EP 4001Iowa Model of Evidence Based Practice Paper
EP 4001Iowa Model of Evidence Based Practice Paper
- Consider some of the models that are used in evidence-based practice (ACE Star, Iowa, Stetler, Ottawa, PARiHS, ARCC, JHNEBP, or KTA).
- Select one model that you could apply to your current facility or to the type of facility you plan to work. EP 4001Iowa Model of Evidence Based Practice Paper
In a 1–2-page paper, address the following:
- Explain why you chose this model to apply to your practice.
- Describe how you would apply this model in practice focusing on the essential steps within the model and why this would be important to your practice.
- In addition, use the Walden Library to locate one resource where the model is applied and summarize the resource.
Be sure to include a reference to the resource at the end of your 1–2-page paper
EP4001: Evidence-Based Practice Models for Research: Understand the importance of using models to facilitate evidence-based practice. Assessment Rubric Does Not Meet Meets Expectations Expectations Module 1: Evidence-Based Practice Models Select one model that Response does not Response adequately you could apply to adequately select an selects an evidence-based your current facility or evidence-based practice practice model that could to the type of facility model that could be be applied to either current you plan to work. applied to either current or or potential work potential work environments. Learning Objective 1.1: environments. Identify evidence-based practice models Explain why you chose Response does not Response adequately this model to apply to adequately justify the justifies the selection of an your practice. selection of an evidenceevidence-based practice based practice model. model. Learning Objective 1.2: Defend the selection of evidence-based practice models Module 2: Application of Evidence-Based Practice Models Explain how you would Response does not Response adequately apply this model in practice adequately explain how explains how you would focusing on the essential you would apply this model apply this model in practice steps within the model. in practice, or it does not and adequately focuses on focus on the essential the essential steps within steps within the model. the model. Rubric Criteria © 2020 Walden University Exceeds Expectations Response clearly selects one evidence-based practice model that can be appropriately applied to either current or potential work environments. Response clearly, thoughtfully, and completely justifies the selection of an evidencebased practice model. Response clearly and completely explains how you would apply this model in practice and thoughtfully focuses on the essential steps within the model. 1 Does Not Meet Expectations Rubric Criteria Learning Objective 2.1: Analyze evidence-based practice models in professional practice Locate one resource where the model is applied and summarize the resource. Learning Objective 2.2: Summarize literature related to evidence-based practice models Response does not adequately locate one resource where the model is applied, or the resource is not adequately summarized. Meets Expectations Exceeds Expectations Response adequately locates one resource where the model is applied and adequately summarizes the resource. Response clearly locates one resource where the model is applied and thoughtfully summarizes the resource. Content contains few spelling, punctuation, and/or grammar/syntax errors. Writing demonstrates adequate sentence and paragraph structure and may require some editing. Content presented is satisfactorily clear, logical, and/or organized, but could benefit from additional editing/revision. Content is free from spelling, punctuation, and grammar/syntax errors. Writing demonstrates appropriate sentence and paragraph structure. Content presented is clear, logical, and well-organized. Professional Skills Assessment Professional Writing Professional Writing: Clarity, Flow, and Organization © 2020 Walden University Content contains significant spelling, punctuation, and/or grammar/syntax errors. EP 4001Iowa Model of Evidence Based Practice Paper
Writing does not demonstrate adequate sentence and paragraph structure and requires additional editing/proofreading. Key sections of presented content lack clarity, logical flow, and/or organization. 2 Professional Writing: Context, Audience, Purpose, and Tone Professional Writing: Originality, Source Credibility, and Attribution of Ideas © 2020 Walden University Content minimally or does not demonstrate awareness of context, audience, and/or purpose. Writing is not reflective of professional/scholarly tone and/or is not free of bias. Style is inconsistent with the professional setting/workplace context and reflects the need for additional editing. Content does not adequately reflect original writing and/or paraphrasing. Writing demonstrates inconsistent adherence to reference requirements, including the use of credible evidence to support a claim, with appropriate source attribution (when applicable) and reference. There are numerous and/or significant errors. Content demonstrates satisfactory awareness of context, audience, and purpose. Tone is adequately professional, scholarly, and/or free from bias, and style is mostly consistent with the professional setting/workplace context. Content clearly demonstrates awareness of context, audience, and purpose. Tone is highly professional, scholarly, and free from bias, and style is appropriate for the professional setting/workplace context. Content adequately reflects original writing and paraphrasing. Writing demonstrates adequate adherence to reference requirements, including the use of credible evidence to support a claim, with appropriate source attribution (when applicable) and references. There are one or two minor errors. Content reflects original thought and writing and proper paraphrasing. Writing demonstrates full adherence to reference requirements, including the use of credible evidence to support a claim, with appropriate source attribution (when applicable) and references. 3 Utilization of the Iowa Model in establishing evidence-based nursing practice Ruth E. Taylor-Piliae Clinical practice based on tradition or established rituals appears to be widespread amongst a variety of nurses and practice settings. However, tradition-based practice may not necessarily be based on sound scientific evidence and could potentially be harmful to patients or result in inappropriate utilization of resources. Conversely, evidence-based practice is the utilization of the best available empirical evidence in the practice setting, to facilitate sound clinical decisionmaking. Suctioning ventilated patients is a necessary and important aspect of patient care. EP 4001Iowa Model of Evidence Based Practice Paper
However, normal saline instillation prior to suctioning, in order to loosen secretions, remains a common nursing procedure despite research suggesting that there is no clear benefit and in some instances may be harmful. Several models have been developed over the past few years to facilitate nursing practice that is based on research or the best available evidence. The Iowa Model, developed at the University of Iowa Hospitals and Clinics, serves as a framework to improve patient outcomes, enhance nursing practice and monitor health care costs. Moreover, it facilitates the application of empirical evidence to clinical practice. This paper will discuss the utilization of the Iowa Model to promote evidence-based nursing practice, with regard to normal saline instillation prior to suctioning, in the critical care unit of a 100-bed hospital in Hong Kong. Patient, staff and fiscal outcomes will also be reported. © 1999 Harcourt Publishers Ltd INTRODUCTION Ruth E. TayiorPiliae RN, PHN, CNS, MN Instructor, The University of Hong Kong, Department of Nursing Studies, G/F, Block B, Queen Mary Hospital, Pokfulam Road, Hong Kong TeL +852 2819 2676; Fax: +852 2872 6079 E-mail: firstname.lastname@example.org. hk Manuscript accepted: 13 November 1999 In the current health care climate people are critically evaluating cost-effectiveness, patient outcomes and quality care. A driving force behind this trend is evidence-based practice (Hicks & Hennessy 1997). Evidence-based practice aims to establish clinical practice based on scientific findings at every level and has the potential to influence nursing research, practice and education in the future (Wallace et al. 1997). The implementation of evidence-based practice is the key to clinical effectiveness as this enables nurses to make sound clinical decisions about appropriate interventions (Taylor-Piliae 1998). Changes to the current health care practice have enormous implications for health care services. Many barriers to the incorporation of empirical © 1999 H a r c o u r t P u b l i s h e r s Ltd evidence into clinicat practice exist, thereby hindering practice changes (Funk et al. 1991). Moreover, many areas of nursing practice currently have little or no research evidence. While the implementation of empirical or scientific findings in clinical practice enables nurses to improve patient care, optimize outcomes and reduce costs, a model or framework to facilitate this process seems necessary. THE IOWA MODEL The Iowa Model (Fig. 1), developed at the University of Iowa Hospitals and Clinics (Titler et al. 1994), serves as a framework to improve patient outcomes, enhance nursing practice and Intensive and Critical Care Nursing(1999) 1 5 , 3 5 7 – 3 6 2 357 Intensive a n d Critical Care Nursing Triggers to Improve Practice Through Research Knowledge Focused Triggers . EP 4001Iowa Model of Evidence Based Practice Paper
1. National Agencies or Organizational Standards & Guidelines 2. Philosophies of Care 3. Questions from Institutional Standards Committee 4. New Information in the Literature Problem Focused Triggers 1. Risk Management Data 2. QA/QI* Data 3. Identification of Clinical Problem 4.TQM/CQI** IAssemble Relevant Research Literature I Critique & Evaluate for Use in PracticeI No Yes Research Base Not Sufficiently Developed to Guide Practice Research Base is Sufficiently D e v e l o p e d to Guide Practice 1. Select Outcomes to be Achieved 2. Design Nursing/Multidisciplinary Practice . Implement Practice Changes on a Pilot Unit • Evaluate Process & Outcomes 5. Modify Intervention as Needed L Conduct Research Determine Consult with I [ Scientific Experts Principles I Change Practice I 2 oniorO oes i * i i ~af~ Fiscal **TQM/CQI=Total Quality Management/Continuous Quality Improvement *QA/QI=Quality Assessment/Quality Improvement ~ Fig. 1 358 = a decision point The Iowa Model of Research-based Practice to Promote Quality Care (Reproduced with permission from Titler et al. 1994). Intensive and Critical Care Nursing (1999) 15, 357-362 © 1999 Harcourt Publishers Ltd Use of the Iowa Model in evidence-based nursing practice monitor health care costs. The Iowa Model was an outgrowth of a quality-assurance model, which serves to stimulate investigation or exploration of quality-improvement measures. Moreover, the Iowa Model facilitates the application of empirical evidence to clinical practice through a realistic and efficient approach to promote the establishment of evidence-based nursing practice. The Iowa Model includes triggers, either problem- or knowledge-focused, which serve as catalysts for nurses to search and evaluate the existing scientific evidence. Next, changes to improve practice are implemented when substantiated by a sufficient research knowledge base. Finally, the effects of practice changes upon selected outcomes are monitored over time, in order to facilitate the changes and provide a feedback mechanism. This model has been utilized successfully to facilitate practice changes based on the best available evidence, to improve patient outcomes and contain health care costs in a variety of clinical practice settings (Titler et al. 1994; Cruz et al. 1997; Lundin et al. 1998). Recently, an improvement in outcomes after cardiac catheterization was guided by the use of this model (Lundin et al. 1998). Earlier ambulation after cardiac catheterization improved patient comfort and satisfaction, with significant cost savings. In addition, no adverse outcomes were found. EP 4001Iowa Model of Evidence Based Practice Paper
problems encountered in clinical practice such as nursing management of pain, diarrhoea in tube-fed patients or w o u n d care encourage nurses to think about their practice and question the rationale for their actions (Titler et al. 1994). The new knowledge or information from published guidelines or recent research findings serves to stimulate nurses to question current practices. Hence, the routine use of normal saline instillation prior to suctioning ventilated patients came into question in the critical care unit of a 100-bed private hospital in Hong Kong. The Iowa Model was used to guide change in nursing practice regarding normal saline instillation prior to suctioning ventilated patients. CLINICAL PROBLEM Suctioning ventilated patients in critical care is a common and important nursing procedure. Patients requiring mechanical ventilation are unable to mobilize and expectorate secretions due © 1999 H a r c o u r t P u b l i s h e r s Ltd to the presence of an artificial airway interrupting the mucociliary system. Therefore, suctioning is a necessary aspect of patient care to aid the removal of secretions in order to maintain a patent airway and promote optimal ventilation and oxygenation. However, suctioning has also been associated with several serious and potentially hfe-threatening complications including hypoxaemia, atelectasis, bronchospasm, hypertension, cardiac arrthymias, tissue trauma, infection, distress, fear, anxiety, pain and increased intracranial pressure (Bostick & Wendelgass 1987; Druding 1997; Raymond 1995). Due to the seriousness of these complications, definitive practice guidelines for safe and effective suctioning need to be founded upon the best available empirical evidence. Traditionally, nurses have routinely instilled 3-10 ml of normal saline (NS) in the endotracheal (ET) or tracheal (T) tube before suctioning (Ackerman 1985). The main reason for instilling NS is the belief that this loosens or thins secretions, stimulates a cough and lubricates the suction catheter (Raymond 1995; Wood 1998). Research regarding normal saline instillation (NSI) has found this practice interferes with the alveolar-capillary oxygen exchange causing a decrease in oxygen saturation, an increase in the rate of respiratory infections and in intracranial pressure (Ackerman 1993; Bostick & Wendelgass 1987; Raymond 1995). Current research suggests that this practice has no clear benefit and in some instances may be harmful. Furthermore, patients often panic or feel as though they are drowning during the nurse’s routine instillation of NS via their E T / T tubes (Jablonski 1995). EP 4001Iowa Model of Evidence Based Practice Paper
Triggers which stimulated the critical care nursing staff to consider their practice regarding suctioning ventilated patients included: the patients’ responses to suctioning after NSI, such as grimacing, choking, and a drop in oxygen saturation (SaO2) as measured by the pulse oximeter. Moreover, new information found in the literature suggested the use of humidification or saline nebulizers was effective in thinning secretions and promoting airway clearance. Thus, a literature review regarding NSI prior to suctioning was undertaken. LITERATURE REVIEW Guidelines by Demers and Saklad (1973) to minimize the harmful effects of suctioning Intensive and Critical Care Nursing (1999) 1 5 , 3 5 7 – 3 6 2 359 Intensive and Critical Care Nursing concluded that NSI is not effective in thinning or liquefying secretions, while nebulizers may help moisten secretions, promoting airway clearance. They stated that ‘water in the form of aerosol is of proven value in thinning secretions and promoting their clearance, mucous and water in bulk forms are immiscible and occupy separate phases in vitro, even after vigorous shaking’ (Demers & Saklad 1973, p. 544). Research on NSI dates back more than two decades. Research by Hanley and colleagues (1978) studied the course of instilled radioactive normal saline in five intubated dogs and two intubated patients with respiratory failure. Serial images of the distribution of the radioactivity in the chest were recorded during the saline instillation and for an additional 30 rain. They found the saline only reached the mainstem bronchi and elicited no cough in their subjects. Moreover, suctioning recovered only 10.7-18.7% of the instilled saline and caused a delayed airway clearance of up to 30 rain, due to the mucociliary action and rate of absorption within the airway. However, their suctioning technique was not described. The relationship between NSI and oxygenation of 45 postoperative open-heart surgery patients was examined by Bostick and Wendelgass (1987). Each patient was randomly assigned to one of three groups. Prior to suctioning, Group One received no saline, Group Two received 5 ml saline and Group Three received 10 ml saline. Arterial blood gas oxygen saturation levels (PaO2) were measured 5 rain before and 20 rain after the procedure. The results showed no significant difference in the PaO2 levels after the procedure, amongst the groups. However, there was a trend toward lower PaO2 values with larger amounts of saline instillation. The researchers concluded that the decrease in PaO2 levels might have been the result of the NSI impeding alveolar-capillary oxygen exchange. EP 4001Iowa Model of Evidence Based Practice Paper
Bostick and Wendelgass (1987) also weighed the aspirated sputum for each of the three groups. Although a significant difference was found between the experimental groups (5 ml and 10 ml NSI) and the control group (no NSI), the clinical significance of this finding is unclear. This is because the increase in weight may have been a result of the combined saline and airway secretion weight and not the airway secretion weight alone. 360 Intensive and Critical Care Nursing (1999) 15, 357-362 In another study (Gray et al. 1990), 15 critically ill, intubated patients with pulmonary disease were studied to determine physiological responses, the amount of material suctioned and the discomfort associated with suctioning, either with or without NSI. A repeated measures design was used with each patient suctioned once, both with and without NSI, with a 90 min interval between the two methods. Measurements were taken before, immediately after and 15 min after suctioning. No significant differences were found in heart rate, blood pressure, respiratory rate or arterial blood gas values between the two groups immediately after or 15 min after suctioning. Moreover, no difference in patient discomfort was found. Gray and colleagues found the NSI resulted in coughing and a significant increase in the amount of material suctioned. The researchers concluded that NSI elicited a cough response in all patients, which may enhance secretion clearance. However, the secretion content was not analysed, which brings the relevance of this finding into question. The effect of 5 ml NSI on oxygen saturation was examined among 40 critically ill and intubated patients (Ackerman 1993). A single case, repeated measures, counter-balanced design was used to allow subjects to serve as their own controls. Subjects were alternately suctioned with or without NSI over a 24 h period. The oxygen saturation (SaO2) was measured before, immediately after and at i min intervals up to 5 min after suctioning. Ackerman (1993) found that NSI had a negative effect on SaO2 that worsened over time. These changes were statistically significant at 2-, 3-, 4- and 5min intervals. The researcher concluded that NSI prior to suctioning should be abandoned as a routine procedure. Recent research by Hagler and Traver (1994) examined the extent to which NSI and suction catheter insertion dislodge viable bacteria from ET tubes. ET tubes from 10 critically ill patients who had been intubated for at least 48 h were examined immediately after extubation. A random order for both NSI and suction catheter insertion was used for each tube. Dislodged material was cultured for analysis, which found catheter insertion dislodged up to 60 000 viable colonies while NSI dislodged up to 310 000 viable bacterial colonies. The risk of infection caused by dislodging viable bacteria into the lower airway © 1999 H a r c o u r t P u b l i s h e r s Ltd Use of the Iowa Model in evidence-based nursing practice must be considered against the potential benefits of ET suctioning to the patient. Additionally, the risk is multiplied with each suctioning episode. The researchers conclude that NSI should be omitted as a routine procedure due to potential for lower airway infection. The relationship betwe…
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