truth about

their loved one’s condition, without “sugarcoating” on the part of doctors and other medical

personnel (Bond, Draeger, Mandleco, & Donnelly, 2003, p. 67). Family members just want to

know what they are facing—whether the person is certainly going to die, might live, or will

almost certainly live. The transferability of these findings could be compromised by the thinness

of the description provided in the article, which only devoted one short paragraph to the issue

and one table of family members’ responses. Family members of different patients might feel

differently, particularly given the small size of the sample.

Quantitative Studies

a. In the Wyatt et al. study, subjects were assigned to groups based on whether they

received the intervention and no additional agency-based home care, the agency-based home

nursing care, or no home nursing care (Wyatt, Donze, & Beckrow, 2004, p. 324). The women

had all had a positive breast cancer diagnosis and a lumpectomy, and their demographic

variables, functional status, and quality of life at baseline were very similar (Wyatt, Donze, &

Beckrow, 2004, p. 324). These great similarities increase the validity of the findings, because

the only significant variable is the treatment they received.

b. Instrument validity and reliability provided for the SF-36 Healthy Survey was statistical

in nature. The article stated that reliability coefficients on pre-test measures were .89 and on

post-test measures were .91 (Wyatt, Donze, & Beckrow, 2004, p. 326). Validity was related to

scoring, which was done according to a 0-100 scale, with the higher number indicating better

physical functioning (Wyatt, Donze, & Beckrow, 2004, p. 326).

4

Reading Research

Literature

Ridge & Goodson

a. Column graphs

Work

Home Management

5

Reading Research

Literature

The inferential test used to determine statistical significance was the p-test. The p-value

for work was 0.831, and the p-value for home management was 0.003 (Ridge & Goodson, 2000,

p. 76). The results for work are not statistically significant but those for home management are

statistically significant; statistical significance is predicated on the p-value being less than 0.05.

Both results were clinically significant, however, as evidenced by the noticeable improvement in

functional status.

b. This study’s findings can be used to improve at least one aspect of patient care by

implementing a change proposal based on the six steps of the Rosswurm and Larrabee model.

Rosswurm and Larrabee’s (1999, p. 318) “model for evidence-based practice” starts by

identifying a need for change in practice as the first step and then linking it to problem

interventions and potential outcomes as the second step (Rosswurm & Larrabee, 1999, p. 318).

The third step is to conduct a literature search and carefully assess the information found,

synthesizing the best evidence and considering any risks and benefits associated with

alternatives, as well as their feasibility (Rosswurm & Larrabee, 1999, p. 318). In the fourth step,

the proposed change is defined and the implementation process outlined, and required resources

are identified (Rosswurm & Larrabee, 1999, p. 318). Step five involves implementation and

evaluation of the change in practice as a pilot study; during this pilot, the solution is carefully

evaluated to determine whether it should be modified, adopted, or rejected (Rosswurm &

Larrabee, 1999, p. 318). The sixth and final step is to integrate the change into the standards of

practice and inform the stakeholders about it (Rosswurm & Larrabee, 1999, p. 318). Training is

provided to the staff to enable them to implement it, and ongoing monitoring takes place to

ensure that the process and outcomes are as anticipated (Rosswurm & Larrabee, 1999, p. 318).

6

Reading Research

Literature

In the Ridge and Goodson (2000, p. 81) study, it was proposed that further interventions

might include “activity and exercise management, physical comfort promotion, and self-care

facilitation.” Based on these suggestions, a proposal is offered for improving an aspect of patient

care—an approach for promoting physical comfort in hip replacement patients.

Step 1: The findings from this study can improve hip replacement patient comfort.

Step 2: To find out how to increase hip replacement patients’ physical comfort, a PICO-

formatted clinical question related to this problem was developed: Among patients that have just

had hip replacement surgery, do changes in mattress or the use of ergonomic chairs reduce pain

as much as pain medication does? The focus of this question is treatment, as changes in the

patient’s physical surroundings and accommodations could potentially reduce pain sufficiently to

replace pain medication or boost its efficacy in relieving pain.

Step 3: In a search of CINAHL and Medline, this PICO-formatted question yielded little useful

information. Starting with CINAHL, the search used was: patient AND hip replacement surgery

AND pain reduction AND (mattress OR ergonomic chair) AND pain medication. On CINAHL,

there were 91,489 results, and a scan of the first 60 results showed only one that mentioned

mattresses and none mentioning ergonomic chair. The one article that mentioned mattresses was

not discussing home care but the use of a special Nimbus bed for in-hospital patients that

facilitate the nurse’s efforts to move or roll the patient so as to avoid pressure on the affected hip

and prevent dislocation.

Using the same search strings on Medline resulted in zero results. However, changing

the search string to: mattress AND hip replacement yielded 29 results, of which one was the

same article about the Nimbus bed. However, Medline associated several “related articles” with

that one, and these were very informative. The abstract to “Pressure relieving support surfaces: a

7

Reading Research

Literature

randomized evaluation” discussed the PRESSURE—“Pressure Relieving Support Surfaces: a

Randomized Evaluation” Trial, which found that mattress overlays were an acceptable substitute

for a new mattress if a new mattress could not be obtained, as both provided the same pressure

relief (Nixon, Nelson, Cranny, Iglesias, Hawkins, Cullum, Phillips, Spilsbury, Torgerson, &

Mason, 2006, p. 1). Another related article homed in more closely on the target information I

was seeking, as it included mattresses and seat cushions in the mix with pressure-relieving beds

and sought to determine to what extent these items reduce pressure ulcer incidence compared

with standard support surfaces (Cullum, McInnes, Bell-Syer, Legood, 2004). The study

concluded that “higher specification foam mattresses” were preferable to standard hospital foam

mattresses in the hospital setting and that seat cushions and overlays needed further evaluation

(Cullum, McInnes, Bell-Syer, Legood, 2004). These results led me to adapt my focus from

comfort in general to relief of pressure ulcers and to focus on mattresses and mattress overlays as

a viable and effective solution.

Step 4: Using the information from the articles as a base, a solution was formulated that would

promote greater patient comfort in terms of combating bedsore development. The solution

proposed is that all hip replacement patients be assigned in hospital to special beds that have

higher specification foam mattresses on them and that they be advised to replace their mattress at

home with a high specification foam mattress or add a high specification mattress overlay, at

least during their convalescent period.

Step 5: One barrier for this solution is cost, as good-quality mattresses are quite expensive. The

overlays are far less expensive but not as durable, although they have comparable efficacy per

the study. A facilitator for this barrier would be a memory foam mattress supplier representative,

who could work to obtain group discounts both for the hospital and the patients.

8

Reading Research

Literature

Step 6: In order to implement this solution, resources and staff education will be necessary. Staff

needs to understand why the new mattresses will be in use, and patients should also receive

instruction along with the offer of the group discount so that they can make an informed decision

about replacing their home mattress or buying an overlay for it. Other resources include

brochures, slide presentations, and other informational and instructional items to help both staff

and patients recognize the benefits of the mattresses and overlays and any special issues that

might be associated with them. In addition, a system of monitoring and feedback should be

established to track the efficacy of this intervention, both at the hospital and home levels, and the

intervention should be modified as needed to achieve maximum effectiveness.

9

Reading Research

Literature

References

Bond, A.E., Draeger, C.R.L., Mandleco, B., Donnelly, M. (2003). Needs of Family Members of

Patients with Severe Traumatic Brain Injury. Critical Care Nurse, 23(4), (Aug), 63-72.

Cullum, N., McInnes, E., Bell-Syer, S.E., Legood, R. (2004). Support surfaces for pressure ulcer

prevention. Cochrane Database System Review, 3. PubMed. Retrieved on August 18,

2009 from: http://www.ncbi.nlm.nih.gov/pubmed/15266452?

ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_Di

scoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pu

bmed

Manriquez, J.J., Villouta, M.F., Williams, H.C. (2007). Evidence-based dermatology: Number

needed to treat and its relation to other risk measures. Journal of the American Academy

of Dermatology, 56(4), (Apr), 664-671. Science Direct. Retrieved on August 17, 2009

from: http://www.sciencedirect.com/science/journal/01909622

Nixon, J., Nelson, E.A., Cranny, G., Iglesias, C.P., Hawkins, K., Cullum, N.A., Phillips, A.,

Spilsbury, K., Torgerson, D.J., Mason, S. (2006). Pressure relieving support surfaces: a

randomized evaluation. Health Technology Assessment, 10(22), iii-163. PubMed.

Retrieved on August 18, 2009 from: http://www.ncbi.nlm.nih.gov/pubmed/16750060?

ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_Di

scoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pub

med

Ridge, R.A., Goodson, A.S. (2000). The Relationship between Multidisciplinary Discharge

Outcomes and Functional Status after Total Hip Replacement. Orthopaedic Nursing,

19(1), (Jan/Feb), 71-82.

10

Reading Research

Literature

Rosswurm, M.A., Larrabee, J.H. (1999). A Model for Change to Evidence-Based Practice.

Image: Journal of Nursing Scholarship, 31(4), 317-322. Wiley InterScience. Retrieved

on August 18, 2009 from:

http://www3.interscience.wiley.com/cgi-bin/fulltext/119939497/PDFSTART

Wyatt, G.K., Donze, L.F., Beckrow, K.C. (2004). Efficacy of an In-Home Nursing Intervention

Following Short-Stay Breast Cancer Surgery. Research in Nursing & Health, 27, 322-

331.

11