Nursing Research and Evidence-Based Practice
Essentials of Evidence Based Practice
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Introduction
It is estimated that patient falls in hospitals occur among 700,000 to 1,000,000 people in the United States. As well, approximately one third is preventable (Agency for Healthcare Research and Quality [AHRQ], 2013). Fall risk assessment tools, and alarm systems which alert staff when patients attempt to leave the bed or chair unassisted, are two methods among others utilized to reduce falls incidences. Evidence-based practice (EBP) in accordance with patient falls and the applicability to the author’s organization are the topics of this paper.
Patient Care Experience
Recently, an 83 year old male with dementia was hospitalized for pneumonia and under my care, on the night shift. As part of the routine admission process, all patients are evaluated for fall risk. In this patient’s case, a fall risk evaluation tool was one EBP method used to predict and prevent such an incident. High risk status was concluded due to mobility issues, dementia, and incontinence, in accordance with the Hendrich Fall Risk Assessment tool in the electronic health record. Research by Hendrich, Bender, and Nyhuis, in 2003, as cited by Schmidt (2012, April 5) found that intrinsic factors such as “confusion, altered elimination needs and impaired gait and mobility” among others were predictors of falls (para 6). A second intervention used was a bed alarm. Evidence based research for this method showed mixed results. Ward-Smith, Barret, Rayson and Govro (2014) concluded that use of a bed alarm system did not prevent falls, with one reason being the frequency of false alarms caused ignorance by staff, over time. The authors also stated further research in evaluating which patients would be appropriate for the alarm use would be beneficial. Shorr, Chandler, Mion, Waters, Liu, Daniels, Kessler and Miller, (2012), cited a cluster randomized trial which supported a reduction in falls with alarms in use. Still, in searching CINAHL, no studies in the past 5 years were found in support of bed alarms as a fall reduction method. I surmise the use of bed alarms in my facility came as a result of the elimination of the previous routine practice of waist and vest restraint application.
Background and PICOT Questions
Since support of the use of alarm systems was either mixed or nonexistent, and given the previously mentioned in-hospital high incidence of patient fall statistics, more effective measures for reduction must be researched. In formulating an EBP research question, background definitions must be delineated and general knowledge questions answered. For example, in researching best practices for dementia patient fall reduction in acute care hospitals, I would answer the following questions
What constitutes a patient fall?
What is dementia?
What are some common signs and symptoms of dementia?
What factors place dementia patients at risk for falling?
What are the effects of hourly rounding on the incidence of falls in dementia patients in acute care hospitals?
How do patient sitters affect falls in dementia patients?
What are the cost factors in an individual institution, associated with patient safety?
Preparing a researchable question also involves a population or patient (P), an intervention (I), a comparison (C), an outcome (O) and when appropriate, a time frame (T) (Polit and Beck, 2017, p. 33) . For this issue of falls, I would ask the following research question: What are the effects of hourly rounding versus the presence of patient sitters in reducing the incidence of falls in hospitalized dementia patients on the night shift? (P= hospitalized dementia patients I=hourly rounding C=patient sitters O= reduction of falls T= night shift). A study by Feil and Wallace (2014) showed a statically significant reduction in fall rates through the use of patient sitters, which included dementia patients. A study by Morgan, Flynn, Robertson, Robertson, New, Forde-Johnston, and McCulloch (2017) noted a 50% reduction in falls through intentional rounding on a neuroscience ward which used a designated nurse for implemented activity engagement, toileting or other patient needs during the study period. The extra nurse was in addition to regular staff.
Organizational Factors in EBP
At the present time, dementia patient falls are not usually a problem on my unit. Occasionally, one to one care is employed when such patients are unable to be kept safe by other means. Since I work in a critical access hospital and patient census is low, staff to patient ratio is not frequently a significant issue either. However, depending on the EBP measure, cost would be a barrier to implementation due to low revenue and volume. I have worked in environments where patient sitters were rarely used due to the cost, and instead, the ward secretary sat at the patient’s bedside with a lap top computer performing order entry and other usual tasks, while simultaneously working to keep the dementia patient safe. Culture might also play a role. Having read the research in support of simulation for critical access hospital nursing education, I approached the Director of Nursing regarding a skills fair. I also offered to plan it and man a station by coming in on a day off if necessary, and work without pay. I was met with resistance and the instruction that I could create a scenario such as a cardiac arrest, with a less experienced colleague, and fulfill my desire that way. I could not help wondering why there was no support for a unit wide educational endeavor. I attempted to engage a colleague as instructed, but was unsuccessful. As yet, the measure has not been implemented. Since current financial issues are of concern hospital wide, the understanding that there are “bigger fish to fry” may be at work, but what could be more costly than a patient or staff member injury due to a lack of knowledge or skill?
EBP Barrier and Conclusion
Shaheen, Foo, Luyt, Zhang, Theng, Chang, & Mokhtar, (2011) cited a study in which nurses’ complaints of having insufficient authority to implement changes in patient care practices was a barrier to implementing EBP. After a great deal of thought, I realized I might succeed if I asked the emergency department (ED) director for support. Several days prior to this writing, I did just that. Results were positive and specific stations to be included were discussed, but since this manager has an upcoming vacation, further planning will be delayed. In the past, supervisors have spoken of implementing educational offerings on the unit. As of yet, such events have not materialized. My hope is the skills fair idea will not be another statistic.
References
Agency for Healthcare Research and Quality.(2013). Preventing falls in hospitals. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.ht
Feil, M., & Wallace, S. (2014). The use of patient sitters to reduce falls: Best practices. Pennsylvania Patient Safety Advisory, 11(1), 8-14. Retrieved from http://www.patientsafe
tyauthority.org/ADVISORIES/AdvisoryLibrary/2014/Mar;11(1)/Pages/08.aspx
Morgan, L., Flynn, L., Robertson, E., New, S., Forde-Johnston, C., & McCulloch, P. (2017). Intentional Rounding: a staff-led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1-2) 115–124. doi:10.1111/jocn.13401
Polit, D. F., & Beck, C. T. (2017). Evidence-based nursing: Translating research evidence into practice. In Nursing research: Generating and assessing evidence for nursing practice (pp. 25-45). (10th ed.). Philadelphia, PA: Wolters Kluwer.
Schmidt, B. (2015, April 5). AHRQ: Evidence-based methods and tools help reduce risk of falls in hospitals. Retrieved from http://www.psqh.com/analysis/evidence-based-methods-and-tools-help-reduce-risk-of-falls-in-hospitals/#sthash.ztlE7JRV.dpuf
Shaheen, M., Foo, S., Luyt, B., Zhang, X., Theng, Y-L., Chang, Y-K., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses’ perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99(3), 229–236. doi: 10.3163/1536-5050.99.3.010
Shorr, R., Chandler, A., Mion, L., Waters, T., Liu, M., Daniels, M., Kessler, L., & Miller, S. (2012). Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients. A cluster randomized trial. Annals Of Internal Medicine, 157(10), 692-699. doi: 10.7326/0003-4819-157-10-201211200-00005
Ward,-Smith, P., Barret, L., Rayson, K., and Govro, K. (2015). Effectiveness of a bed alarm system to predict falls in an acute care setting. Clinical Nursing Studies, 3(1). doi: 10.5430/cns.v3n1p1
