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Reading Research
Literature
Running head: RRL #5
Reading Research Literature - Number Five
NR 449ON - Evidenced Based Practice
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Reading Research
Literature
Reading Research Literature - Number Five
Clinical Significance
a. Table
# Remaining Oriented # Experiencing Confusion
Treatment Group (Pt) 270 30
Control Group (Pc) 240 60
(Significantly different results: p < 0.01)
b./c. Calculations and Explanations
AR = Absolute Risk = Events/n = 30/300 = 0.1, indicating the risk of ICU patients
developing confusion.
ARR = Absolute Risk Reduction = Pc – Pt = 60 – 30 = 30, indicating how much lower
the probability of confusion is in the treatment group.
RR = Relative Risk = Pt/pc = 30/60 = 0.5, indicating the percentage of treatment-group
patients having an outcome divided by the percentage of control-group patients having an
outcome.
RRR = Relative Risk Reduction = 1 – RR = 1 – 0.5 = 0.5, indicating the proportional
difference in the rates of outcomes between the treatment group and the control group.
Odds = 30/60, indicating how many treated patients out of a group of untreated patients
experiencing confusion would also experience confusion.
OR = Odds Ratio = (30/270)/ (60/240) = 0.4444, indicating the odds of confusion in the
treatment group divided by the odds of confusion in the control group.
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NNT = Number Needed to Treat = 1/ARR = 1/30, indicating the number of patients
needed to treat, explains how effective the treatment was (Manriquez, Villouta, &
Williams, 2007, p. 665).
d. The clinical significance of these findings is that ICU patients are less likely to become
disoriented if warm ambient lighting is used in the ICU in a 16-hour on/8-hour off cycle.
e. The clinical significance is consistent with the statistical significance, as the statistics
demonstrate its veracity.
Qualitative Studies
a. In the Bond et al. study, the participants were appropriate to provide data relevant to the
purpose of the study. First of all, since it was a qualitative study, qualitative results were being
sought, not quantitative results. Second, the data needed related to how the family members of
ICU patients presenting with traumatic brain injury felt about their loved one’s care; since all of
the participants were indeed family members of ICU patients presenting with traumatic brain
injury, they were fully qualified to provide information on how they felt about the patient’s care.
b. Based on the description of phenomenology given in the article, this is a
phenomenological study by virtue of the fact that it not only examines what the experience of
being a family member of an ICU patient with a traumatic brain injury is like, it also attempts to
elucidate the meaning of the family members’ experience in that context (Bond, Draeger,
Mandleco, & Donnelly, 2003, p. 66). The article includes “direct quotes that relate to a
particular theme the researcher has identified,” which is also consistent with a phenomenological
study (Bond, Draeger, Mandleco, & Donnelly, 2003, p. 66).
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c. The theme of “need to know” signifies the family members’ need to know the truth about
their loved one’s condition, without “sugarcoating” on the part of doctors and other medical
personnel (Bond, Draeger, Mandleco, & Donnelly, 2003, p. 67). Family members just want to
know what they are facing—whether the person is certainly going to die, might live, or will
almost certainly live. The transferability of these findings could be compromised by the thinness
of the description provided in the article, which only devoted one short paragraph to the issue
and one table of family members’ responses. Family members of different patients might feel
differently, particularly given the small size of the sample.
Quantitative Studies
a. In the Wyatt et al. study, subjects were assigned to groups based on whether they
received the intervention and no additional agency-based home care, the agency-based home
nursing care, or no home nursing care (Wyatt, Donze, & Beckrow, 2004, p. 324). The women
had all had a positive breast cancer diagnosis and a lumpectomy, and their demographic
variables, functional status, and quality of life at baseline were very similar (Wyatt, Donze, &
Beckrow, 2004, p. 324). These great similarities increase the validity of the findings, because
the only significant variable is the treatment they received.
b. Instrument validity and reliability provided for the SF-36 Healthy Survey was statistical
in nature. The article stated that reliability coefficients on pre-test measures were .89 and on
post-test measures were .91 (Wyatt, Donze, & Beckrow, 2004, p. 326). Validity was related to
scoring, which was done according to a 0-100 scale, with the higher number indicating better
physical functioning (Wyatt, Donze, & Beckrow, 2004, p. 326).
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Ridge & Goodson
a. Column graphs
Work
Home Management
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The inferential test used to determine statistical significance was the p-test. The p-value
for work was 0.831, and the p-value for home management was 0.003 (Ridge & Goodson, 2000,
p. 76). The results for work are not statistically significant but those for home management are
statistically significant; statistical significance is predicated on the p-value being less than 0.05.
Both results were clinically significant, however, as evidenced by the noticeable improvement in
functional status.
b. This study’s findings can be used to improve at least one aspect of patient care by
implementing a change proposal based on the six steps of the Rosswurm and Larrabee model.
Rosswurm and Larrabee’s (1999, p. 318) “model for evidence-based practice” starts by
identifying a need for change in practice as the first step and then linking it to problem
interventions and potential outcomes as the second step (Rosswurm & Larrabee, 1999, p. 318).
The third step is to conduct a literature search and carefully assess the information found,
synthesizing the best evidence and considering any risks and benefits associated with
alternatives, as well as their feasibility (Rosswurm & Larrabee, 1999, p. 318). In the fourth step,
the proposed change is defined and the implementation process outlined, and required resources
are identified (Rosswurm & Larrabee, 1999, p. 318). Step five involves implementation and
evaluation of the change in practice as a pilot study; during this pilot, the solution is carefully
evaluated to determine whether it should be modified, adopted, or rejected (Rosswurm &
Larrabee, 1999, p. 318). The sixth and final step is to integrate the change into the standards of
practice and inform the stakeholders about it (Rosswurm & Larrabee, 1999, p. 318). Training is
provided to the staff to enable them to implement it, and ongoing monitoring takes place to
ensure that the process and outcomes are as anticipated (Rosswurm & Larrabee, 1999, p. 318).
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In the Ridge and Goodson (2000, p. 81) study, it was proposed that further interventions
might include “activity and exercise management, physical comfort promotion, and self-care
facilitation.” Based on these suggestions, a proposal is offered for improving an aspect of patient
care—an approach for promoting physical comfort in hip replacement patients.
Step 1: The findings from this study can improve hip replacement patient comfort.
Step 2: To find out how to increase hip replacement patients’ physical comfort, a PICO-
formatted clinical question related to this problem was developed: Among patients that have just
had hip replacement surgery, do changes in mattress or the use of ergonomic chairs reduce pain
as much as pain medication does? The focus of this question is treatment, as changes in the
patient’s physical surroundings and accommodations could potentially reduce pain sufficiently to
replace pain medication or boost its efficacy in relieving pain.
Step 3: In a search of CINAHL and Medline, this PICO-formatted question yielded little useful
information. Starting with CINAHL, the search used was: patient AND hip replacement surgery
AND pain reduction AND (mattress OR ergonomic chair) AND pain medication. On CINAHL,
there were 91,489 results, and a scan of the first 60 results showed only one that mentioned
mattresses and none mentioning ergonomic chair. The one article that mentioned mattresses was
not discussing home care but the use of a special Nimbus bed for in-hospital patients that
facilitate the nurse’s efforts to move or roll the patient so as to avoid pressure on the affected hip
and prevent dislocation.
Using the same search strings on Medline resulted in zero results. However, changing
the search string to: mattress AND hip replacement yielded 29 results, of which one was the
same article about the Nimbus bed. However, Medline associated several “related articles” with
that one, and these were very informative. The abstract to “Pressure relieving support surfaces: a
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randomized evaluation” discussed the PRESSURE—“Pressure Relieving Support Surfaces: a
Randomized Evaluation” Trial, which found that mattress overlays were an acceptable substitute
for a new mattress if a new mattress could not be obtained, as both provided the same pressure
relief (Nixon, Nelson, Cranny, Iglesias, Hawkins, Cullum, Phillips, Spilsbury, Torgerson, &
Mason, 2006, p. 1). Another related article homed in more closely on the target information I
was seeking, as it included mattresses and seat cushions in the mix with pressure-relieving beds
and sought to determine to what extent these items reduce pressure ulcer incidence compared
with standard support surfaces (Cullum, McInnes, Bell-Syer, Legood, 2004). The study
concluded that “higher specification foam mattresses” were preferable to standard hospital foam
mattresses in the hospital setting and that seat cushions and overlays needed further evaluation
(Cullum, McInnes, Bell-Syer, Legood, 2004). These results led me to adapt my focus from
comfort in general to relief of pressure ulcers and to focus on mattresses and mattress overlays as
a viable and effective solution.
Step 4: Using the information from the articles as a base, a solution was formulated that would
promote greater patient comfort in terms of combating bedsore development. The solution
proposed is that all hip replacement patients be assigned in hospital to special beds that have
higher specification foam mattresses on them and that they be advised to replace their mattress at
home with a high specification foam mattress or add a high specification mattress overlay, at
least during their convalescent period.
Step 5: One barrier for this solution is cost, as good-quality mattresses are quite expensive. The
overlays are far less expensive but not as durable, although they have comparable efficacy per
the study. A facilitator for this barrier would be a memory foam mattress supplier representative,
who could work to obtain group discounts both for the hospital and the patients.
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Step 6: In order to implement this solution, resources and staff education will be necessary. Staff
needs to understand why the new mattresses will be in use, and patients should also receive
instruction along with the offer of the group discount so that they can make an informed decision
about replacing their home mattress or buying an overlay for it. Other resources include
brochures, slide presentations, and other informational and instructional items to help both staff
and patients recognize the benefits of the mattresses and overlays and any special issues that
might be associated with them. In addition, a system of monitoring and feedback should be
established to track the efficacy of this intervention, both at the hospital and home levels, and the
intervention should be modified as needed to achieve maximum effectiveness.
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References
Bond, A.E., Draeger, C.R.L., Mandleco, B., Donnelly, M. (2003). Needs of Family Members of
Patients with Severe Traumatic Brain Injury. Critical Care Nurse, 23(4), (Aug), 63-72.
Cullum, N., McInnes, E., Bell-Syer, S.E., Legood, R. (2004). Support surfaces for pressure ulcer
prevention. Cochrane Database System Review, 3. PubMed. Retrieved on August 18,
2009 from: http://www.ncbi.nlm.nih.gov/pubmed/15266452?
ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_Di
scoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pu
bmed
Manriquez, J.J., Villouta, M.F., Williams, H.C. (2007). Evidence-based dermatology: Number
needed to treat and its relation to other risk measures. Journal of the American Academy
of Dermatology, 56(4), (Apr), 664-671. Science Direct. Retrieved on August 17, 2009
from: http://www.sciencedirect.com/science/journal/01909622
Nixon, J., Nelson, E.A., Cranny, G., Iglesias, C.P., Hawkins, K., Cullum, N.A., Phillips, A.,
Spilsbury, K., Torgerson, D.J., Mason, S. (2006). Pressure relieving support surfaces: a
randomized evaluation. Health Technology Assessment, 10(22), iii-163. PubMed.
Retrieved on August 18, 2009 from: http://www.ncbi.nlm.nih.gov/pubmed/16750060?
ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_Di
scoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pub
med
Ridge, R.A., Goodson, A.S. (2000). The Relationship between Multidisciplinary Discharge
Outcomes and Functional Status after Total Hip Replacement. Orthopaedic Nursing,
19(1), (Jan/Feb), 71-82.
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Rosswurm, M.A., Larrabee, J.H. (1999). A Model for Change to Evidence-Based Practice.
Image: Journal of Nursing Scholarship, 31(4), 317-322. Wiley InterScience. Retrieved
on August 18, 2009 from:
http://www3.interscience.wiley.com/cgi-bin/fulltext/119939497/PDFSTART
Wyatt, G.K., Donze, L.F., Beckrow, K.C. (2004). Efficacy of an In-Home Nursing Intervention
Following Short-Stay Breast Cancer Surgery. Research in Nursing & Health, 27, 322-
331.
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