EVIDENCE-BASED PROJECT, PART 2: ADVANCED LEVELS OF CLINICAL INQUIRY AND SYSTEMATIC REVIEWS NURS 6052

EVIDENCE-BASED PROJECT, PART 2: ADVANCED LEVELS OF CLINICAL INQUIRY AND SYSTEMATIC REVIEWS NURS 6052

EVIDENCE-BASED PROJECT, PART 2: ADVANCED LEVELS OF CLINICAL INQUIRY AND SYSTEMATIC REVIEWS NURS 6052

Introduction

• This presentation will discuss:
• A clinical issue of interest- CLABSI
• Developing my PICOT question
• Research Databases used
• Peer-reviewed articles
• Strengths of Systematic Reviews

The following presentation will discuss a clinical issue of interest that I have identified. I will describe how I developed my PICOT question. In addition, I will state the databases I used to conduct my search for the peer-reviewed articles and list the articles used.  Besides, I will describe the level of evidence for each article and explain the strengths of using systematic reviews for clinical research.

Clinical Issue of Interest

• Clinical issue- Central line bloodstream infection
• A lab-confirmed bloodstream infection
• It affects patients with central line catheters
• CDC estimate about 41,000 CLABSI annually
• Contributes to: prolonged hospital stays
• High patient care costs & mortality
• Prevention: Aseptic techniques, surveillance, & management

Central line bloodstream infection (CLABSI) is my chosen clinical issue of interest. It is a laboratory-confirmed bloodstream infection not associated with an infection at another site, which occurs within 48 hours of a central line placement (Bell & O’Grady, 2017). CLABSI affects hospitalized patients with central line catheters. It occurs when microorganisms enter a patient’s central line and then into their bloodstream.

CLASI is an issue of interest since the CDC estimates that about 41,000 bloodstream infections are caused by contaminated central lines in U.S. hospitals annually (Bell & O’Grady, 2017). Besides, it contributed to prolonged hospital stays and increased patient care costs and mortality. Nevertheless, most CLABSI cases can be prevented through appropriate aseptic techniques, surveillance, and management interventions (Bell & O’Grady, 2017). The CDC and Infectious Diseases Society of America (IDSA) have developed CLABSI prevention guidelines during central line insertion and maintenance.

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PICO

In hospitalized patients with central lines, does daily chlorhexidine baths compared with daily bath with regular soap and water decrease the incidence of CLABSI infections during the hospital stay?

EVIDENCE-BASED PROJECT, PART 2: ADVANCED LEVELS OF CLINICAL INQUIRY AND SYSTEMATIC REVIEWS NURS 6052

Developing the PICO Question

• Identified population of interest- patients with central line
• Researched for an EBI from peer-reviewed articles
• Intervention- use of daily chlorhexidine baths
• Comparison intervention- bath with regular soap and water
• Indentified outcome- decreasing CLABSI infections

Research Databases

I used several research databases to search peer-reviewed articles on interventions effective in addressing CLABSI among hospitalized patients. The databases include:

PubMed, MEDLINE, Cochrane Library, and CINAHL Plus.

Peer-Reviewed Articles

Musuuza, J. S., Guru, P. K., O’Horo, J. C., Bongiorno, C. M., Korobkin, M. A., Gangnon, R. E., & Safdar, N. (2019). The impact of chlorhexidine bathing on hospital-acquired bloodstream infections: a systematic review and meta-analysis. BMC infectious diseases, 19(1), 1-10. https://doi.org/10.1186/s12879-019-4002-7

Reyes, D. C. V., Bloomer, M., & Morphet, J. (2017). Prevention of central venous line-associated bloodstream infections in adult intensive care units: a systematic review. Intensive and Critical Care Nursing, 43, 12-22. https://doi.org/10.1016/j.iccn.2017.05.006

Reynolds, S. S., Woltz, P., Keating, E., Neff, J., Elliott, J., Hatch, D., … & Granger, B. B. (2021). Results of the Chlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line-associated bloodstream infections Study (Changing Baths): a stepped wedge cluster randomized trial. Implementation Science, 16(1), 1-16.  https://doi.org/10.1186/s13012-021-01112-4

Scheier, T., Saleschus, D., Dunic, M., Fröhlich, M. R., Schüpbach, R., Falk, C., … & Schreiber, P. W. (2021). Implementation of daily chlorhexidine bathing in intensive care units for reduction of central line-associated bloodstream infections. Journal of Hospital Infection, 110, 26-32. https://doi.org/10.1016/j.jhin.2021.01.007

Levels of Evidence

• Musuuza et al. (2019)- Level I evidence
• Reyes et al. (2017)- Level I evidence
• Reynolds et al. (2021)- Level II evidence
• Scheier et al. (2021)- Level III evidence

Musuuza et al. (2019) is a level I evidence article. It employs a systematic review and meta-analysis of randomized controlled trials, cluster-randomized trials, and quasi-experimental studies.

Reyes et al. (2017) is a level I evidence. It conducted a systematic review of Randomized controlled trials and observational studies.

Reynolds et al. (2021) is a level II evidence article since it uses evidence from a stepped wedge cluster randomized trial.

Scheier et al. (2021) is a level III evidence article since it uses evidence obtained from well-designed controlled trials but without randomization.

Strengths of Using Systematic Reviews for Clinical Research

• Minimizes bias- reliable & accurate conclusions
• Information is easier for the reader to understand
• Produce reliable estimates on interventions’ impact
• Disclose where knowledge is lacking
• Save time for research discoveries & implementation
• Increase generalizability & consistency of outcomes

Systematic reviews concentrate on a specific clinical question and carry out an extensive literature search to discover studies with sound methodology (Møller et al., 2018).

Advantages of using systematic reviews in clinical research include:

1. The method employed to find and select the studies minimizes bias and thus highly likely to lead to reliable and accurate conclusions (Møller et al., 2018).
2. Systematic reviews sum up findings from multiple studies, making the information easier for the reader to understand.
3. They abide by a strict scientific design founded on explicit, pre-specified, and reproducible methods. Consequently, they produce reliable estimates about the impact of interventions to make defensible conclusions (Møller et al., 2018).
4. They disclose where knowledge is lacking, which guides future clinical research.
5. They save time used in research discoveries and implementation (Møller et al., 2018).
6. Systematic reviews also increase the generalizability and consistency of outcomes.

References

Bell, T., & O’Grady, N. P. (2017). Prevention of Central Line-Associated Bloodstream Infections. Infectious disease clinics of North America, 31(3), 551–559. https://doi.org/10.1016/j.idc.2017.05.007

Møller, M. H., Ioannidis, J. P., & Darmon, M. (2018). Are systematic reviews and meta-analyses still useful research? We are not sure. Intensive Care Medicine, 44(4), 518-520. https://doi.org/10.1007/s00134-017-5039-y

Nursing Staff Shortages

The clinical issue of interest I selected is nursing staff shortages in relation to nurse burnout and patient outcomes. For as long as I have been a nurse, I have experienced this issue firsthand. I wonder, though, how many people are affected by this. How many other nurses are putting in almost double the workload and resulting in burnout? How many patients are affected from a safety and quality of care standpoint?

Evidence-Based Practice

Evidence-based practice (EBP) is a problem-solving approach used in order to develop and provide the highest quality of care for the best patient outcomes (Stillwell et al., 2010). In order to retrieve relevant information, it is first necessary to establish a clearly defined question. The approach most commonly used to define this information is the PICO framework: P- Patient or Problem, I- Intervention, C- Comparison, and O- Outcome (Davies, 2011).

Research

To begin, I started a broad search on the nursing research page through Walden. I first typed in “nursing staff shortages” which produced 850 results. In an attempt to narrow down my research, I added “patient outcomes” in addition. This cut my options down to only 15, so I removed the “patient outcomes” phrase and replaced it with “quality of care” which resulted in 148. I then performed an advanced search to limit articles to “peer-reviewed scholarly journals only”, bringing the results down to 124. Finally, I wanted to be sure I was reviewing the most recent data, so I set a parameter to include articles only between the years 2018 to 2022. This really helped to simplify the process by reducing the number of articles to a manageable 65.

PICO

My PICO question for my chosen topic became more solidified as I continued my research. The problem (P) is nursing shortages have an impact on patient safety and quality of care (Tang et al., 2019). Interventions (I) are aimed at autonomy, recognition, and communication. Comparison (C) is done via three different instruments: the Maslach Burnout Inventory, the Job Satisfaction Scale, and the Basel Extent of Rationing of Nursing Care-R (BERNCA-R) and included feedback from 594 nurses (Uchmanowicz et al., 2020). Finally, the outcome (O) reveals that retaining expert nurses will have a positive effect on quality patient care.

References

Davies, K. S. (2011). Formulating the Evidence Based Practice Question: A Review of the Frameworks. Evidence Based Library and Information Practice, 6(2), 75–80. https://doi.org/10.18438/B8WS5N

Stillwell, S. B. , Fineout-Overholt, E. , Melnyk, B. M. & Williamson, K. M. (2010). Evidence-Based Practice, Step by Step: Asking the Clinical Question. AJN, American Journal of Nursing, 110 (3), 58-61. doi: 10.1097/01.NAJ.0000368959.11129.79.

Tang, J. H.-C., Hudson, P., Smith, M., & Maas, R. (2019). Evidence-Based Practice Guideline: Nurse Retention for Nurse Managers. Journal of Gerontological Nursing, 45(11), 11–19. https://doi.org/10.3928/00989134-20191011-03

Uchmanowicz, I., Karniej, P., Lisiak, M., Chudiak, A., Lomper, K., Wiśnicka, A., Wleklik, M., & Rosińczuk, J. (2020). The relationship between burnout, job satisfaction and the rationing of nursing care—A cross‐sectional study. Journal of Nursing Management (John Wiley & Sons, Inc.), 28(8), 2185–2195. https://doi.org/10.1111/jonm.13135

From a practice viewpoint, clinical issues represent the care aspects prioritized when performing clinical interventions. They are primarily the everyday events in health care delivery that adversely affect health outcomes. Clinical issues often inform research problems. In this case, they are the basis for evidence-based application in health practice where nurses and other care providers integrate scientific evidence with clinical expertise and patient preference to enhance health outcomes. This presentation describes the clinical issue of interest, PICOT development, and the databases used to conduct the search process. It also identifies the research databases used, APA citations for the peer-reviewed articles used, and levels of evidence. The last part is a detailed analysis of the strengths of systematic reviews as the highly recommended evidence type for clinical research.

To provide optimal patient care, nurses should always be in the right physical and mental health state. Unfortunately, clinical issues hamper nurses’ ability to provide quality and satisfactory care. Workplace incivility in nursing is among the common clinical issues profoundly affecting health outcomes. Typical among nurses, workplace incivility involves rude and disrespectful actions towards colleagues. Incivility shows disregard for others’ feelings and needs, often intending to harm or hurt them. The effects of incivility are far-reaching since it is positively correlated with anxiety and job burnout besides lowering nurses’ self-esteem (Shi et al., 2018). Other effects necessitating evidence-based interventions include the affected nurses negatively perceiving the nursing profession (Alshehry et al., 2019) and being highly vulnerable to medical errors (Abdollahzadeh et al., 2017). The outcomes are detrimental to the quality of patient care.

The PICOT approach is highly recommended in health practice when developing interventions for clinical problems. When creating the PICOT question, the problem or population in question is first identified. It should be vivid too. The issue of interest is workplace incivility among nurses. The other central components include the intervention and comparison. The intervention suggested to reduce workplace incivility is policy interventions and awareness programs compared to no intervention. From a practice viewpoint, the intervention should lead to a specific objective: reducing workplace incivility to promote a healthy working environment. The time frame defines the time it will take for an intervention to realize the desired outcome. In this case, six months.

To make informed decision about a clinical issue, nurses and other health care providers should search for evidence from the leading research databases. Since workplace incivility is a nursing issue, the search was limited to nursing research databases. As a reliable source of scholarly and peer-reviewed sources, CINAHL Plus with Full Text provides access to literature related to nursing and allied health. JAMAevidence has many nursing and health care articles. Trip Pro is largely a search engine that enables a nurse to access research evidence relevant to clinical practice. Systematic reviews and practice guidelines can be accessed via Trip Pro. Google Scholar facilitates search for peer-reviewed articles.

The full citations of the above articles have been provided in the reference list. As indicated, the articles focus on different research areas related to workplace incivility. The broadened focus enhances understanding of the topic to justify why evidenced-based interventions are necessary. The article by Kile et al. (2019) examined the effectiveness of education and cognitive rehearsal in managing workplace incivility. Both interventions enhance awareness of workplace incivility. Abdollahzadeh et al. (2017) examined how to prevent workplace incivility from a nurses’ perspective. Armstrong (2018) primarily focused on nursing workplace incivility prevention. The last article by Shi et al. (2018) examined the link between workplace incivility and job burnout.

Nurses should use the highest level of evidence to guide decision-making in health practice. Systematic reviews provide high-level evidence since they comprehensively search for evidence from multiple credible sources. Besides the high quality of evidence, systematic reviews narrowly focus on a clinical question. By synthesizing available evidence of a particular topic, systematic reviews help nurses and other health care providers to make more informed decisions regarding practice issues. Most systematic reviews identify research biases and flaws in the synthesized literature and propose areas that require further research based on the research gaps. As a result, they inform decision-making and guide future research.

This presentation primarily focused on workplace incivility as the clinical issue of interest. It deserves maximum attention due to its adverse impacts, including reducing nurses’ self-esteem, contributing to burnout and anxiety, and increasing the chances of nurses committing medication errors. Nursing and health care research should always be informed by the highest evidence level possible. As a result, systematic reviews are highly encouraged due to their high level of evidence and in-depth analysis of a clinical problem. Their use enhances understanding of a clinical problem and ensures that the evidence used to guide interventions is relevant to the reviewed issue.

References

›Abdollahzadeh, F., Asghari, E., Ebrahimi, H., Rahmani, A., & Vahidi, M. (2017). How to prevent workplace incivility?: Nurses’ perspective. Iranian Journal of Nursing and Midwifery Research, 22(2), 157-163. https://doi.org/10.4103/1735-9066.205966

›Armstrong, N. (2018). Management of nursing workplace incivility in the health care settings: A systematic review. Workplace Health & Safety, 66(8), 403-410. https://doi.org/10.1177%2F2165079918771106

›Kile, D., Eaton, M., deValpine, M., & Gilbert, R. (2019). The effectiveness of education and cognitive rehearsal in managing nurse‐to‐nurse incivility: A pilot study. Journal of Nursing Management, 27(3), 543-552. https://doi.org/10.1111/jonm.12709

›Shi, Y., Guo, H., Zhang, S., Xie, F., Wang, J., Sun, Z., … & Fan, L. (2018). Impact of workplace incivility against new nurses on job burn-out: A cross-sectional study in China. BMJ Open, 8(4), e020461. doi:10.1136/ bmjopen-2017-020461

 Evidence-Based Project, Part 1: Identifying Research Methodologies

NURS-6052C

Essentials of Evidence-Based Practice

Matrix Worksheet Template

 

Matrix Worksheet Template

Use this document to complete Part 1 of the Module 2 Assessment, Evidence-Based Project, Part 1: Identifying Research Methodologies.

Full citation of selected article	Article #1	Article #2	Article #3	Article #4
	Tolia, V. N., Murthy, K., Bennett, M. M., Greenberg, R. G., Benjamin, D. K., Smith, P. B., & Clark, R. H. (2018). Morphine vs. methadone treatment for infants with neonatal abstinence syndrome. The Journal of Pediatrics, 203, 185-189. https://doi.org/10.1016/j.jpeds.2018.07.061	Sutter, M. B., Watson, H., Yonke, N., Weitzen, S., & Leeman, L. (2022). Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study. BMC Pediatrics, 22(1), 1-7. https://doi.org/10.1186/s12887-022-03401-3	Davis, J. M., Shenberger, J., Terrin, N., Breeze, J. L., Hudak, M., Wachman, E. M., … & Lester, B. (2018). Comparison of safety and efficacy of methadone vs. morphine for treatment of neonatal abstinence syndrome: a randomized clinical trial. JAMA Pediatrics, 172(8), 741-748. Doi:10.1001/jamapediatrics.2018.1307	Gullickson, C., Kuhle, S., & Campbell‐Yeo, M. (2019). Comparison of outcomes between morphine and concomitant morphine and clonidine treatments for neonatal abstinence syndrome. Acta Paediatrica, 108(2), 271-274. https://doi.org/10.1111/apa.14491
Why you chose this article and/or how it relates to the clinical issue of interest (include a brief explanation of the ethics of research related to your clinical issue of interest)	This article was chosen because it is a primary peer-reviewed article. It relates to the clinical issue of interest (Treating Neonatal Abstinence Syndrome (NAS) in neonates) as it compares the efficacy of morphine and methadone as a form of treatment for NAS. The ethics of research related to the issue of interest include nonmaleficence and beneficence.	This article was chosen since it is a primary research article with one of the best research designs (randomized controlled trial). It is relevant as it reports the findings comparing the effectiveness of methadone and morphine in treating neonatal opioid withdrawal syndrome. It is important to determine which medication is more effective to reduce the length of hospitalization. The ethics of research related to the clinical issue include informed consent.	This article was chosen because it directly relates to the clinical topic of interest. It is also a primary peer-reviewed article; hence the results are valued. It relates to the clinical issue as it reports the findings of the use of methadone and morphine in neonatal abstinence syndrome. Among the ethics of research related to the issue of interest is informed consent.	This article was also chosen due to the fact that it is a peer-reviewed article that addresses the area of interest in relation to the treatment of NAS. The article is related to the area of interest since it focuses on the use of morphine in treating NAS.
Brief description of the aims of the research of each peer-reviewed article	The aim of the research was to compare the efficacy of morphine or methadone in reducing the length of stay among patients with neonatal abstinence syndrome. By identifying which medication is more effective infants will be treated more effectively, reducing the risk of long-term effects.	The aim of this study was to compare the length of treatment and hospital length of stay when using methadone and morphine to treat neonatal opioid withdrawal. This study identified that morphine is more effective in treating NAS and reduces the length of hospitalization.	The aim of this research was to determine the efficacy and safety of morphine and methadone in treating neonatal abstinence syndrome.	The aim of this study was to explore whether the addition of clonidine to morphine, as compared to morphine alone, is more effective in decreasing the length of treatment of patients with NAS. The study determined that adding clonidine reduced the length of stay.
Brief description of the research methodology used Be sure to identify if the methodology used was qualitative, quantitative, or a mixed-methods approach. Be specific.	The research methodology used in the Cohort study method. This is a quantitative research method since the data obtained was statistically analyzed.	The research methodology used in the article is a single-center randomized controlled trial. This is also a quantitative study method.	The research methodology applied in this research is a randomized controlled trial which is a quantitative methodology.	The applied research methodology used is a retrospective cohort study design. This methodology is also quantitative.
A brief description of the strengths of each of the research methodologies used, including reliability and validity of how the methodology was applied in each of the peer-reviewed articles you selected.	One of the strengths of cohort studies is that they are less prone to bias, and they can offer better data quality on primary exposure. The methodology was reliable and valid, as identified from the statistical analysis of the data using various statistical parameters.	Randomized controlled trials have various strengths, such as decreasing selection bias and minimizing confounding. The reliability and validity were evident as the methodology played a major role in eliminating bias hence reliable results.	Randomized controlled trials have various strengths, such as decreasing selection bias and minimizing confounding. The reliability and validity were evident as the methodology played a major role in eliminating bias hence reliable results.	Among the strength of the study include they are relatively cheaper and are more useful in cases of rare exposures. The validity and reliability were evident from the statistical parameters employed.
General Notes/Comments	This study supports the use of methadone treatment as it leads to decreased length of stay.	This article supports the identified clinical issue and shows the efficacy of using pharmacological approaches.	This randomized controlled trial showed that methadone has better impacts and hence should be preferred.	The major finding as the patients treated with the combination needed longer treatment time.

References

Davis, J. M., Shenberger, J., Terrin, N., Breeze, J. L., Hudak, M., Wachman, E. M., … & Lester, B. (2018). Comparison of safety and efficacy of methadone vs. morphine for treatment of neonatal abstinence syndrome: a randomized clinical trial. JAMA pediatrics, 172(8), 741-748. Doi: 10.1001/jamapediatrics.2018.1307

Gullickson, C., Kuhle, S., & Campbell‐Yeo, M. (2019). Comparison of outcomes between morphine and concomitant morphine and clonidine treatments for neonatal abstinence syndrome. Acta Paediatrica, 108(2), 271-274. https://doi.org/10.1111/apa.14491

Sutter, M. B., Watson, H., Yonke, N., Weitzen, S., & Leeman, L. (2022). Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study. BMC Pediatrics, 22(1), 1-7. https://doi.org/10.1186/s12887-022-03401-3

Tolia, V. N., Murthy, K., Bennett, M. M., Greenberg, R. G., Benjamin, D. K., Smith, P. B., & Clark, R. H. (2018). Morphine vs. methadone treatment for infants with neonatal abstinence syndrome. The Journal of Pediatrics, 203, 185-189. https://doi.org/10.1016/j.jpeds.2018.07.061

Hoare, Z., & Hoe, J. (2013). Understanding quantitative research: Part 2.27(18), 48–55.

         doi:10.7748/ns2013.01.27.18.48.c9488

Hoe, J., & Hoare, Z. (2012). Understanding quantitative research: Part 1. , 27(15), 52–57.  

          doi:10.7748/ns2012.12.27.15.52.c9485

One way to streamline and improve the research process for nurses and researchers of all backgrounds is to utilize the PICO search strategy. PICO is a format for developing an excellent clinical research question before starting one’s research. It is a mnemonic used to describe the four elements of a sound clinical foreground question (CINAHL, 2019). I previously worked at a Recovery Clinic in Ohio.  Opioid Epidemic was part of my job. Considering Ohio is in the top 10 for opioid use, we are funded by a state grant to combat this epidemic. The opioid epidemic has been spiraling out of control since 1999 and not getting any better. The CDC estimates that around One hundred thirty people die from opioid overdoses a day (CDC, 2019). The epidemic is only growing, but the use of Narcan can help some of these fatal overdoses. Narcan can reverse the deadly effects of opioids and requires no medical training to use (Narcan, 2019). At the patients’ first visit I supply them with a box of Narcan. Ultimately, this leads me to my PICO(T) question: (P) In opioid users who have (I) access to Narcan compared with those without (C) access to Narcan at risk of (O) having a fatal overdose while using opioids.  Strategies to increase the rigor and effectiveness of a database search would be to use more databases. According to Melnyk & Fineout-Overholt (2018), it is critical to use the right database for the best match.

Resources

Center for Disease Control and Prevention. (n.d). Retrieved September 16, 2019, from https://www.cdc.gov/drugoverdose/epidemic/index.html

CINAHL. (2019). EVIDENCE-BASED NURSING PRACTICE: 7 Steps to the Perfect PICO Search [Image]. Retrieved from https://www.ebsco.com/sites/g/files/nabnos191/files/acquiadam-assets/7-Steps-to-the-Perfect-PICO-Search-White-Paper.pdf

Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer.