Identifying a Focus of Practice Inquiry


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IDENTIFYING A FOCUS OF PRACTICE INQUIRY


LEA ANN MATURA AND VIVIAN NOWAZEK


INTRODUCTION


There are numerous sources of ideas for identifying the focus of an inquiry. The literature review presents what is currently known about the topic of interest and the gaps in the literature. Once a thorough search and evaluation of the available evidence have been conducted, the focus of the study can be defined in the form of a purpose, objectives, and specific aims, along with well-developed research questions. This chapter delineates the components needed to define a research topic. Examples are included to illustrate the concepts and to facilitate practice in critically evaluating material from an evidence-based perspective.


SOURCES OF TOPICS AND PROBLEMS


When a researcher is identifying a topic of inquiry, several sources can provide guidance in determining the question or problem to investigate. Some areas previously identified as starting points include clinical practice, the research literature, professional organizations, and conferences (Polit & Beck, 2020). Likewise, there are multiple examples from varying clinical settings or domains of healthcare where ideas may be generated. Clinical problems or questions, the literature, regulatory agencies, new diagnoses, social media, sentinel events, and legislative issues are only a few possibilities, but these examples may stimulate thoughtful reflection on practice as we look forward to future studies. Once an idea is generated, a search of the literature is the next step in discovering what is already known and not known about the topic.


Clinical Problems or Questions


The clinical setting is an excellent place to generate research questions. For example, when a patient has an acute injury such as an ankle sprain, a commonly prescribed regimen is applying rest, ice, compression, and elevation (RICE) therapy within 72 hours of the injury (Ueblacker et al., 2016). However, is there sufficient evidence to support this therapy? We need data to support our interventions; perhaps RICE is an ineffective therapy, but more research is needed.


Another pervasive problem in healthcare is the prevention of pressure injuries. Standard practices recommend turning patients every 2 hours, but there continues to be little support for this practice or other measures to prevent pressure injuries. A recent literature review investigated turning frequency in adult bed-ridden patients to prevent hospital-acquired pressure injuries (Jocelyn Chew et al., 2018). The majority of studies could not reach a conclusion for frequency 120of turning. However, few studies have focused solely on frequency of turning and pressure ulcer prevention or development. One study using a descriptive correlational design analyzed the outcomes of a quality improvement project evaluating a turning intervention to prevent facility-acquired pressure injuries (Harmon et al., 2016). The study assessed a “turn team assignment” on pressure injury incidence in a surgical intensive care unit. Data were collected on cueing to turn, concurrent turning, independent turning in lieu of the cue, staff support, and possible barriers to turning and repositioning. Pressure injuries declined from 24.9% to 16.8% over 12 months. There was an association between verbal cueing and turning (r = 0.82; p < .05). A turn team using verbal cueing appears to be an effective intervention that decreases pressure injury occurrence. In another study the investigators implemented a multi-component intervention that included pressure-reducing beds; nutritional support; mandatory 2-hour change of posture; turning clocks; early surgical intervention; spot checks by the wound care nurse; and education to patients and caregivers (Lam et al., 2018). Over a 3-year period the incidence of hospital-acquired pressure injuries at the institution was initially 1.36%, which decreased to 0.98% in year 2 and to 0.39% in year 3 (p = .002).


Literature


Reading and critiquing the literature are other mechanisms for identifying gaps in what is known and not known in clinical practice. For example, in a randomized controlled trial, the investigators assessed the effectiveness of auricular acupressure on sleep in patients with breast cancer undergoing chemotherapy (Yoon & Park, 2019). Participants were randomized to auricular pressure on specific acupoints beneficial for sleep or a control group that received placebo auricular pressure on points not traditionally associated with improving sleep for 6 weeks. The quality of sleep was significant between the experimental and control groups (F = 4.152, p = .048). There were no significant differences in total sleep time, sleep efficiency, sleep latency, or number of times awakened during sleep. This study shows a non-pharmacological treatment for symptoms. However, more research is needed to determine if different doses produce different effects, how long the effects last, and can these results be translated to other disorders?


Regulatory Agencies


Regulatory agencies such as The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) are rich sources for research ideas (TJC, 2019). TJC collaborated with the American Heart Association and the American College of Cardiology to develop performance measures, or core measure sets, for acute myocardial infarction (AMI). These measures specify evidence-based interventions necessary to provide patients with quality care. These measures include such interventions as smoking-cessation education. Nursing is in an excellent position to test interventions that assist patients in their smoking-cessation efforts. Examples of other measures include pneumonia, stroke, and venous thromboembolism.


Technology


Mobile technology continues to expand in healthcare. In a randomized controlled trial of patients with irritable bowel syndrome, participants were randomized to telephone or web-based therapy or treatment as usual (Cook et al., 2019). Those in the treatment group received information on healthy eating patterns, managing stress, and reducing symptom severity. The telephone 121intervention received a self-help manual and 8 hours of telephone therapist support. The web-based participants received online access to an interactive website and 2.5 hours of telephone therapist support. All groups had a reduction of symptoms at 1 year. The telephone group had 84% greater adherence rates than the other groups. Conclusions and implications of this study show that traditional face-to-face cognitive behavioral therapy, web, and telephone delivered therapy still require trained therapist input. These results show the need to design and test technology that is easily deployed and used by providers and patients.


New Diagnoses


Discoveries in healthcare are frequent, including new diagnoses, especially because of research in genetics. As new syndromes are defined and new diseases and diagnoses are discovered, there will be an increasing need for research in these areas. Infectious diseases are continuing to emerge and evolve. For example, the Zika virus is spreading in the United States and can cause microcephaly and severe fetal brain defects (Baud et al., 2017). Zika is also associated with pregnancy loss and can cause issues with the infant’s eyes and deformities of the joints. We do not know the long-term effects of the Zika virus, and currently there is no vaccine. Nursing can play a key role in assisting in the care of these infants and their families, which is a topic for investigation.


An example of a new genetic syndrome is a microdeletion of 15q13.3, which causes intellectual disabilities, epilepsy, and facial and digital dysmorphisms (Hassfurther et al., 2015). Although this disorder is thought to affect about three out of 1,000 individuals with intellectual disabilities, there is a need for further investigation to determine the impact of this syndrome on patients and their caregivers. This again gives nursing an excellent opportunity to investigate the impact of this syndrome and possible interventions to improve patient care.


Similarly, researchers discovered a new genetic syndrome, which revealed a microduplication of chromosome 22q11.2 in patients previously diagnosed with DiGeorge anomaly/velocardiofacial syndrome (DG/VCFS; Radio et al., 2016). The phenotypic features of this new syndrome are widely spaced eyes and superior placement of the eyebrows, with increased distance from the eyebrow to upper eyelid crease, downslanting palpebral fissures, and a long narrow face. These features are different from DG/VCFS, which led researchers to conclude that this is a new syndrome. Nursing would be especially poised to conduct research to improve the care and lives of these patients and their families.


Social Media


Social media represents another avenue for generating ideas for investigation. Examples of social media include Facebook, Twitter, and blogs. In a recent study, social media was used as a means to improve influenza vaccination rates at a private college (Monn, 2016). In addition to provider education and announcement of immunization clinics, a Facebook college web portal was used to increase immunization rates by announcing the time and place of the vaccination clinicals and distributing three wellness articles via the portal. Results of this strategy showed a 226% increase in the number of students vaccinated compared to previous years.


In a randomized controlled trial investigators aimed to determine the effectiveness of Facebook alone or with text messaging to encourage optimal calcium intake (Rouf et al., 2020). Results showed that at the end of the program there was no increase in milk consumption (odds ratio [OR] 1.51, 95% CI 0.61–3.75 Facebook; OR 1.77, 95% CI 0.74-4.24 Facebook plus text messages; p = .41) or calcium-rich foods (p = .57). Knowledge improvement did improve in the Facebook 122plus text message group (p < .001). Using social media shows promise in providing health education and promoting health and may be used in future research.


Sentinel Events


Unfortunately, untoward or sentinel events sometimes occur. TJC defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function” (TJC, 2019). These events may be related to system problems, knowledge deficits, equipment malfunction, or a variety of other related problems. Some examples of sentinel events captured by TJC’s sentinel database in 2019 included delays in treatment; falls; postoperative complications; suicide; and wrong patient, wrong site, and wrong procedure. Nurses are well poised to study how these important occurrences happen and to develop effective interventions for prevention.


While the nursing bedside report has been suggested as a way to enhance patient safety, this is an example where little is known through research if this actually does keep patients safer. One study aimed to describe how bedside nurses can use bedside shift reports to keep patients safe (Groves et al., 2016). In this qualitative study it was found that the nursing bedside report is a storytelling mechanism at shift change that allows nurses to identify any patient risks that may potentially cause harm. The researchers speculated that shift report can actually prevent errors and improve patient safety, but more research is needed.


Legislative Issues


Other opportunities for nursing research are related to legislative and health policy issues. Nursing is an integral part of health policy discussions and should conduct research on legislative issues in order to promote and protect the public’s health. There have been several states that have legalized recreational marijuana; however, we know little about changes in marijuana use and cannabis use disorder after recreational marijuana legalization. Investigators aimed to examine the associations between recreational marijuana legalization enactment and changes in marijuana use, frequent use, and cannabis use disorder in the United States between 2008 and 2016 (Cerdá et al., 2019). Results showed that among participants between 12 to 17 years, past-year cannabis use disorder increased from 2.2% to 2.7% after recreational marijuana legalization enactment, a 25% higher increase than that for the same age group in states that did not enact recreational marijuana legalization (OR, 1.25; 95% CI, 1.01–1.55). Therefore, more research is needed to assess how these increases occur and to identify subpopulations that may be especially vulnerable.


There have been several states that have implemented opioid prescribing mandates to help with the opioid epidemic. In 2016 Rhode Island passed a law that limited Rhode Island prescribers to a maximum of 30 mg equivalents per day, 20 total doses, or a total of 150 mg equivalents in the first opioid prescription for opioid-naïve patients. The legislation went into effect in April 2017. One study aimed to evaluate the prescribing opioids after orthopedic trauma before and after implementing opioid-limiting mandates (Reid et al., 2019). The post-law patients received less opioids (363.4 vs. 173.6 MMEs, p < 0.001) in the first postoperative prescription. They also received less cumulative levels of opioids during the 30-day postoperative period (677.4 vs. 481.7 MMEs, p

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Oct 17, 2021 | Posted by in NURSING | Comments Off on Identifying a Focus of Practice Inquiry
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