DNP 820 Identification and Evaluation of Literature for Proposed Intervention – Part 1
Literature Evaluation Table – DPI Intervention
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PICOT-D Question: For elderly and debilitated patients [P], will the implementation of a pressure preventive bundle [I], compared to routine pressure injury care [C], reduce the incidence of pressure injury [O], within 60 days? [T].
DNP 820 Identification and Evaluation of Literature for Proposed Intervention – Part II
Table 1: Primary Quantitative Research – Intervention (5 Articles)
APA Reference (Include the GCU permalink or working link used to access the article.) |
Research Questions/ Hypothesis, and Purpose/Aim of Study | Type of Primary Research Design | Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project)How was the data collected? | Interpretation of Data (State p-value: acceptable range is p= 0.000 – p= 0.05) | Outcomes/ Key Findings (Succinctly states all study results applicable to the DPI Project.) |
Limitations of Study and Biases | Recommendations for Future Research | Explanation of How the Article Supports Your Proposed Intervention |
| Darvall, J. N., Mesfin, L., & Gorelik, A. (2018). Increasing frequency of critically ill patient turns is associated with a reduction in pressure injuries. Critical Care and Resuscitation, 20(3), 217-222. https://europepmc.org/article/med/30153784. | Hypothesis: A change from 5-hourly turns to 3-hourly turns will significantly reduce pressure injury incidence in critically ill patients. Aim of the study: the study determined the significant difference between 5-hourly turns and 3-hourly turns in reducing the incidence of pressure injuries in critically ill patients. | A pre-post intervention evaluation study | Setting/sample: the study was conducted in an intensive care unit at the Royal Melbourne Hospital, Australia. Participants included patients admitted during pre-intervention period (1094) and the study’s post-intervention period (1165). Methods: patient turns were conducted by the nursing staff and clinical assistants amid other interventions for reducing pressure injury incidences, such as regular skin checks, protective dressings, and risk assessment. Random turn audits and chart reviews were conducted monthly. Similar instruments can be applied to the DPI project. Data collection: pressure injury data were derived from the reporting database. | Pressure injury incidence halved in the post-intervention period (p < 0.001). | The key finding was that a change in turn frequency from 5-hourly turns to 3-hourly turns reduced the pressure injury incidence by 50%. As a result, older adults and critically ill patients can benefit from a similar change in the frequency of turns. | Darvall et al. (2018) did not evaluate the potential detrimental effects of increased turning on patients. As a result, the findings are skewed to the positive impacts. | Researchers recommend a future studies through a prospective, multi-center trial. Future studies should also be randomized to reduce systematic errors. | The single-center study affirmed the positive impacts of repositioning and increasing the frequency of turns to reduce pressure injury incidence. Repositioning is a core component of the DPI project’s care bundle. |
| Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desai, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19. https://doi.org/10.1016/j.ijnurstu.2017.12.012 | Hypothesis: optimizing turning compliance with wearable sensors provides a better protective effect against developing pressure injuries than traditional reminders. Aim of the study: the research assessed the effectiveness of wearable patient sensors in improving total time with turning compliance and pressure injuries prevention in critically ill patients. | Randomized controlled trial. | Setting/sample: the study was conducted on 1564 patients in two ICUs in a large academic medical center in California. Among the 1564, 1312 underwent randomization. Methods: patients in the intervention group (n =659) received optimized turning practices, influenced by real-time data from wearable patient sensors while the control group (n = 653) received turning care guided by traditional turn reminders. The DPI project can use similar instruments to optimize turning during repositioning. Data collection: the wearable patient sensors relayed data to a secure SQL database every ten seconds. Position changes were then calculated to determine the degree of position change. | The primary finding relevant to the DPI project was that the intervention group had fewer pressure injuries than the control group (p =0.031) | The study demonstrates that optimizing turning compliance can reduce the incidence of pressure injuries in critically ill patients. | Pickham et al. (2018) highlighted that the study was not immune to the threats of internal validity due to presence of confounding variables. Selection bias was also noticed since the researchers randomized clusters instead of individuals. | A similar study in the future that randomizes individuals instead of clusters is crucial. | The study demonstrates the link between optimizing patient turns and reducing pressure injuries. The DPI project seeks to use interventions that optimize turns to reduce pressure ulcers among the elderly and debilitated patients. |
| Hahnel, E., El Genedy, M., Tomova‐Simitchieva, T., Hauß, A., Stroux, A., Lechner, A., … & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high‐risk intensive care unit patients: A randomized controlled parallel‐group trial. British Journal of Dermatology, 183(2), 256-264. https://doi.org/10.1111/bjd.18621 | Hypothesis: appropriately dressing pressure ulcer predilection areas will significantly reduce the incidence of pressure ulcers in patients in ICUs. Aim of the study: to determine whether applying preventive dressings on pressure ulcer predilection areas, besides standard prevention, reduces the incidence of pressure ulcers in patients in ICUs. | A randomized, controlled | Setting/sample: the study was conducted on 475 patients in a tertiary care hospital in Berlin, Germany. Methods: besides standard prevention, patients in the intervention group (n = 212) had preventive dressings applied to the sacrum and heels. The dressings were renewed every 3 days and the susceptible area checked. A similar approach can be used in the DPI project, but the frequency will be different. Data collection: Hahnel et al. (2020) measured the risk for pressure ulcers using the hospital standard and the Braden scale. A 1-h skin inspection and pressure injury classification instruction was also used. | The cumulative pressure ulcer incidence was lower in the intervention group (2.8%) than in the control group (10.5%) (p =0.001). | The results affirm that preventive dressings, besides standard prevention, effectively reduce pressure ulcers on predilection (sacrum and heels) areas. | The study was associated with performance and detection bias since the participants were not blinded to the study procedures and randomized allocation. A selection bias was also reported. | Future studies where participants are blinded will reduce the reported bias. | The study found preventive dressings effective in reducing the incidence of pressure injuries. Preventive dressing is among the DPI project preventive bundle’s components. |
| Yap, T. L., Horn, S. D., Sharkey, P. D., Zheng, T., Bergstrom, N., Colon-Emeric, C., … & Kennerly, S. M. (2021). Effect of varying repositioning frequency on prevention of pressure injuries in nursing home residents: TEAM‐UP cluster‐randomized clinical trial results. Research Square, 1-21. https://doi.org/10.21203/rs.3.rs-717425/v1 | Hypothesis: the effectiveness of repositioning significantly varies with the intervals. Aim of the study: the research evaluated the clinical effectiveness of different repositioning intervals (2, 3, and 4-hours) in adult nursing home residents. | A pragmatic cluster randomized controlled trial. | Setting/sample: the study was conducted in 9 nursing homes from a large proprietary system in 34 states in the U.S. 992 residents from the 9 centers participated in the study. Methods: The study had three arms with each containing three nursing homes. Each arm was assigned one repositioning interval (2-hour, 3-hour, or 4-hour) as standard care during the 4-week study period. A wireless patient monitoring system notified the nursing staff about the patients’ repositioning need by displaying it. The DPI project will not apply similar instruments due to cost implications. Data collection: Yap et al. (2021) tracked events using the patient monitoring system. Data were further recorded via the nursing homes’ electronic health records and risk management system for pre-post analysis. | The primary finding was that pressure injury incidence during the intervention was 0.0% and 5.24% in Baseline (p =0.001). The other finding was that repositioning compliance was better in 4-hour repositioning (95%) than 3-hour repositioning (90%) and 2-hour repositioning (85%). | The study confirmed the effectiveness of repositioning in reducing the incidence of pressure injuries in health care facilities. | Cluster trials in settings without extensive preliminary analyses have a large degree of uncertainty. Selection bias: Yap et al. (2021) excluded nursing homes with severe pressure injury risk. | Yap et al. (2021) recommended additional research to identify specific race and risk differences factors influencing outcomes in pressure injury incidence. | The study explored the effectiveness of repositioning intervals, an essential component of the DPI project’s preventive bundle. |
| Santamaria, N., Gerdtz, M., Kapp, S., Wilson, L., & Gefen, A. (2018). A randomised controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: The Border III Trial. International Wound Journal, 15(3), 482–490. https://doi.org/10.1111/iwj.12891 | Hypothesis: Multi-layer silicone dressing offers better protection against pressure injuries than standard care based on international guidelines among residents in aged care faciliities. . Aim of the study: it assessed the clinical effectiveness of multi-layer silicone foam dressings in reducing pressure injury development in high-risk residential aged care patients. | A randomized controlled trial | Setting/Sample: The study was conducted in 40 residential aged care facilities in Australia. A total of 288 aged care residents were enrolled in the study. Methods: Data Collection: Setting/Sample: Methods: Data Collection: Data Collection Methods: – Control Group (n=150): Data Collection Procedures: This comprehensive data collection approach aimed to capture key factors influencing pressure injury development, allowing for a thorough analysis of the effectiveness of the intervention in comparison to standard care. The methodology used in this study can serve as a valuable reference for implementing data collection procedures in the DPI project, ensuring a systematic and detailed examination of relevant variables. |
Pressure injuries’ incidence was higher in the control group than in the intervention group (p = 0.004) | Appropriate dressing can reduce the risk of developing pressure ulcers in aged care adults. The use of silicone sacrum and heel dressing offers a better protective benefit to high-risk patients such as the elderly than standard care. | Santamaria et al. (2018) did not blind both the subjects and the assessor to the presence or absence of the intervention. The study also included individuals with impaired cognitive function and may have introduced a potentially unknown bias to the study. | Further research is recommended to ascertain whether aging-related tissue changes are the cause of a higher incidence of sacral pressure injuries in aged care residents compared to acute patients. | Skin care through appropriate dressing is a core component of pressure ulcers preventive bundle. The article confirms its effectiveness by demonstrating a significant difference between the intervention and control groups. |
Table 2: Additional Primary and Secondary Quantitative Research (10 Articles)
APA Reference (Include the GCU permalink or working link used to access the article.) |
Research Questions/ Hypothesis, and Purpose/Aim of Study | Type of Primary or Secondary Research Design | Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project)How was the data collected? | Interpretation of Data (State p-value: acceptable range is p= 0.000 – p= 0.05) | Outcomes/ Key Findings (Succinctly states all study results applicable to the DPI Project.) |
Limitations of Study and Biases | Recommendations for Future Research | Explanation of How the Article Supports Your Proposed DPI Project |
| Zhang, X., Wu, Z., Zhao, B., Zhang, Q., & Li, Z. (2021). Implementing a pressure injury care bundle in Chinese intensive care units. Risk Management and Healthcare Policy, 14, 2435–2442. https://doi.org/10.2147/RMHP.S292579 | Hypothesis: implementing a pressure injury care bundle based on the best evidence will reduce pressure injury incidence in intensive care units significantly. The study assessed the effectiveness of pressure injury care bundle in preventing the development of pressure injuries in intensive care units and to identify how nurses’ compliance rates changed during the implementation process. | A quasi-experimental pre- and post-intervention design. | Setting/sample: the study was conducted in all critical care units in Chinese hospitals from 26 provinces. All adult patients admitted in the ICUs during the study were included. Methods: Zhang et al. (2021) designed a care bundle checklist to analyze implementation and compliance. A checklist can be used in the DPI project. Data collection: the unit staff collected the number and stage of pressure injuries at three time points. A compliance checklist was used to measure the implementation compliance rate at two time points. | Implementing the pressure injury care bundle impacted care positively by reducing pressure injury rates from 13.86% to 10.41% while the nurses’ compliance increased from 55.15% to 60.15% after the care bundle implementation (p =0.00) | A standard care bundle based on the best evidence can reduce the incidence of pressure injuries significantly. The bundle’s key elements relevant to the DPI project were pressure-reducing device, patient repositioning, skin care, ad risk identification. | The before and after study design was susceptible to time changes. Besides, researchers did not collect all participants’ demographic characteristics; thus, they could not analyze how different demographic characteristics impacted the interventions on patients. | Future research should explore how pressure injury prevention interventions affect patients with different characteristics such as age, gender, and disease severity. | The article confirms the effectiveness of preventive care bundle in reducing the incidence of pressure injuries. The DPI project compares the effectiveness of a preventive bundle with routine pressure injury care. |
| Hassan, N., & Afzal, M., Sehar, S., & Gilani, S. A. (2020). Effects of body repositioning in immobilized patients to prevent pressure ulcer in intensive care units at public hospital, Pakistan. Iris Journal of Nursing & Care- IJNC, 2(4), 2020. http://dx.doi.org/10.33552/IJNC.2020.02.000543 | Hypothesis: body repositioning will reduce pressure ulcer incidence in patients admitted in intensive care units. Aim of the study: assessing the effect of body repositioning in immobilized patients to prevent pressure ulcers. | A quasi-experimental with non-equivalent control group design | Setting/sample: the study was conducted in intensive care units of neurosurgery department at a public hospital in Pakistan. All immobilized patients admitted in the ICU were enrolled in the study. Methods: the research instrument had three essential segments: patients’ socio-demographic data, Braden risk assessment scale, and repositioning (frequency and outcomes) of immobilized patients. Patients susceptible to pressure injuries received 2-hourly repositioning and the schedule attached at the bedside. A risk assessment scale will be used in the DPI project to evaluate the risk of pressure ulcers. Data collection: nurses recorded repositioning turns and pressure injuries and filled the Braden risk assessment form which was kept it in the nursing file. | There was a major difference between the interventional and control group mean of body repositioning. p = 0.000 (less than 0.001) showed a significant difference. | Repositioning (2-hour) patients can reduce the incidence of pressure ulcers among debilitated patients. | The sample proportion was small and from a particular confined group. Thus, the results cannot be comprehensive to the broader population. | Future research on repositioning is needed but should recruit a larger sample from a broader population to ensure that the results are generalizable. | The article confirms the effectiveness of repositioning, which is among the components of the DPI preventive bundle. |
| Hekmatpou, D., Mehrabi, F., Rahzani, K., & Aminiyan, A. (2018). The effect of Aloe Vera gel on prevention of pressure ulcers in patients hospitalized in the orthopedic wards: A randomized triple-blind clinical trial. BMC Complementary and Alternative Medicine, 18(1), 1-11. https://doi.org/10.1186/s12906-018-2326-2 | Hypothesis: an evidence-based skin care routine can reduce pressure ulcers among orthopedic patients. Aim of the study: to investigate Aloe Vera gel’s effectiveness in preventing pressure ulcers in patients admitted in the orthopedic ward. | A randomized, triple-blind clinical trial. | Setting/sample: the study was conducted on 80 purposefully selected patients in an orthopedic ward in Arak town, Iran. Methods: in the intervention group, nurses rubbed pure Aloe Vera gel on areas at risk of pressure injuries such as hips, sacrum, and heels. The control group’s care was through water gel and starch. A similar skin care routine will be applied in the DPI project but not necessarily with Aloe Vera gel. Data collection: pressure ulcers signs on the susceptible areas (sacral, hips, and heels) were evaluated on days 3, 7, and 10. | Data analysis showed a significant difference in the incidence of pressure ulcers between the groups (p =0.047). Twelve pressure ulcer cases were recorded in the control group while only three were reported in the intervention group. | The statistical difference implied that Aloe Vera gel prevented the occurrence of pressure ulcers in the intervention group. | The sample was limited. | Researchers recommended future studies with more samples. | The study confirmed the effectiveness of skin care, which is among the components of the DPI preventive bundle. |
Table 3: Theoretical Framework Aligning to DPI Project
| Nursing Theory Selected | APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) | Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project |
| Imogene King’s goal attainment theory | King, I. M. (1994). Quality of life and goal attainment. Nursing Science Quarterly, 7(1), 29-32. https://doi.org/10.1177/089431849400700110 King, I. M. (1999). A theory of goal attainment: Philosophical and ethical implications. Nursing Science Quarterly, 12(4), 292-296. https://doi.org/10.1177/08943189922107205 | Nursing theories serve as intricately organized bodies of knowledge, offering detailed insights that assist nurses in explaining various phenomena within the field. On a broad scale, these theories delineate the nature of nursing practice and elucidate the fundamental role of nurses in day-to-day healthcare scenarios. Imogene King’s theory of goal attainment is particularly relevant to the Direct Practice Improvement (DPI) project, and its foundational principles will be employed to steer the implementation process.
King’s theory is rooted in the belief that the care process is transactional, with the nurse playing a central role in assisting patients in maintaining their health (King, 1999). To achieve optimal outcomes, it is imperative that patients comprehend the care process and actively participate in decision-making, essentially becoming care partners in implementing the treatment plan. In the context of the DPI project, the application of King’s goal attainment theory involves a collaborative approach where the nurse and the patient jointly identify the problem, set mutual goals, and devise mechanisms to achieve these goals, aligning with King’s goal theory recommendations (King, 1994). This approach ensures that the goals and functions of both the nurse and the patient are harmoniously aligned. This collaborative approach will also be mirrored in the implementation of the DPI project’s preventive bundle within the long-term care facility. The nurse will facilitate a mutual understanding, ensuring that patients comprehend the significance of the preventive bundle for pressure ulcers, the targeted outcomes, and their roles in each step of the process. By actively involving patients and aligning goals and functions, the implementation process is more likely to be successful, promoting better patient outcomes in the context of pressure ulcer prevention in the long-term care setting. The DPI project, guided by King’s theory, emphasizes the transactional nature of the nurse-patient relationship, fostering collaboration for improved healthcare outcomes. |
| Change Theory Selected | APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) | Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention |
| Kurt Lewin’s change theory | Burnes, B. (2004). Kurt Lewin and the planned approach to change: A re‐appraisal. Journal of Management studies, 41(6), 977-1002. https://doi.org/10.1111/j.1467-6486.2004.00463.x Lorenzi, N. M., & Riley, R. T. (2000). Managing change: An overview. Journal of the American Medical Informatics Association, 7(2), 116-124. https://doi.org/10.1136/jamia.2000.0070116 | Change theories serve as frameworks for introducing positive transformations in patient care, operating on the premise that change is a disruptive process requiring systematic implementation. Given the intricate and sensitive nature of patient care, nurses must systematically introduce change, developing effective strategies to address potential resistance (Hussain et al., 2018). Kurt Lewin’s change theory provides a systematic approach tailored to fit the proposed Direct Practice Improvement (DPI) intervention.
Lewin’s theory introduces the concepts of restraining and driving forces, suggesting that these forces influence individuals and groups in varying ways, shaping their reactions to change. Restraining forces seek to maintain the status quo, while driving forces propel change in a direction that triggers its occurrence (Lorenzi & Riley, 2000). Lewin outlines three distinct phases of change: unfreezing, change, and refreezing. The unfreezing phase involves preparing for change, while the change step encompasses the actual implementation of the desired change (Burnes, 2004). Refreezing follows, aiming to solidify the implemented change and make it sustainable over time. In the context of the DPI project, the unfreezing phase is critical. It necessitates preparation among the organization’s management, patients, and all stakeholders for the changes brought about by the preventive bundle. This preparation involves ensuring a comprehensive understanding of the benefits of the proposed preventive bundle and addressing concerns to minimize resistance. The subsequent change phase involves implementing various components of the preventive pressure bundle, aimed at enhancing patient outcomes by reducing the incidence of pressure ulcers among the elderly and debilitated patients in the long-term care facility. The final step, refreezing, entails several measures to sustain the change. Continuous evaluation of outcomes, progressive support from management, and the dissemination of results are integral components of this phase. This approach ensures that the change becomes ingrained in the organizational culture, promoting its long-term sustainability. Moreover, sharing the results with other nurses enables the dissemination of knowledge and encourages the implementation of the preventive bundle in the future, fostering a culture of ongoing improvement in patient care practices. |
Table 4: Clinical Practice Guidelines (If applicable to your project/practice)
| APA Reference – Clinical Guideline (Include the GCU permalink or working link used to access the article.) |
APA Reference – Original Research (All) (Include the GCU permalink or working link used to access the article.) |
Explanation for How Clinical Practice Guidelines Align to DPI Project |
| N/A | Place the primary quantitative research used in the clinical practice guidelines in Table 1. This is part of the primary quantitative research used to support your intervention. | N/A |
References
Darvall, J. N., Mesfin, L., & Gorelik, A. (2018). Increasing frequency of critically ill patient turns is associated with a reduction in pressure injuries. Critical Care and Resuscitation, 20(3), 217-222. https://europepmc.org/article/med/30153784.
Hahnel, E., El Genedy, M., Tomova‐Simitchieva, T., Hauß, A., Stroux, A., Lechner, A., … & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high‐risk intensive care unit patients: A randomized controlled parallel‐group trial. British Journal of Dermatology, 183(2), 256-264. https://doi.org/10.1111/bjd.18621
Hassan, N., & Afzal, M., Sehar, S., & Gilani, S. A. (2020). Effects of body repositioning in immobilized patients to prevent pressure ulcer in intensive care units at public hospital, Pakistan. Iris Journal of Nursing & Care- IJNC, 2(4), 2020. http://dx.doi.org/10.33552/IJNC.2020.02.000543
Hekmatpou, D., Mehrabi, F., Rahzani, K., & Aminiyan, A. (2018). The effect of Aloe Vera gel on prevention of pressure ulcers in patients hospitalized in the orthopedic wards: A randomized triple-blind clinical trial. BMC Complementary and Alternative Medicine, 18(1), 1-11. https://doi.org/10.1186/s12906-018-2326-2
Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-127. https://doi.org/10.1016/j.jik.2016.07.002
King, I. M. (1994). Quality of life and goal attainment. Nursing Science Quarterly, 7(1), 29-32. https://doi.org/10.1177/089431849400700110
King, I. M. (1999). A theory of goal attainment: Philosophical and ethical implications. Nursing Science Quarterly, 12(4), 292-296. https://doi.org/10.1177/08943189922107205
Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desai, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19. https://doi.org/10.1016/j.ijnurstu.2017.12.012
Santamaria, N., Gerdtz, M., Kapp, S., Wilson, L., & Gefen, A. (2018). A randomised controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: The Border III Trial. International Wound Journal, 15(3), 482–490. https://doi.org/10.1111/iwj.12891
Yap, T. L., Horn, S. D., Sharkey, P. D., Zheng, T., Bergstrom, N., Colon-Emeric, C., … & Kennerly, S. M. (2021). Effect of varying repositioning frequency on prevention of pressure injuries in nursing home residents: TEAM‐UP cluster‐randomized clinical trial results. Research Square, 1-21. https://doi.org/10.21203/rs.3.rs-717425/v1
Zhang, X., Wu, Z., Zhao, B., Zhang, Q., & Li, Z. (2021). Implementing a pressure injury care bundle in Chinese intensive care units. Risk Management and Healthcare Policy, 14, 2435–2442. https://doi.org/10.2147/RMHP.S292579
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