Practice Innovation for School of Health - Essay Example

Practice Innovation for School of Health INTRODUCTION Based on the topic under consideration, the writer has set the essay in the context of an evidence based practice and practice innovation whereby a focused question has been created for practice innovation. Based on the focused question and the need to have sufficient data in answering the focused question, a structure search has also been undertaken to comprehensively give evidence to the question. Based on the core results of the evidence for practice innovation, there is going to be a synthesis, appraisal and evaluation of the selected articles of the search that took place. Presently, the topic being dealt with is “effect of implementing hourly intentional nursing rounds on health improvement of patients in an acute medical ward.” The entire evidence based practice and critical analysis of articles are going to be undertaken based on a strict adherence to School of Health & Social Care's guidelines for presentation, referencing and confidentiality and consent (Leighty, 2006). RATIONALE FOR THE CHOICE OF TOPIC The practice of intentional hourly nursing rounds is a practice that has been with the health sector for a very long time. Most often, nurses would take the pain to go round their patients to have a follow up of how well they are doing and responding to treatment (Melnyk and Fineout-Overhold, 2005). This practice was actually associated with several advantages and benefits as in most cases it helped in improving the health situations of patients and reduced hospital related problems such as falls. However with time, the practice would not be as effective as it used to be because there were general shortage of nurses in most parts of Europe and the United States. Today, the issue of nursing rounds has been revisited because of the advantages that it carries. By successfully completing this research work, there are a number of advantages and importance that are going to be experienced. In the first place, the place of intentional nursing rounds in improving the health of patients in acute medical wards is going to be defined. By definition, there is going to be a clear stand taken on whether or not the practice is really worth its value and whether or not it should be continued. What is more, this is going to be a research with much academic importance as it is going to offer its self as a critical review of existing works of literature to draw conclusions on the revelance, validity and reliability of the findings that have been made by earlier researchers. Finally, the research work shall be a tool for outlining some of the most needful innovations that are needed in nursing practice, especially when it comes to nurses in acute wards. From a professional perspective, the paper is going to help in reviving the act of evidence based practice that once use to be the focus and fulcrum around which nursing practices were undertaken. Today, there is much evidence to suggest that because of how most practitioners lack the basic ideas of differentiating between sources of literature that are credible and those that are not, most nursing practitioners have given up on evidence based practice (Meade, et al, 2006). This has also led its self up to denying nurses of the benefits that they would have had in undertaking evidence based practice. FOCUSED QUESTION To undertake the present research as an evidence based practice, there are a number of stages that are going to be used in arriving at the eventual goal of the study. The first of such is the creation of a focused question. The focused question is very relevant to the entire study because it is going to serve as the scope around which data is going to be collected (Orr, Tranum and Kupperschmidt, 2007). By this, reference is being made to the fact that the focused question is going to assist the researcher in knowing the best database to use, the best type of search to undertake, the kind of articles to look for and the type of reviews to undertake. More importantly, it must be stressed that the focused question is structured with the PICO framework. By this, the question should be broken down into divisible components including population, which refers to the group of respondents that the researcher shall be applying the intervention on; intervention, which deals with the solutions to be put in place to solve an identified problem; comparison, which deals with the alternative to the intervention; and outcome, which deals with an expected result. Based on the above, the focused question of the study is given as: “in an acute medical ward, will implementing hourly intentional nursing rounds improve patients’ safety, quality of the care and satisfaction?” STRUCTURED SEARCH The second stage of the evidence based practice is to undertake a comprehensive structured search that will result in settling on the articles to be used for the entire study. Khan et al 2011 p. 23 have explained that a structured search is a systematic format used in undertaking an inclusion and exclusion mechanism on available database and articles to select the best ones that correspond to a structured focused question. Even though there are several forms of databases, the use of electronic database have become one of the commonest. There are a number of reasons for this including the fact that they are easily accessible and others some of the world’s most stocked evidence of research works that have been undertaken over the years. The fact that the electronic database promises to provide a very wide array of possible articles gives the researcher a huge task and responsibility of ensuring that nothing but the best is selected out of the available data. It is in line with this that it is always important to structure the search around the focused question that is set. Most preferably, it is important to ensure that keywords are formed from the focused question based on the PICO elements. That is, the search structure must portray how selection is being done based on the population, intervention, comparison and outcome outlined by the researcher. Generally using and basing the present structured search on the Boolean operators, a number of keywords were selected. Beaven and Craig (2012, p. 58) explain that once the keywords are set, “words and terms can be combined using the Boolean logic, which involved combining with AND or an OR in such a way that using AND will always detect documents that include both terms whereas OR will find documents that include one or both term. Two major databases used were namely CINAHL and MEDLINE. The keywords created were hourly rounding, nursing rounds, bed sores, acute medical ward, patient safety, call light. SUMMARIES OF EVIDENCE The search conducted resulted in three major evidences being landed upon. These were two quantitative articles and one qualitative article. The general purpose of having these two pieces of evidence namely qualitative and quantitative was to ensure that a mixed research was achieved at the end of the day. With a mixed research, the researcher was hopeful that the strengths of each of the evidence were going to complement the weaknesses of the other (Tea et al, 2008). For example whereas quantitative research limits the subjective judgment of the researcher to the critical analysis of evidence, qualitative research does (Alexander, 2010). Again, it was necessary to have these two different forms of evidence to example the relationship that exists in terms of the data collection processes and how these could generally affect the results of study presented. The research approach used in the qualitative was the ethnography approach, which means that there was a conscious effort by the researchers in examining and exploring a cultural phenomenon (Bernardo, 2007). As in the general context of ethnography, there was a reflection on report findings on a system of meanings that exists among a cultural group and in this context the ethnographic approach was used to outline the major challenges faced by nurses in two inpatient units in the implementation of hourly rounding. On the part of the quantitative evidences that were selected, they made use of the quasi-experimental approaches. In fact much of the quasi-experimental method has had elements of a real experimentation just that there is lack of the use of random assignment (Bravo, Earls and Johnson, 2011). To this end, a 506-bed teaching hospital was acquired where the effect of hourly round was determined on fall rates, call light usage and the general satisfaction of patients on the service they received from nurses. Later in the paper, there shall be a critical analysis of the contents of the various articles. CRITICAL ANALYSIS Qualitative research study design The researchers used an ethnography research design where the social interactions that exist between nurses and patients were determined in terms of the hourly rounds performed by the nurses as an inpatient duty requirement to patients. There were a number of ways that this research design came as highly advantageous for the study that was undertaken. For instance the researchers, who acted as ethnographers had the opportunity of collecting first hand data from the setting through observation, making it possible for them to immerse themselves directly in the social interaction that was taking place (Craig, 2012). What is more, it served as a platform for collecting holistic social accounts of the interactions that existed at the ward in the forms of nurse-patient society. This way, it was possible to explore and relate a number of social phenomena that would otherwise have had very insignificant connection with each other (Craig and Stevens, 2012). A typical example of this was when through the research design it was possible to gather data on level of satisfaction on the part of care received by patients. framework to be used In order to find the appropriateness of the impact of the entire research process on the topic and other components of the research such as literature review, research design, data collection, findings and conclusion, a qualitative critical review form was designed to be the framework for assessing the qualitative research. This critical review form had components made up of the study purpose, literature, study design, sampling, data collection, and data analysis. Under each of these components sub-components where set, which were accompanied by questions assessing the inclusion and exclusion of some key factors in each component. A sample of this framework which gives a vivid description of the form has been uploaded at the appendix. evaluation of the study Trustworthiness Even though a great deal of work went into the selection process for the various articles for use in this study, it is still very important that the contents of the article be subjected to critical review to ensuring that the study is trustworthy. A major aspect in the evaluation of the study has to do with the trustworthiness of the study. By trustworthiness, reference is being made to the fact that the findings of the study can be relied on as credible in relation to the processes and procedures that went into the entire data collection method (Cumming and Olswang, 2009). In the present circumstance, the trustworthiness of the qualitative research shall be judged based on four major elements namely credibility, dependability, confirmability and transferability. Collectively, the study should be in a position to producing an all-round average score on a qualitative assessment of these four criteria. Credibility A credible article is generally one that can be depended upon as offering highly reliable data. Because the credibility of the study is much dependent on the data, it is inherent on the authors of the work to ensure the processes that go into the collection of data are very fair and free from all forms of bias and doubts (Denham, 2001). In most cases, because qualitative research offers itself up to the use of subjective judgment by researchers, most researchers abuse this privilege and refuse to ensure fairness in their data collection process. Often, researchers will be bias in the selection of sample size as well as in the implementation of the intervention. Once this happens, the tendency that results will be a true reflection of the existing situation becomes jeopardized and thus the entire credibility of the work becomes affected. The work of Deitrick et al (2012) whose qualitative article was selected can thus be subjected to credibility check by making use of their data collection exercise including the selection of sample size. In the first place, the results can be described as being credible since the selection of sample size was necessitated by any acts of pre-conceived intentions. For example the two surginal block units used were similar in patient population and fall rates. This means that patient population difference could not affect the credibility of the results. What is more, there was the creation of a control as well as an experimental group with the two wards. Consequently, the researchers had the opportunity of internally assessing the impact of the intervention used on a related setting, which was the control unit. Finally, a very large population of N = 4,418 was used, giving the researchers an access to a wide range of variables to be tested on the respondents. Dependability The dependability of the study is much related to the credibility of it because they both deal with the reliability of the collective study (Deverick and Keith, 2010). However when it comes to dependability, there is much focus on consistency in the application of methods by the researchers. It is in line with this that The Natural Leader Instinct (2010) explains that “dependability is an assessment of the quality of the integrated processes of data collection, data analysis, and theory generation.” A number of factors would therefore account for the dependability or consistency of the methods used by the researchers. For instance there should be signs of completeness in the methods used by the researcher. When it comes to the selection of sample size for example, sampling must be done till redundancy is reached. Again, the application of intervention must be thorough and not applied in a haphazard and unstructured manner. Finally, data collection must take place within a well defined and definite time frame. In relation to the above factors on dependability, there are a number of ways that the researchers attempted to achieve dependability but it was not in all cases that they might have succeeded very well. For example there was a major weakness in the sampling procedure used by the researchers. Generally, there was purposive sampling technique whereby all patients who had experienced falls for a certain number of times were included. This eliminated the issue of redundancy because there was no definite mechanism used to categorize respondents according to their frequency of falls. In terms of the application of intervention however, the researcher met the set criteria of ensuring that each patient received an evenly distributed rate of hourly visit. Within the periods of hourly rounds, there was an eight point agenda set for the nurses to fulfill. This 8 point agenda was tabulated and presented in the research report. Confirmability Confirmability refers to generalized principle whereby the entire processes and procedures used in undertaking the study must be in line with accepted norm of practice. So in this scenario, the simple question that was needed to be asked was whether or not the researchers had undertaken their research by following the accepted norms and standards for undertaking an ethnography research. Other questions on confirmability could also be raised on the conduct of qualitative research in general. Once these outlines are followed, Lincoln and Guba (1985) explain in Natural Leader Instinct (2010) that the confirmability would squarely be a “measure of how well the inquiry’s findings are supported by the data collected.” In this direction, it is important that researchers would always ensure that their findings do not portray a different result from what the qualitative data collection procedure was aimed at doing. With the article selected, the confirmabilty of their work was judge by drawing a parallel relation between the data collection and the research findings. From this context, it was established that there was a direct relation between the data collection and results when it comes to number of falls. For example the data collection was set within three major time categorizations namely pre-implementation, implementation and post-implementation stages. At each stage, different data were collected on the number of falls and call-light recorded. For the experimental group, the determination stage was to be the differences in values in falls and call-light at the post-implementation stage. Lo and behold after the intervention was implemented by making nurses undertake hourly rounds from 6am to 10pm each day, post-implementation data collection brought out a result of 23% clinical reduction in number of falls that were experienced earlier. Among the control group however, no such differences were noticed. In terms of call-lights however, there was no direct relation between data collection and results, meaning that there was no confirmability. This is because on a constant basis, the number of call-light kept increasing and decreasing even at the implementation stages of the intervention. Transferability As it may resound in its name, transferability generally refers to “the degree to which the findings of this inquiry can apply or transfer beyond the bounds of the project” (Natural Leader Instinct, 2010). This however brings to task the need to clearly identify what is meant by the term ‘bounds of the project’. In most cases, the bounds of the project may be defined as the setting within which the research was conducted (DiCenso et al, 2001). However, for an ethonography such as this one where an entire social phenomenon is supposed to be measured, the bound of the project may well be expanded to include all other settings that come under the social structure of the said project (Gerrish and Lacey, 2006). In current situation therefore, transferability will be achieved only if there is evidence to show that the findings can be replicated in other hospitals based on the same intervention. Having made the point on transferability above, it would be said that the best, if not the only way to judge the transferability of such an ethnography research as the one undertaken by Detrick et al (2012) is to make use of secondary data (Hammer, 2012). This is because most secondary data will be made up of cases of similar experimentations whereby the same intervention was used to assess the same outcome. From this perspective, much could be said on the strength of the article as the researchers undertook an extension review of literature to understudy what other reviewers and researchers had done in relation to their topic. However, the weakness that exists in the use of secondary data is that the researchers did not contain enough sources as there were only three studies about hourly rounds used by the researchers (Detrick et al. 2012, p. 24). Such scanty number of studies does not make it possible to fairly judge whether or not the study is transferability within a larger context. 3.Quantitative research The researchers of both quantitative researches followed the use of quasi-experimental design. Generally, the quasi-experimental is a unique kind of experiment that has a number of the features of an experiment but not generally all (LeTexier, 2000). One of the major components where there exists a difference with the quasi-experiment is where the use of random assignment is concerned. Thus in experiment, there is randomization but in a quasi-experiment, this is missing. In quasi-experiment, a great deal of use is made of the variables involved, namely the dependent and independent variables. The researcher would commonly have the chance to manipulate the independent variables to trigger the dependent variables. Quasi-experiment has generally received a lot of negative reviews on its quality based on hierarchy of evidence. It has been argued for instance that the absence of random assignment allows for a control and manipulation, which can lead to desired results that only satisfy the expectations of the researcher (LoBiondo –Wood and Haber, 2009). From all indications, this is a situation that compromises reliability and could not be accepted as a sign of quality of delivery. Approximation of data is also very common in quasi-experiment and this has also been debated against greatly as this reduces the quality of results (Parkes, 2001). All of this not withstanding, quasi-experiment can be used to enhance quality of study if used in a situation where the use of randomization is ethically not allowed or impractical. Because two different quantitative articles were considered together, two different assessment frameworks were prepared for each article. Generally, the idea behind the framework, a sample of which has been attached at the appendix was to ensure that there was a correlating relation and impact between the research process and the remaining components of the study. Often, researchers deviate from their study in terms of the research objectives they set for themselves whereby their literature review, research design, sampling, data collection procedure, findings, and conclusions do not relate to the research objectives. For this reason, the framework was prepared to cover all these aspects of research that have been listed. More importantly, there was one of such frameworks for each of the two articles. Reliability and validity of measurement The reliability and validity of research works are often used together but mean two different things and come with two different ideas. Largely, the reliability of measurement can be viewed from the point of conformity whiles validity can be viewed from a point of accuracy. For a quantitative researches such as the ones under study for instance, two areas of measurement that will be used to determine reliability and validity are concepts and methods. Reliability is said to be achieved if the concepts and methods of measurement are relatively the same (Bourgault et al, 2009). Validity is also said to be achieved if the processes going into the data collection process are in line with laid down standards and procedure. As far as validity is concerned, there are two major aspects of measurement that the researchers could be looking at to ensure validity. These are internal and external validity. Generally internal validity on measurement tools can be achieved if researchers shall pay particular attention to selection bias and ensure that the tool is impartial in its selection. Again, history, differential attrition and regression towards the mean are all significant such that researchers must ensure that they conform to stipulated standards of scoring. With external validity, attention must be paid to the population to ensure that there is a generalization between the study’s inferences and the general population used (Castledine, Grainger, and Close, 2006). On the part of reliability, researchers can ensure reliability of their study if they can ensure that there is consistency in the instrument’s measurement. There should therefore not be any forms of deviations that prevent the researchers from recording the same results in similar circumstances in which the measurement tool is applied. The two articles from which the two different studies were taken measured almost the same phenomena. Generally, the researchers undertook co-relational studies that were geared at measuring the relationship between nursing rounds system and quality of patient service at in-patient hospitals. Bassem et al (2011) therefore measured relationship between nursing rounds and (i) use of call light (ii) incidents of patient falls (iii) hospital acquired bed sores and (iv) level of patients’ satisfaction. Todd, Malanie and Cindy (2012) on the other hand measured the relationship between nursing rounds and (i) fall rates (ii) patient satisfaction (iii) call light usage. The measurements were therefore around nursing rounds as an input task and patient healthcare as an output entity. To undertake the research measurements mentioned above, the researchers used a number of measurement tools. Generally, occurrence reports or forms and post-discharge patient satisfaction surveys were used. There were a number of ways that the researchers of both studies had ensured the validity of these measurement tools. For instance for the use of the occurrence reports, the clinical registered nurse was made to set up a team that was tasked with the recording process. What this means is that the duty of data collection was not left in the hands of only a single person. In effect, issues of partiality, prejudice, bias and favoritism were largely catered for. For the post-discharge patient satisfaction survey also, a lot of confidentiality and anonymity of patients were ensured such that patients were not under any pressure to release data that pleased the researchers. In other words, fairness of results was ensured. Internal validity Define internal validity Internal validity touches on the cases of inferences made about the intervention in such a way that the inference made on the intervention must be deemed to be justifiable. Internal validity could also be assessed from a perspective of the variables that are used namely independent and dependent variables. From this perspective, the School of Psychology University of New England (2000) notes that “to the degree that we are successful in eliminating confounding variables within the study itself is referred to as internal validity.” To this end, the internal validity could be defined as measures that ensure that the researcher’s dealings with the variables do not raise any doubts with the results that the intervention will produce. To achieve internal validity of their works, researchers are expected to put in place a number of measures. Because the internal validity of the work is basically structured around the variables and intervention, most of the things that are done to threaten the internal validity of the study are about the variables and the intervention. The National Center for Technology Innovation (2010) for example argues that “the most common threats to internal validity are selection bias, history, maturation, test-retest, differential attrition, and regression towards the mean.” Researchers who are concerned about achieving internal validity are therefore required to ensure that in the selection of their sample size, setting of variables and the application of intervention, they do not indulge in any acts that can compromise the fairness of the study because as soon as this happens, the internal validity of the study becomes jeopardized. With respect to the selected articles presented by . Todd, Malanie and Cindy (2012) on one hand and Bassem et al (2011) on the other hand, there are a number of actions that the researchers undertook that could be said to have helped in achieving internal validity for the two studies. For instance, Todd, Malanie and Cindy (2012) used two separate hospital units that have relatively the same number of patients and the same variables as the control and experimental sample groups. More to this, the selection of respondents was done in a random manner. In support of this, the National Center for Technology Innovation (2010) notes that when random sampling techniques are used “you can be sure that any difference between the treatment group and control group is due to chance alone, and not selection bias.” This is indeed enough justification that internal validity was achieved for Todd, Malanie and Cindy (2012) as their actions towards the selection of participants and definition of variables were not based on acts of bias. In the same vein, Bassem et al (2011) also used a random sampling procedure and went ahead to ensure that data that were collected were repeated over and over again for all eight (8) week period that data collection went on at the hospital. Consequently, it was possible for the researchers to subject their variables to authentication and confirmation of facts. External validity Whiles internal validity is concerned about the casual inference of the intervention, the external validity is more focused on how generalized the research work’s inferences can be made to the population (Franciscan Health System, FHS, 2007). It is against this backdrop that the University of New England writes that “a study that readily allows its findings to generalise to the population at large has high external validity.” In effect, the findings of the research should not be suitable to the sample size alone. Within the sample size also, the result should not be suitable for only selected group of people alone. Rather, whenever the study is replicated within any sector of the population, a relatively similar result must be achieved. Achieving the generalization of findings of the study for the entire population means that the all forms of biases in the dealings with the sample size must be avoided. Invariably, internal validity must be guaranteed. To this end, the first factor that aids in achieving external validity is a need to ensuring that internal validity is first achieved. More to this, limitation on the scope of the study would also help in ensuring external validity because in that case, the researcher gains greater control over the characteristics that the control and experimental groups present. It has often been argued therefore that the type of research design employed by the researcher helps in a large extent in achieving external validity because whereas some research designs allows for the use of a confined fewer number of members in he population, others open themselves up for the use of a very large population size (Kimball, Hays and Kalman-Yearout, 2008). In the two studies conducted by Todd, Malanie and Cindy (2012) and Bassem et al (2011), one of the best streanghts that their studies possess in achieving external validity has to do with the efforts put in place by the two groups of researchers to ensuring that internal validity were achieved. Moreover, in both cases, the researchers made use of an identified population size where control over the variables of the participants was not going to be a difficulty. For example, even though the researchers had the chance of undertaking a survey of all hospitals in the city, they used single hospitals, where they could easily monitor activities of participants; especially nurses and patients. It is not for nothing that at the end of the day, it was possible for the researchers to take feedback from patients in the control group. Conclusion Since the different pieces of evidence gathered were set around the same theme and objective, it is possible to generalized and summarized their findings together. Generally, the aim of the three studies were to find the relationship that existed between nurses hourly rounds and the rates of falls, bed call light use, and the general satisfaction among patients within various wards of different hospitals. Some of the wards used included male ward for stroke patients and patients in a surgical unit. The differences in patient orientation meant that should a similar trend of results be found, then the intervention could be generalized for the entire nurse-patient relationship. Lo and behold, in all three studies, the implementation of hourly rounds as intervention ensured the reduction in number of bed falls and the general improvement of patient satisfaction. Two of the studies achieved significant reduction in the use of call light on the control group while the remaining one did not record any significant reduction in use of call light. Indeed, following the level of validity achieved in both internal and external validities and the fact that the findings solved a direct health practice issue, it could be said that the findings support current practice and that the papers are relevant for nursing adaptation and use. REFERENCE LIST Alexander .A, 2010. Hospital Acquired Methillin Resistant Staphylococcus Aureus. Viewed on 5th Jan, 2013 at http://microbewiki.kenyon.edu/index.php/Hospital-acquired_Methicillin_Resistant_Staphylococcus_Aureus_%28MRSA%29 Bernardo, L.M. (2007) Evidence- Based Emergency Nursing Practice: The Journey Begins. Journal of Emergency Nursing 33:4 (375-376). Emergency Nurses Association. Bourgault, A.M., King, M.M., Hart, P., Campbell, M. J. K., Swartz, S. & Lou, M. (2008). Circle of excellence. 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Blackwell Publishing Ltd. Tea, C., Ellison, M. & Feghali, F. 2008. Proactive patient rounding to increase customer service and satisfaction on an orthopaedic unit. Orthapaedic Nursing, 27(4), 233-240. Read More