Evidence-Based Practice in Vancomycin-Resistant Enterococci and Ambulation - Dissertation Example

? Evidence based practice- Vancomycin-Resistant Enterococci and ambulation Introduction There is a need to change in nursing practice since it is a vital issue. Key actions to encourage change in practice would include identifying a practice problem or opportunity for improvement. A team of stakeholders can also be selected to address the practice problem. This change would involve collecting internal data about the practice, collecting data that can be accessed externally for benchmarking with the internal data; refining the practice problem statement by linking the problem with possible interventions and what is expected as an outcome. In most instances, recognition of a practice problem prompts an evidence based practice (EPB). For instance, an EPB team with the goal of conducting an EPB project in a given duration would have to consider what outcomes by the patient need more improvement (Jones, 2004). Once a practice problem has been realized or determined, data both internal and external is collected. This data should be relevant to the practice problem to confirm that there is indeed the need for change and in the long run, improvement. It is crucial that the focus of evidence based practice is justified because it is resource intensive. A practice problem statement is also prepared so as to clarify what the evidence based practice is exactly (Fulton, 2010). The best evidence is also located using key actions. These are identifying the types and sources of evidence, making arrangements for the search for evidence, and conducting the search for best evidence. Types of evidence could include clinical practice guidelines, systematic reviews, expert reports, single studies as well as critical appraisal topics. The search of evidence is planned as a rigorous, systematic review, which would include formulating the research question to guide the search, selection of the research strategy, choosing the inclusion and exclusion criteria, and planning the synthesis (Kathleen, 2011). Clinical Question The nursing practice to be detailed is based on a hugely serious clinical question. The question seeks to establish whether patients acquired with Vancomycin-Resistant Enterococci (VRE) more likely to recondition due to physical therapy limitations. This is a clinical problem that requires research on how to handle it. The evidence also in his case is that patients with VRE are more likely to recondition due to physical therapy limitations. This is the main objective of evidence based research and what it entails (Parke, 2011). Literacy in significant information is required and access to adequate information so that evidence based practice (EBP) can be researched. The patient is the main stakeholder, and their health is vital. Besides the fact that the infection brings various disadvantages to their movement, policies should be put in place that would encourage movement by them without increasing the risks of spreading the infections. Physical therapy has extremely strict rules in relation to ambulation, but still there exists other kinds of infections that are not warranted to this policy measure. Even though, lobby privileges are awarded to some patients, risks are still there related to spreading the infection because of the infectious risks the VRE has. The patient can still walk and not undergo confinement to bed. The only set back is that infection makes them confined in their rooms leading to physical inactivity. This has its health related hazards like muscle problems for instance muscle atrophy (Lawrenceville, 2006). Synthesis of Literature Literature reviews have been able to provide details of primary research in human health policy as well as their care. These are considered as the highest standards in evidence based health care. They help in the provision of evidence during the investigation of the responses to the interventions of prevention, rehabilitation as well as treatment. They also detail about how valuable and accurate a diagnostic test for a given condition faced by specific patients or group settings (Larrabee, 2009). Important actions are to critically appraising and judging the strength presented from the evidence; synthesizing the evidence, and assessing the feasibility, benefits and risks, which are involved when implementing the practice. The EPB team, after synthesizing the evidence, should decide whether the body of evidence is sufficient quantity and strength to support a practice change. If so, the benefits and risks of the new practice should be considered in order to make a conclusive decision if they are acceptable and whether is feasible to the hospital environment (Kathleen, 2011). Getting evidence into practice is an immensely complex venture. The dynamics involved is wide thus considerations have to be certainly put in place. The promoting action on research implementation in health services framework (PARIHS) was developed so as to bring into light these complexities. It is also used to represent the various factors involved and their interdependence. These factors also play an enormous role in effective implementation of the evidence, in practice. Research that was previously used in the exploration of why research evidence is routinely used in practice has manly focused on the level of individual practitioners who deal with patients with VRE. It also tended to focus on barriers to utilization. While individual focus is indeed vital, giving evidence into practice required more than a focus on addressing individual influencing factors. The PARIHS framework, which mainly has a concept oriented map, if formed on the notion that the implementation of the research based practice depends on the ability to achieve behavior change within the medical institution. The change should also be significant and would involve individuals, teams and organizations (Kleinpell, 2009). Evidence is envisioned in a broad sense within the PARIHS framework including both non propositional knowledge and propositional knowledge from several types of evidence. The evidence can be established through research where studies would be conducted among the patients in order to find out what the practice change to entail. It would aim to find ways to reduce the risks of patients deconditioning as well as to find ways to reduce the risks related to other resistant organisms that do not follow the physical therapy policy (Kluwer, 2008). Clinical experience is also used, and this can be developed from medical practitioners who deal with such patients. This would be able to provide sufficient evidence since they are considered professionals and the change would most certainly be implemented with their assistance. The patient’s and caregivers experiences would also have to be considered. Caregivers face the greatest amount of risk. For instance with the use of PPE’s they are still at risks with infection even though it is minimized. The patients also act as a risks and the infection has a negative social effect on them since they would be quarantined most of time to reduce cross infection. Therapy sessions thus would also have to consider practitioners who would deal with the mental health of these patients. Local context information should also be collected. Context in this case would include the conditions the patients stay and how they use their environment for their benefit. Patients with such conditions tend to stay in small rooms due to limited resources; thus it is only applicable they use what they have and to their advantage (Larrabee, 2009). For evidence to be given high priority, certain criteria have to be met. These include the research evidence that is well conducted and that there is consensus about it. Clinical experience, another important factor, should be made explicit and be verified. This is through criticism and critical reflection and debate. Patient experience is also expected to be high. This is because the patients or their related families play a large role in the decisions since there narration about their experiences are seen as a valid source of providing evidence. Data about the hospital staff and patients is also noteworthy. This is usually information the hospital has over time about the policies and also the data should also be able to show the effect of policies that have been put in place by the hospital. This data can be considered to be part of the evidence base if it is collected in a systematic and presentable manner. This way, it would be easy to be evaluated and acted appropriately. This indicates the need to have a close interaction of both scientific and experiential factors (Lawrenceville, 2006). Nurses have the most experience in using EBP though in a survey conducted, it was established that less than half of the respondents were not familiar with evidence-based medicine. Reviews have been conducted to detail the implementation of EBP in critical care, as in this case the VRE patients. The authors found that outcome research employing evidence based approaches was seen is subspecialty areas such as pediatrics, obstetrics, and general anesthesia. The combination of practitioner expertise with data from systematic research, which has been conducted externally, was described as a benefit of EBP. While EPB has its origins in diagnosis and treatment related competencies of primary care, its branches are applicable to nontherapeutic specialties inclusive of critical care (Jones, 2004). Practice Change Designing the practice change is a crucial aspect of evidence based practice. Key actions would include defining the proposed action change, identifying needed resources, designing the evaluation of the pilot, and finally designing the implementation plan. The description of the new practice may be in the form of a protocol, policy, procedure, or guideline supported by evidence. Needed resources will have to be specific to the new practice and may include personnel, materials, equipment and forms. Even if, the new practice is specific, it should be pilot tested to evaluate it for any necessary adaptation before making it a standard for care. Thus, the EPB members will have to design the implementation plan, and the evaluation plan, considering translation strategies that encourage the promotion of a new practice (Jones, 2004). Some strategies include use of educational sessions, reminder systems, and audit and feedback. After designing the evaluation plan, the EPB team members collect baseline data on the process and outcomes indicators for which they will collect data used in future. Competencies related to this should include use of PICOT questions (patient/population, intervention, comparison intervention or comparison group, outcome, and time frame). The various stakeholders, especially practitioners, need to search for best EPB. This is also to enable them to integrate what they have in the guidelines based on patient preferences. Evidence-based practice mentors could also play a crucial role in the provision of knowledge about individual skills and their behavior. This would be able to understand that each patient is then at greater risk to decondition with a higher possibility of developing muscle atrophy, which can severely, hinder the healing capacity of each individual because of physical inactivity (Fulton, 2010). Practice issue arises because there are other resistant organisms that do not have this policy in place. This increases the risks that the patient would face because of ambulation. Thus, the evidence based practice mentors would be hugely beneficial to facilitate changes in clinician behaviors and also influence the sustainable changes in organizational structure within the hospital. The changes would require specific intervention strategies, persistence and also time as a factor. The mentor is tasked with the role of assessing the hospital's capacity to sustain an EBP culture, in this case the risks that patients face which would lead, to decondition due to physical. These mentors during the design of the practice change would be decisive in building EPB skills and knowledge through conducting group workshops that are interactive in nature. Further, they would also conduct mentoring on a one-on-one basis so as to be able to build a bond with those they mentor during the designing of the practice change (Kluwer, 2008). Design would also entail working with staff to generate internal evidence through outcomes management. They can use enhancing strategies like newsletters and seminars to encourage the change and also get suggestions. Evidence based practice implementation can be used as a model of practicing based on the EBP paradigm. This paradigm uses the EBP process to improve outcomes. The process, during the start, begins by asking clinical questions. This can be by asking the patients about their views as well as the stakeholders involved in their care for instance the nurses. Furthermore, it deals with incorporating the research evidence and also the practice based evidence which would then be used in the point of care decision making. However, only using the steps outlined would not be effective in establishing and implementation of the practice design. The results should be coupled with the expertise of a clinician to gather practice based evidence. This can be data that would be realized form initiatives such quality improvement surveys that would have been conducted earlier. This data would also be information gathered from patient data. This information is interpreted and acted as required. This would encourage effective use of healthcare resources for such patients (Kathleen, 2011). Furthermore, the patient preferences and family values should also be considered. Thus, is because all this is done to increase their healing capacity and they have to be considered during the design of the practice change. This would encourage innovative decision making at the point of care and thus the outcome would be advantageous and would be of high quality. While the patient data and practice evidence is interpreted through the expertise during the formulation of the design, patient preference should always be present. The policy to be put in place would have a direct effect on the patient and is for their good. Ways to minimize and avoid deconditioning of the patient would also be easy to find since the patient would also be of assistance (Larrabee, 2009). Implementation and Evaluation Methods Implementation of the change is a vital aspect after a practice change is designed. Change in practice is implemented and evaluated in various ways. It is also recommended that the appropriateness of the innovation within the hospital be considered before implementation. In determining the implementation potential, all the factors have to be put into consideration. Key actions include implementation of the pilot study which involves; evaluating process, outcomes, and costs; and developing conclusions and recommendations that are required for the practice change. The EPB team members follow the practice plan design. It is also expected that verbal feedback is expected from those who intend to use the new practice, for instance care givers of patients acquired with Vancomycin-Resistant Enterococci (VRE). This would directly reduce the chances of the patients deconditioning due to physical therapy limitations. This feedback would be used to make minor adjustments in the implementation plan that has been established if necessary (Parke, 2011). After the pilot phase concludes, the EPB team should be able to collect and analyze the post pilot data that have been collected. This data is used for comparison with the baseline data in order for them to establish if the implementation plan is applicable. Team members use this data together with verbal feedback to decide if they should adapt, adopt or reject the new practice. The chances that the new practice will be rejected are minimal at this stage. More commonly, the new practice needs to be slightly adapted for a better fit within the hospital environment. Once the decision has been made, a conclusion is prepared, and recommendations are made so as to share them with the administrative leaders (Kleinpell, 2009). A context of caring when applied allows each patient-provider interactions to be individualized. With a hospital that fosters this EBP culture, it would thrive across all levels resulting in transformed healthcare. It would also facilitate in making it easier for implementing the design. This would also add up to the evidence used to change the clinical practice and also evaluation of the outcomes of the practice change. Furthermore, validity of the practice design would be established, therefore, internal consistencies would be established. This is also crucial since nurse satisfaction would be realized. Because of the risks related with dealing with patients acquired with VRE, the nurses would have to be considered as well during the implementation (Kleinpell, 2009). Another factor to be considered is transferability. This is to question whether it is applicable to implement the innovation in the practice setting. If there are some aspects of that which do not concur with the change, for instance the personnel or administrative personnel, and then it would not make sense adopt it even though it is effective in other contexts. Therefore, it would be necessary that it adapts to these conditions and is easier for implementation. There also exist some practical concerns related to feasibility. It would be able to determine the availability of staff and resources, the environment within the organization and also if there is a chance of external assistance. It is also essential to determine of whether there would be sufficient control over the innovations to be out in place (Kleinpell, 2009). Conclusion Key actions include sharing recommendations about the new practice with stakeholders, incorporating the new practice into the standards of care by the nurses, monitoring how the process. Revolves and also the outcome indicators. The practice change recommendations should be effectively applied so that positive results would be experienced from the outcomes. The patients with VRE would more likely be able to gain from the practice change to be implemented. The results of the project would also be disseminated to see how effective it has been. Those involved with this initiative, in this case the nurses and caretakers, should provide information and feedback and their recommendations to all stakeholders. The patients, their families and policy makers from the hospital can be categorized as the main stakeholders with this practice change. The administrative leaders must know of the recommendations so that the new practice may be approved as a standard care to the VRE patients. Once that approval is given, the EPB team members arrange to provide in-service education within the hospital environment especially to VRE patients. Plans should also be made to monitor the process constantly and also the indicators of the outcomes. The level of monitoring the change as well as the frequency is depended upon how well the indicators are being met. The information collected could serve a vital purpose in implementation of the practice change. It is to realize a need of refinement or fine-tuning of the practice change strategy, or even then need of a new EBP project. Furthermore, the EBP team should realize the need to disseminate the details about their project both within and outside the hospital through publications in journals and presentation at professional conferences (Jones, 2004). References Fulton, J. S. (2010). Foundations of clinical nurse specialist practice. New York: Springer. Jones, R. (2004). Oxford Textbook of Primary Medical Care, Volume 1. Oxford: Oxford University Press. Kathleen M. White, S. D.-B. (2011). Translation of Evidence Into Nursing and Health Care Practice: Application to Nursing and Health Care. Ohio: Springer Publishing. Kleinpell, R. M. (2009). Outcome assessment in advanced practice nursing. New York: Springer. Kluwer, W. (2008). Nursing research : generating and assessing evidence for nursing practice. Lippincottt Williams: Philadelphia. Larrabee, J. H. (2009). Nurse to nurse : evidence-based practice. New York: McGraw Hill Medical. Lawrenceville, P. (2006). Peterson's nursing programs 2011. New Jersey: Lawrenceville. Parke, R. (2011). Social development. New Jersey: Wiley. Read More