Evidence-Based Practice and Applied Nursing Research

Evidence-Based Practice and Applied Nursing Research

Introduction
The goal of quantitative research analysis is to find out the association between the two
variables being studied. Quantitative research has to show the results in numeric data that is very
detailed. Often this data is arranged in tablets, charts, or other figures. Using the quantitative
research analysis the future outcome can be predicted. For quantitative research, the researcher
uses surveys and questionnaires to collect the data to be studied and interpreted. For this
research purpose, I evaluated the article Falls in People with Multiple Sclerosis Compared with
Falls in Healthy Controls.
Review of the Literature
The purpose of this study is to compares the risk, circumstances, consequences, and
causes of falls that have been recorded among patients with multiple sclerosis and healthy
controls of similar age and gender. There have been previous similar studies conducted that
showed different results from this study. Those studies have concluded that 50-70% of people
have fallen at least once in three to twelve month period. The review of current literature
concluded that 70% of people with MS have fallen at least once within 6 month despite of being
much younger than population of the previous studies. The goal of this study is to analyze the
survival without falling between population with MS and the healthy controls.
Critique:
The circumstances of falls in this study vary from any other study in terms of how many
people with MS fell inside compared to outside. It was determined that 86% of population in
this study with MS fell outside. This high percentage could be the indication that the individuals
with MS are younger and less disabled and they are able to spend more time outdoors. Also, it
was interesting to note that previous studies had less injuries related to falls in their cohort with
MS. The lower risk for injury is less because they are old and more disabled and not able to go
outside.
Discussion of Methodology
The method used for evaluation of risk, circumstances, consequences, and causes of falls
was a prospective cohort study. It was conducted at a Department of Veteran Affairs and an
academic medical center in the Northern USA. “The Institutional Review Board of the Portland
VA Medical Center and Oregon Health & Sciences University approved this study and the
investigation was conducted according to the principles expressed in the Declaration of
Helsinki”. Participants had to sign informed consent to be able to participate in the study. Local
community neurology clinics assisted with recruiting patients with MS by posting flyers,
informing individuals at support groups about the study, and with the help of healthcare
professional referrals. Healthy control group was formed from people who responded to the
flyers. The criteria for both groups were their age between 18 to 50 years old, ability to sign
their own informed consent to participate in the study, and the ability to keep record of their falls
for 6 month period. The variables in the study were falls and type of injury sustained.
Participants had to record how many falls they had per day and if they have sustained any
injuries and type of injuries. Also, it was important to note what the participant was doing when
the fall occurred and if the fall was inside or outside of the house.
Critique:
For this study Kaplan Meier survival analysis and log-rank tests were used to measure
survival without falling between participants with MS and healthy controls. It measured number
of participants who survived without falling at the end of the trial. It is the simplest way of
computing the probabilities of falling between two groups within 6 months period. Out of 112
potential subjects with MS, only 52 met all the inclusion criteria and consented to participate.
Out of 63 healthy controls who responded to the fliers, 49 completed all measures and were
included in the trial.
Data Analysis
All analyses are based on data from the 52 participants with MS and 49 healthy controls
who have returned all recorded fall calendars. The average age of participants with MS was 39.7
years and people in control group was 38.7 years. Out of 200 total falls recorded, 145 were in
the participants with MS and 55 in the healthy controls. It was clear that people with MS have
fallen more often and have sustained more injuries related to falls. Also, people with MS had
more episodes of recurrent falls. The significant difference was also noted in the location where
the fall occurred for different groups. For people with MS falls occurred inside of the house
while performing activities of daily living. However, healthy control group mostly fell outside
of the house or while climbing the stairs.
Critique:
In my opinion, the reason why more people with MS have sustained more injuries related
to falls, is because these individuals were much younger and less disabled and spent more time
outside of the house. In the other studies only 11% of their participants have reported injuries
related to falls. The reason could be that in the other studies the participants are much older and
disabled and spend more time indoors or totally bed ridden.
Researcher’s Conclusion
The study concluded that the risk for falls, circumstances when the fall occurred, and the
causes of falls for participants with MS and healthy control group differ. Individuals with MS
fall more often and are more likely to get injuries related to falls, and frequently fall indoors
while performing activities of daily living. The study totally made sense to me because it is
obvious that the younger patients are, the more active they are and more often they go outside.
Previous studies had patients who were totally disabled and bedbound and thus had less frequent
falls. Patients in this study were young between the ages of 18 to 50.
2. Critique whether the evidence presented in each section of the journal article supports the
researcher’s conclusion.
The researcher was able to recruit people with MS from neurology clinics and healthy
controls by posting the fliers and obtaining referrals from their healthcare providers. Many
people responded to the fliers. Some individuals with MS were not able to participate due to
their inability to make informed consent and record their falls in the calendars. Also, only people
between the ages of 18 to 50 were able to participate. For 6 months the fall episodes were
recorded and the circumstances of falls. It was determined that that out of 200 falls, 145 falls
were from the participants with MS and 55 falls in the healthy controls. The evidence supports
researcher’s conclusion that people with MS fall more often and sustain more injuries related to
falls. Most falls in people with MS are inside while performing activities of daily living.
3. Explain the protection of human subjects and cultural considerations of the journal article.
All individuals who were able to participate in the study had to be between the ages of 18
to 50 years old. They had to be alert and oriented and able to sign their own consents. Also, it
was important to be able to record their falls in the calendars over 6 months period. People with
MS had to have MRI-confirmed diagnosis of MS. The research was aimed to identify the risks
for falls with individuals with MS and the circumstances when the fall occurred. Hopefully,
after conducting this study, individuals with MS will be more aware what to do to avoid falls.
The subjects were selected fairly with confirmed diagnosis of MS. Exclusion criteria were a
self-reported condition of MS, other neurological conditions affecting gait and balance, unable to
follow direction in English, blindness, or unable to ambulate more than 100 meters (Sreeram V.
Ramagopalan, 2017). The benefit of this study was to maximize the safety of the individuals
with MS by making them more aware of their limitations and hopefully prevent future falls. To
make sure that subjects adhere to the participation protocol, participants were contacted by phone
each month to remind them to return their calendars and to answer any study-related questions.
4. Strengths and limitations of the study.
This study has many strength and a couple of limitations. One of the strength is that it is
the first study that compares the risk of falls in people with MS compared to healthy people of
similar age and gender. Knowing the risks of falls in individuals with MS could assist with
determining the interventions to reduce fall related injuries in individuals with MS who
experience significant frequency of falls. Using fall calendar is the gold standard to assessing
falls because it decreases bias from misclassification. The limitation of the study is the fact that
this study focuses on younger individuals with MS which could suggest that they have different
risk taking behaviors and level of activity than older people.
5. How the evidence informs nursing practice.
The evidence suggests that people with MS fall more frequently and sustain more injuries
related to falls. This information could be very helpful for nurses in their day to day practice.
When carrying for the individuals with MS, nurses need to pay special attention to them to
prevent falls. Avoiding falls and injuries should be nurses’ main goal when it comes to patients’
safety. Identifying individuals who are prone to falls and taking an extra step to educate patients
and families about ways to avoid falls could be life saving. Knowing which circumstances cause
falls in individuals with MS, nurses can shift their focus on educating them to modify their home
environment for safety.
B. Qualitative Research
Introduction
Hospice is a government program designed to offer medical care and services to support
families and patients to maintain quality of life when illness is unlikely to be cured. This
program is for people who will not benefit from the curative measures anymore and have been
given life prognosis of less than six months. Hospice services also provide emotional and
spiritual support during the illness and to the families after their loved one passes. Hospice
services in the United States have been widely used providing satisfaction among patients and
caregivers. However, there are situations when families opt for hospitalization if symptoms are
not properly managed by hospice team. In the study it was determined that approximately 25%
of hospice patients disenroll from hospice due to hospitalization. There are options that can be
offered to the families and patients who are in crisis to avoid hospitalization. The goal of this
study is to understand the reason for hospitalization among hospice patients from the perspective
of hospice team members.
Review of the Literature
The objective of this study is to understand the main reason for hospice patients’
hospitalizations by conducting a qualitative study using a grounded theory approach. The study
was performed by interviewing interdisciplinary team members who were involved in patient
care. Most of the time patients end up revoking hospice services due to uncontrolled pain,
caregiver burden, or shortness of breath. Every crisis is unique; however, to better understand
how to manage commonly experienced crises, interdisciplinary team members need to develop
individualized care plan to assist caregivers when problems arise.
Critique:
The authors visited hospice cite and interviewed their members. Their work was supported by
the contributions from the National Institute of Aging, National Institute on Drug Abuse, the Howard
and Phyllis Schwarts Philanthropic Fund, the John A. Hartford Foundation, and the Empire Clinical
Research Investigator Program (Phongtankuel, V., Scherban, B. A., Reid, M. C., Finley, A., Martin, A.,
Dennis, J., & Adelman, R. D., 2016). Authors were able to identify that during crisis hospices are able
to provide continuous level of care or general inpatient for symptom management or caregiver relief.
According to the article, 21.1% of hospices did not provide higher level of care to their clients who were
discharged.
Discussion of Methodology
This study design was a qualitative study using grounded theory approach from data
collected in seven focus groups. Investigators visited seven nonprofit hospice organizations
located in the city of New York. According to the article, the institutional review boards of Weill
Cornell Medical College and Visiting Nurse Service of New York Hospice approved the study.
Interdisciplinary team members were interviewed and based on their responses, new topics were
introduced. All responses were recorded and then analyzed. All the data was then shared with
the team members who validated that the investigator’s interpretation of the identified themes was
credible.
Critique:
The study suggests that by conducting cross-sectional study using a grounded theory
approach and collecting data from seven focus groups will bring credible findings. The team
members themselves agreed that the identified themes have captured their thoughts and feelings
about the reasons why patients become hospitalized.
Data Analysis
The results identified eight major reasons why hospice patients become hospitalized. The
major reason is due to not fully understanding hospice philosophy. Some of the other ones
include; lack of understanding terminal diagnosis and/or prognosis, desire to continue with their
primary care physicians, caregiver role strain or burnout, unmanageable signs and symptoms of
distress, caregivers’ reluctance to administer morphine, emergency response of 911 is faster than
hospice, and finally families’ difficulty accepting patients’ mortality (Phongtankuel, V. et al.,
2016). Evidence suggests that most of the time hospice patients ended up hospitalized due to
their lack of understanding their prognosis and/or hospice care. Under hospice, the focus of care
shifts from traditional medical care to comfort and palliative care only. Also, it was evident that
families prefer care to be provided by their primary care physicians and hospital when the crisis
occurs. Transition into hospice could be very unfamiliar to the families and patients and it takes
time for trust and relationship to develop among the IDT members and the hospice recipients.
After analysing the data that was provided by the participants, it was clear that the reason for
hospitalization is the lack of explanation of hospice benefits upon admission. The physician did
not have a clear discussion with patients and families about their prognosis and the methodology
in shift of care.
Critique:
Data was collected directly by interviewing hospice IDT members who participate
directly in patient care. The investigators analysed all the data and then discussed with the
hospice staff their findings. Then the findings were reconciled until everybody agreed that the
reasons for hospitalizations are related to their thoughts and feelings. Everybody agreed that
investigators had credible findings.
Researcher’s Conclusion
Researchers were able to identify eight main reasons why hospice patients end up
hospitalized. Most of the time it is due to lack of understanding of hospice philosophy and goals
of care. It was concluded that there should be further reseach done with the perspective of
caregivers and patients on the reasons why they opted out from hospice care. There has to be
future interventions on behalf of the hospice team to involve all the team members and especially
physicians during initial explanation of hospice services and benefits. Open communication
among physicians, patients, caregivers, and hospice IDT members will provide comfort,
symptom management, prevention of crisis care, and ultimately prevention of hospitalization.
2. Critique whether the evidence presented in each section of the journal article supports the
researcher’s conclusion.
Researcher identified eight factors affecting families and patients decision for
hospitalization. It was concluded that one of the main reasons that hospice patients become
hospitalized is due to their lack of understanding of hospice philosophy. Educating terminally ill
patients and families about proper interventions for symptom control in imperative to preventing
crisis from occurring.
3. Explain the protection of human subjects and cultural considerations of the journal article.
During the study none of the hospice beneficiary names have been released to the public.
This was a qualitative study and only the opinions of hospice staff were interpreted about the
reasons of patients’ hospitalizations. The names of hospice IDT members have not been
identified in this study.
4. Identify strengths and limitations of the study.
One of the limitations of the study is that it was conducted within one single site. There
are many more hospice organizations and each organization could have other useful information
that could benefit in this study. Participants have an experience caring for a diverse patient
population of big city, which may not accurately represent the patient population served in other
regions of the country (Phongtankuel, V. et al., 2016). Only members of the hospice team have
been interviewed. Patients’ and caregivers’ perception and reason for hospitalization could
differ. Also, participants of the study can have trouble recalling the information, which could be
bias. The study mentions ways to help caregivers to overcome some of the barriers they are
having with the use of morphine. Study mentions interventions to help lessen the stigma of
opiate use and improve knowledge about pain management among caregivers (Phongtankuel, V.
et al., 2016).
5. How the evidence informs nursing practice.
Hospice program became very widely used especially in the past decade. With the
changes in healthcare system and budget cuts, hospice program saves medicare spending. There
are many benefits to this program. It provides care to the patients in their familiar environment
surrounded by their family and friends. Nursing care is being provided in the patients’ homes.
Referenses
Mazumder, R., Murchison, C., Bourdette, D., & Cameron, M. (2014). Falls in People with
Multiple Sclerosis Compared with Falls in Healthy Controls. PLoS ONE, 9(9), e107620.
http://doi.org/10.1371/journal.pone.0107620
Phongtankuel, V., Scherban, B. A., Reid, M. C., Finley, A., Martin, A., Dennis, J., & Adelman,
R. D. (2016). Why Do Home Hospice Patients Return to the Hospital? A Study of Hospice
Provider Perspectives. Journal Of Palliative Medicine, 19(1), 51-56. doi:10.1089/jpm.2015.0178