NR 505 Research Literature, Design, Sampling and Implementation Assignment
NR 505 Research Literature, Design, Sampling and Implementation Assignment
Research Literature Support
My PICo question is: “What are nurse practitioners (NPs) experiences in providing care to patients who have fallen in an LTC and fractured bones in the United States?”
The first article to support the identified nursing concern is “Fall prevention program in the community: A nurse practitioner’s contribution” by B. E. Harrison. The purpose of the research study is to examine the effectiveness of two fall prevention programs in senior community settings led by nurse practitioners. The research approach that used was a quasi-experimental pretest-posttest design. Data collection methods used were direct observation of NPs, a pretest to measure outcome of interest prior to implementing program treatment, followed by a posttest on the same outcome of interest after subjects attended weekly class on fall prevention. The results of the research study were obtained using paired t test analysis and sowed that fall risk scores improved P < .05. Overall, NPs who collaborate to implement fall prevention programs help reduce fall risk and improve health outcomes for patients. One strength of the research study is the direct observation of NPs in the clinical setting. One limitation of the research study was the small sample group.
The purpose of the research study for article two, “Exploring the nurse practitioner role in managing fractures in long-term care,” by Kaasalainen et al. is to examine the level of involvement of NPs in activities related to preventing falls and managing fractures in long-term care (LTC) settings. The research approach used was a sequential explanatory mixed methods design. This involved two phases: a cross-sectional survey that was then followed by qualitative interviews. Data collection methods used were online survey in which all 12 NPs responded and a follow-up interview in which 11 of the 12 NPs participated. Results of the research study show NPs were primarily involved in caring for residents after a new fracture occurred and that NPs used patient’s history of falls to assess risk of future fractures. One strength of the research study is the phases in which the data was collected. One limitation of the research study was data was collected in one demographic area and only addressed the perspective of NPs.
Article three, “The NPs Role of Assessing and Intervening with Older Adult Drivers,” by
T. Arms aims to identify specific behaviors and strategies used by NPs when assessing the physical frailty and walking ability of older drivers. The research design used was the critical incident technique, a qualitative research method developed by J.C. Flanagan that creates a functional description of behavioral activity. The data collection method used was an open-ended self-administered critical incident survey conducted with a sample of 21 NPs. The results of the research study show that NPs vary in the ways in which they assess patients for physical frailty and walking ability, and NPs are inconsistent in clinical practice of intervening with older adults who have been noted for physical frailty and sensory impairments. One strength of the research study is 21 NP participants in this study closely represent the national NP demographics. One limitation of the research study is that it focused on fall prevention in relation to driving abilities of older adults.
The purpose of the research study for article four, “Implementing an Evidence-Based Fall
Prevention Program in an Outpatient Clinical Setting,” by Li et al. is to investigate the if the Tai Ji Quan-based program, previously shown to be effective for reducing the risk of falls in senior adults, can be utilized in outpatient clinical settings. The research approach that was used a quantitative single-group pre-post design. Study participants were required to attend the Tai Ji Quan training program twice a week for 24 weeks. Data collection methods used were direct observation by researchers and post program surveys disseminated to healthcare providers to include nurse practitioners and to study participants. Results of the research study show healthcare providers to include NPs should implement evidence-based recommendations for the management of falls and balance issues in older adults; Implementing the Tai Ji Quan program maximizes senior participation in community-based fall prevention programs. 61% of senior participants who completed the program reported they continue weekly Tai Ji Quan practice on their own. One strength of the research study is the length of the study and the perspectives of other healthcare providers was involved. One limitation of the research study is the lack of a comparison group and the lack of information about how clinicians decided who to refer to this fall prevention study.
Article five by Burland et al., “The evaluation of a fall management program in a nursing
home population,” intends to observe and evaluate the fall management program in a nursing home to determine if the mobility of residents had increased and injurious falls decreased. The research approach used was a quasi-experimental, pre-post, comparison group design. The data collection methods were the use of data collectors who entered occurrence report information into spreadsheets from 12 nursing homes, which totaled 1046 residents. Overall result of the research study is fall prevention programs benefit older patients. Minor falls trended up, injurious falls remained constant, and hospitalized falls decreased (0.036–0.021 ppy; p = .043). Non-program residents exhibited the same fall rate. Residents in fall prevention programs residents had fewer injurious falls and falls in the hospital. One strength of the research study is the varied clinical settings observed for fall prevention programs and the varied ages of the participants. One limitation of the research study was the use of the non-randomized design and administrative data does not contain much of the needed information for research because it is not meant for that purpose.
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The objective of the study in article six, “CONNECT for better fall prevention in nursing homes: Results from a pilot intervention study,” by Colon-Emeric et al. is to determine if implementation of the FALLS and CONNECT programs improve care delivery in nursing homes and reduces falls among residents. The research approach used was a cluster randomized trial. Data collection methods used were nursing staff completed surveys about interactions at baseline: 3 months immediately after implementation of CONNECT (control period) and 6 months immediately after implementation of FALLS. A sample of randomized resident charts were extracted for fall risk reduction documentation examination. The results of the research study significant improvements in the use of fall prevention strategies and communication quality were observed in intervention community nursing homes but not in VA nursing homes. Fall rates did not change in control facilities but decreased by 12% in intervention facilities. One strength of the research study is two LTC setting were used to compare data. One limitation of the research study the FALLS intervention program is a standardized template that most facilities choose to alter upon implementation.
Article seven, “Nurses’ perceptions of implementing fall prevention interventions to mitigate patient-specific fall risk factors,” by Wilson et al. aims to examine nurses’ perceptions about utilizing evidence-based practice (EBP) fall prevention interventions to lessen patient fall risks and applying strategies that promote use of fall prevention interventions. The research approach is qualitative. Data collection methods used were face-to-face interviews and listening to and analyzing the audio recordings. Results of the research study show fall prevention strategies and programs are beneficial to patients and use of EB fall prevention interventions help tailor specific fall risk factors for patients. Specifically, using fall prevention strategies in three risk-factor categories: mobility, toilet assistance, and medications were beneficial. One strength of the research study is that it focuses on NPs first-hand experiences with fall prevention programs. One limitation of the research study does not focus on LTC setting s but multiple clinical settings.
Article eight, “Effectiveness of multifaceted and tailored strategies to implement a fall-
prevention guideline into acute care nursing practice…,” by Breimaier, Halfens, & Lohrmann reviews a research study that aims to analyze the required time to be invested and effectiveness of varied and tailored strategies for implementing an EBP fall-prevention guideline into nursing practice in acute care hospital settings. The research design approach was a before-and-after, mixed-method design applied within a participatory action research approach (PAR). Data collection methods used were questionnaire, group discussions and semi-structured interviews.
Results of the research study are nurses’ knowledge on fall prevention increased 4.1% and how to access the Falls Clinical Practice Guideline (CPG) increased significantly between baseline and final assessment by p ≤ .001. One strength of the research study is specific fall prevention equipment was assessed to include baby monitors, one-way glide sheets, and handrail in the corridor. One limitation of the research study was that two other studies were being conducted at the same time, so resources and study participants were limited to the attention they could provide.
The purpose of the research study for article nine, “Improving hospital patient falls:
Leveraging staffing characteristics and processes of care,” by Aydin et al. is to develop predictive models for falls and injuries related to falls, as well as explore the restraint prevalence and processes of care within nursing unit structures. The research approach used quantitative. Data collection methods used was self-reported survey received from 215 hospitals. Results of the research study show hospitals with fewer frail and at-risk patients had fewer falls among patients and injuries from falls. Prevention protocol implementation was high among nurses. Patients are also at risk for fewer falls with higher nurse expertise and shorter length of stay.
One strength of the research study is the high sample group. One limitation of the study is there was no guideline as to checking the validity of the self-reported information received from hospitals.
Article ten, “The effect of a translating research into practice intervention to promote use
of evidence-based fall prevention interventions in hospitalized adults…,” by Titler et al. intends to evaluate the impact of implementing EBP fall prevention interventions targeted to patient-specific fall risk factors in thirteen adult medical-surgical units from three community hospitals.
The research approach utilized was a pre–post implementation cohort design. Researchers collected data for dependent variables at baseline and after completion of the 15-month program initial phase. Nurse questionnaires were used to measure adoption of evidence-based fall prevention practices. A Medical Record Abstract Form was used to gather data about risk-specific fall prevention interventions. Results of the research study are fall rates were reduced by 22%, and the types of falls changed from major or moderate to minor injuries. However, fall injury rates did not decline. Fall prevention interventions improved p < 0.001 in patient mobility, toileting, and cognition, but did not change for those taking medications. One strength of the research study multi-faceted, evidence-based fall prevemtion interventions were used. One limitation of the research study is the age range of participants was too broad, 21 and up, so generalizing specific interventions according to age groups is not suggested.
Research Approach and Design
The research approach that will be used isquantitative. This research approach has a
well-ordered design that allows researchers to study scientific phenomena by employing all the fundamentals of quantitative methods: control, manipulation, random assignment, and random selection (Yilmaz, 2013). I also chose the quantitative approach because it will provide me with the data and statistics I am looking for to validate my findings (Choy, 2014). Quantitative allows for a high possibility of internal and external validity of the research, so transferring the data to a larger population set is favorable (Noble & Smith, 2015). After data is collected, analyzed, and presented in a statistical form instead of personal comments, any researcher conflict occurs is often settled via a level of reproducibility that is allowed in quantitative research (Noble & Smith, 2015).
Quantitative research is objective and conclusive (Choy, 2014). The quantitative research approach provides the format and methodology to distinguish and quantify multiple reasons why patient’s fall in clinical settings, as well as apply the same methods to determining which NP designed fall- and injury-prevention programs are effective and which programs are ineffective. Furthermore, quantitative research will allow me to compare my findings with data from clinical settings that do not have NP designed fall- and injury-prevention programs and determine if NPs even inform patients about fall prevention strategies. Since quantitative research is comprised of methods that allow for the comprehensive examination of the actions of a small or large group of participants, I will then be able to understand how prevalent the results are to small and large populations. A quantitative approach also involves examining behavior primarily for group means and standard deviations (Choy, 2014). I can contrast the research gathered from all clinical settings, and eventually come up with a generalized outcome that may prove my hypothesis that clinical settings with NP designed fall prevention programs report less falls and injuries from falls with patients who are part of the program.
There are three types of quantitative design: experimental, quasi-experimental, and non-experimental. Each of these methods must apply a certain level of control to emphasize objective measurements and the statistical, mathematical, or numerical analysis of data (Yilmaz, 2013). The use of a correlational, quasi-experimental design will be implemented to investigate the proposed nursing concern. The use of a correlational design allows me to explore the relationship between independent and dependent variables using statistical analyses measures. An example of this would be a model-testing, such as deciding which established fall prevention program should NPs model their prevention programs after within their practice settings. Correlational designs are not focused cause and effect and is mostly observational in terms of data collection (Yilmaz, 2013). Adding the quasi-experimental methodology allows the researcher to establish a “Causal-Comparative” (cause-effect relationship) between two or more variables that the correlational design omits. In a quasi-experimental design, the researcher identifies control groups and compares the results of control groups exposed to the variable, but the researcher does not assign groups or manipulate the independent variable (Yilmaz, 2013).
The advantage to using quantitative research designs is the ability to control variables and the outcomes of those variables (Yilmaz, 2013). This typically provides an unbiased result. Since data is numerical, it minimizes the chances of it being misinterpreted. A disadvantage to quantitative research methods is the size of the sample population. While many quantitative studies use small population samples, the samples should be large as to validate numerical outcomes that will then be turned into statistical information (Yilmaz, 2013). This provides “reliability” for replication purposes; thus, the more statistically accurate the outputs will be. Too much control over variable does not allow for real-world research application.
Sampling Method and Target Population
The preferred sample population of nurses is nurse practitioners; however, experiences of registered nurses (RNs) and licensed practical nurses (LPNs) will be considered. Nursing patients must be adult males and females, ranging in age from 21 years old and above (around or above 90 years old). Study participants must be in a long-term care or acute care facility for more than 48 hours. These facilities include but are not limited to nursing homes, acute care hospitals, and LTC rehabilitation facilities. The proposed sampling method is quota nonprobability. Due to the fact that study subjects are already employed in LTC environments and patients are already designated at LTC facilities, the assembled sample has the same proportions of individuals as the entire population with respect to known characteristics, traits or focused phenomenon. One advantage to the quota sampling method is potential study participants are selected from a specific subgroup (Espejo, 2015). So, this is similar to tailoring the sample population to achieve the desired outcomes. One disadvantage to this sampling method is random sampling is not used (Espejo, 2015). Therefore, it difficult to determine any possible sampling error, which is considered biased.
Description of the Sampling Procedure
Sample size specifies how many study participants are required to compile statistically complete results. When determining sample size, researchers make educated guesses on how many people match the demographic characteristics of the research topic (Espejo, 2015). For instance, to determine the criteria for this EBP research topic project, the researcher would look up the national description of NPs in acute care or LTC settings. The general population size would be the total number of nurse practitioners who fit this criterion. When determining sample size, researchers must also keep in mind the margin of error (confidence interval) (Espejo, 2015). No sample size is exact; therefore, the researcher must decide how much higher or lower than the population mean the sample mean is allowed to fall (Espejo, 2015). For example, a basic statistic regarding falls in LTC settings may say, “Each year, approximately 35% of adults aged 60 years and older fall in nursing homes and injure themselves.” This number is an approximation representative of the entire population of 60-year-old patients in nursing homes, so the researcher may set the margin of error to show +/- 7%. Researchers need to be as accurate as possible. So, the confidence level, the mean that falls within the confidence interval, should be at least 90% or above (Espejo, 2015). The next factor to consider in determining sample size is standard of deviation, which is level of differences expected in the responses of study subjects (Espejo, 2015). Standard deviation is generally set at .5 to ensure the sample size will be large enough to confirm or disprove the researcher’s theory (Espjeo, 2015). For example, an ideal sample size for the proposed EBP research project should be measured against how many LTC facilities are in proximity to the researcher. According to American Hospital Directory (2017), there are over 235 LTC facilities and approximately 114 hospitals in the State of Georgia. Using the online “sample-size” calculator provided by Qualtrics.com (2018), confidence level was set at 90%, population size was set at 349, margin of error was set at 5%. The “ideal sample size” or how many LTC facilities that should be polled is 153.
Inclusion criteria is defined as characteristics that prospective subjects must have to participate in the study (Garg, 2016). Exclusion criteria is characteristics that disqualify potential subjects from participating in the study (Garg, 2016). Inclusion criteria for nurses is the nurse must be currently employed or have been employed at a long-term care facility for two or more years. Nurses must also have experience in implementing fall prevention and injury programs in clinical settings. Inclusion criteria for nurses’ patients are must be an adult at least 21 years old, placed in LTC setting for more than 48 hours, has fallen or is at risk for falls. Exclusion criteria for nurse subjects will be nurses who do not work with the indicated patient population, nurses who work with indicated patient population but in at-home settings, and nurses who have had less than two years’ experience working in acute care or LTC settings that do or do not utilize fall prevention strategies or programs.
All research participants have rights that include knowing why the research is being conducted, being informed of the risks or side effects that will or may occur, asking questions during any phase of the research, requesting that personal information be kept private, and dropping out of the research project at any time (Wolf et al., 2015). Participants should be well informed about patient rights regarding confidentiality and anonymity, protection from harm, and informed consent.
Upholding confidentiality means only members of the research team can identify and access the responses of research subjects. Researchers are expected to do everything humanly possible to prevent anyone outside of the project from accessing or altering the responses of subjects. Anonymity goes a little bit further than confidentiality protocols. Anonymity means researchers do not request or collect identifying, private, or contact information of participants. Some basic information such as gender and eight may be collected because it is essential to the study, but for the most part, no pertinent information is requested. Measures researchers can take to improve or increase confidentiality and anonymity are to use codes instead of names on important documents, store documents in a locked cabinets and secure areas, encode computer data, and properly dispose of documents (Wolf et al., 2015). Research staff should sign confidentiality agreements and be assigned login codes to access participant information (Wolf et al., 2015)
Safeguarding research participants from harm provides that researchers will implement and enforce safety measures that set the rules for respecting patients’ dignity and that guard against foreseen dangers (Wolf et al., 2015). The caveat to protecting participants from harm is all research studies have some amount of risk associated with them; however, it is the researcher’s duty to not impose or allow any additional or unnecessary risks. Researchers must be aware of participants’ mental and physical states. Participants who look or feel uncomfortable should be removed from the study, and patients who are a harm to themselves and others should also be removed (Wolf et al., 2015).
Getting informed consent is one of the most important measures that researchers must take as this protocol is guided by federal and state regulations governing research participation. Informed consent is making sure participants sign consent forms (Wolf et al., 2015). Getting verbal consent is not a valid way to prove informed consent, and researchers should not coerce or bribe potential subjects into signing forms (Wolf et al., 2015). Translators should be provided to participants if a language barrier is detected, and researchers should answer all questions before allowing subjects to sign participation documents (Wolf et al., 2015). Some suggestions on ensuring informed consent protocols are followed are to review each signed document for a legible signature, initials in the correct areas, and date.
PDSA Change Model
According to Agency for Healthcare Research and Quality (AHRQ), the Plan-Do-Study-
Act (PDSA) change model is one method researchers can utilize to determine whether the appropriate change protocol has been implemented in a research study design. The PDSA change model is most appropriate to implement the evidence-based nursing practice solution because it provides an outline for the researcher to evaluate the outcome of an implemented idea, improve on the initial plan, and retest the theory (AHRQ, 2015). For each stage, researchers must outline their objective in a succinct statement. The first step is the “planning” phase in which researchers write out what they want to. During the “do” phase, researchers carry out the plan and monitor what occurs. At the “study” phase, results of the testing are analyzed to determine if goals were reached. At the “act” step, researchers record statements on whether the newly implemented plan worked or did not work out, as well as and what can be implemented differently in the next PDSA cycle to address any shortcomings or mistakes. The following example has been included for the proposed EBP project as outlined by the Agency for Healthcare Research and Quality (2015):
Tool: Nurse Practitioner Survey Feedback
Step: Distribution of Surveys
Cycle: 1st Try
I plan to: test the process of handing out nurse/patient engagement surveys and getting them back no later than five days after handing them out.
I hope this produces: no less than 20 completed surveys per week.
Steps to execute:
Surveys will be displayed next to the computer by the nurse sign-in station.
Nursing supervisor will encourage nurses and NPs to fill out a survey during break.
This process will be attempted for two weeks.
I observed the nursing supervisor successfully remind nurses about the survey if the supervisor was at the desk during the start of the morning shift. I noticed the nursing supervisor reminded nurses less as the day moved on.
The measurement goal was not met. At the conclusion of two weeks, only 13 surveys had been returned. The initial process does not work well.
What has been concluded from this first phase is that nursing supervisors have so many responsibilities that they do not have time to remind nurses to fill out the surveys. Also, many nurses commented that they did not want “to work” on their breaks. We need to approach nurses while they are not at work. We will try to email the surveys to nurses’ emails and request they send it back within five days of receiving the survey link.
Overcoming Barriers to Implementing EBP Falls Prevention Strategies
The biggest barriers to implementing fall prevention programs in LTC setting are lack of information and motivation. NP leaders play a significant role in overcoming these barriers. NP leaders can inform nursing staff about falls prevention EBP practices during staff meetings and start of shift meetings. NPs can lead open discussions that allow staff to provide feedback on the status of at risk patients, as well as whether benchmarks and goals have been reached. To motivate nurses to stay diligent about helping patients avoid falls, NP leaders can institute a merit-based program that rewards the nurse with the least patient falls per month. Once nurses feel comfortable they will be supported by management if they implement EBP falls prevention strategies, the clinical setting will change to a more patient centered environment. Supporting EBP practices is an organizational effort. NP leaders can improve access to falls prevention resources by having these resources available onsite for nurses to interact with. Resources may include pamphlets and brochures on falls prevention strategies, videos that teach falls prevention methods, and simulated training modules that engage nurses in real-world clinical situations. NP leaders can also encourage administrative boards to adopt policies requiring all nurses to undergo falls prevention training.
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