EBP Project Proposal Part II: Lit Review

A comprehensive literature review using the PICO question described in the last post will help to reveal if the chosen intervention is beneficial based on the best available evidence (Everett & Titler, 2006; Hall & Roussel, 2014). This is a vital step prior to trialing the chosen intervention on a pilot unit (Everett & Titler, 2006; Hall & Roussel, 2014). Using a team approach to allow for division of labor will help tremendously by distributing the research burden but also removes potential selection bias caused by an individual completing the literature review alone.

When completing a literature review, the team must identify databases that may contain research relevant to the EBP project; examples include CINAHL, MEDLINE, PubMed Clinical Queries, National Guideline Clearinghouse, Scopus, the Cochrane Library, Joanna Briggs Institute, National Academies, and Agency for Healthcare Research and Quality (Hall & Roussel, 2014). Meeting with a research librarian who specializes in healthcare, nursing, medicine or a field related to the project may also reveal other relevant resources. Seeking advice from an EBP expert will also be helpful to identify potential resources.

Once several databases have been chosen, the research team needs to identify appropriate search terms and date range (Hall & Roussel, 2014). Starting the search in PubMed is helpful because it allows researchers to identify Medical Subject Headings (MeSH®), which is the “National Library of Medicine's controlled vocabulary thesaurus” (National Library of Medicine [NLM], 2015). Using MeSH® Terms will most likely generate the most comprehensive search results because it identifies terms related to the topic (e.g. vitamin C, ascorbic acid) (NLM, 2015). PubMed also offers tutorials that describe how to best utilize the database (NLM, 2016).

Many databases allow the search to be narrowed to a specific date range. This allows researchers to keep the body of evidence needing review to a manageable level as well as ensures data used is up-to-date. In general, the team should choose evidence published in the last five to ten years, depending on the nature of the project and number of available studies (Hall & Roussel, 2014).

Finally, there are special considerations for scholarly EBP projects. First, it is important to choose a phenomenon of interest that gets you excited. Combing a problem or knowledge focused trigger with a personal passion is vital to carry you through the arduous process of scholarly writing and research (Everett & Titler, 2006). Secondly, once you have browsed the literature, write an outline and a concept map, which will help reveal relationships between concepts (Moran et al., 2014). Setting achievable goals with deadlines is also paramount for completing the project on time (Moran et al., 2014; Zaccagnini & White, 2017).

Finally, find an EBP champion to mentor you through the process; hopefully this person can be your scholarly project chair. Make a conscious effort to communicate regularly with your project chair. Experience writing an undergraduate honors thesis taught me to give myself extra time to complete a project to allow for unforeseen barriers that come up along the way. Lastly, do not give up. Expect detours; that way when they come you have already mentally visualized yourself successfully navigating through them. YOU CAN do it! 

References

Everett, L. Q., & Titler, M. G. (2006). Making EBP part of clinical practice: The Iowa Model. In Teaching Evidence-Based Practice in Nursing (pp. 295-324). New York: Springer Publishing Company.

Hall, H. R., & Roussel, L. (2014). Evidence-based practice: An integrative approach to research, administration, and practice. Burlington, MA: Jones & Bartlett Learning.

Moran, K. J., Burson, R., & Conrad, D. (2014). The Doctor of Nursing Practice scholarly project: A framework for success. Burlington, Mass: Jones & Bartlett Learning.

National Library of Medicine. (2015). Fact sheet: Medical Subject Headings (MeSH®). Retrieved from https://www.nlm.nih.gov/pubs/factsheets/mesh.html

National Library of Medicine. (2016). PubMed Tutorial. Retrieved from https://www.nlm.nih.gov/bsd/disted/pubmedtutorial/cover.html

Zaccagnini, M. E., & White, K. W. (2017). The doctor of nursing practice essentials: A new model for advanced practice nursing (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

EBP Project Part I: Using PICO

This last semester I had the opportunity to write the first draft of my evidence-based practice (EBP) scholarly project proposal for my Doctor of Nursing Practice (DNP) program. This experience has given me new insights into the processes of EBP and proposal writing. Using a conceptual framework is important to guide the EBP process because it helps guide the EBP process by providing an outline for the steps that need to be taken (Hall & Roussel, 2014; Moran, Burson, & Conrad, 2014). While many models exist, I will be using the Iowa Model of EBP since it has been noted to be a useful in nursing EBP projects and is the model endorsed by my DNP program (Everett & Titler, 2006; Hall & Roussel, 2014).  

In the Iowa Model, the EBP project is stimulated by triggers that can be knowledge or problem focused (Everett & Titler, 2006). An example of a knowledge focused trigger would be new research that shows a need for change in clinical practice (Everett & Titler, 2006). In this day and age, every hospital is stacked up against other facilities of comparable size who offer similar services; quality metrics from an institution are compared to metrics of other facilities in a process called benchmarking (U.S. Centers for Medicare & Medicaid Services [CMS], n.d.). A quality indicator, such as surgical site infection rates, would be an example of benchmarking data that could be a problem focused trigger for an EBP project (Everett & Titler, 2006).

Developing a Patient Population, Intervention, Comparison, and Outcome (PICO) question is really helpful when completing a literature review because it narrows the focus to a particular issue (Hall & Roussel, 2014). In the Iowa Model, the problem portion of the PICO question is derived from the knowledge and problem focused triggers (Everett & Titler, 2006; Hall & Roussel, 2014). After identifying a trigger, one must consider the organization’s priorities; this is the second step in the Iowa Model and shows the necessity to weigh the potential benefits that can be gained from an EBP project against competing issues and needs (Everett & Titler, 2006). If the knowledge or problem focused trigger is an organizational priority, an interdisciplinary EBP team can be formed of key stakeholders and those with EBP expertise (Everett & Titler, 2006; Hall & Roussel, 2014).

Developing a succinct and focused PICO question helps to generate a search that is neither too broad nor too narrow (Hall & Roussel, 2014). After identifying a problem, the next step is to consider potential solutions. The “I” in PICO stands for “Intervention” (Hall & Roussel, 2014, p. 256). In the example of surgical site infection as the problem focused trigger, using chlorhexidine soap for baths pre-operatively could be the intervention the team chooses to investigate in the literature (Everett & Titler, 2006; Hall & Roussel, 2014). The PICO question could be, “Do preoperative chlorhexidine baths lower surgical site infections compared to standard antimicrobial soaps?”. In this question, surgical site infection rates are the outcome of interest, and bathing with the standard bar or liquid soap used in the hospital is the comparison intervention (Hall & Roussel, 2014). 

References

Everett, L. Q., & Titler, M. G. (2006). Making EBP part of clinical practice: The Iowa Model. In Teaching Evidence-Based Practice in Nursing (pp. 295-324). New York: Springer Publishing Company.

Hall, H. R., & Roussel, L. (2014). Evidence-based practice: An integrative approach to research, administration, and practice. Burlington, MA: Jones & Bartlett Learning.

Moran, K. J., Burson, R., & Conrad, D. (2014). The Doctor of Nursing Practice scholarly project: A framework for success. Burlington, Mass: Jones & Bartlett Learning.

U.S. Centers for Medicare & Medicaid Services. (n.d.). What is hospital compare? Retrieved from https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html

Building Your Portfolio

The process of building your portfolio can start when you are in nursing school. Participation in extracurricular service activities, especially when they are related to nursing, is one way to boost your marketability after graduation. Community service activities (CSER), for example, is a great opportunity to use your skills to benefit others as well as a great addition to your resume. When I was sophomore nursing student, I taught a class on the effects of drug addiction on the brain to a group of women recovering from various addictions at a local Teen Challenge. Other great opportunities to serve and simultaneously hone nursing skills and expand your knowledge base is volunteering in the nursing skills lab and tutoring student nurses in nursing courses, such as Patho, Med/Surg, and pharmacology. I did both of these when I was an upperclassman, and there is so much truth in the old adage that the teacher learns more than the student.

You also don't have to wait until you pass your boards to start attending continuing education (CE) activities such as professional conferences. There are usually plenty of offerings for local CE opportunities. Honors students might be interested in petitioning critical care as this involved attending a single critical care conference when I attended LUSON. See your instructor for current petitioning requirements.

Nursing Undergraduate Honors Thesis

Your Honors Thesis will likely be one of the more challenging writing projects of your undergraduate studies, but it can be very interesting and rewarding if you pick a topic that has the potential to contribute to the body of nursing knowledge and is something you are passionate about. Writing your Honors Thesis does not have to be a dry and dreary task, although it can be at times. For me it was a scholastic adventure that took me down a road I did not expect. I discovered pieces of evidence I was not looking for, and it took on a shape that I had not anticipated. But that is the wonder of nursing. God's creation is so complex we are continuously surprised and delighted by the mysteries of His handiwork. Our earthly bodies daily testify to the glory of our King and tell of His wondrous deeds (Psalm 78:4).

If you are a sophomore or a junior nursing student figuring out your thesis topic, I suggest looking in and looking around; look in to find what is really important to you or what interests you, and look around to find out what is going on in nursing and medicine. Once you pick a topic, find a mentor, this will usually be your thesis chair, to help you to find a searchable question to answer in your thesis. Formulating a question using Patient Intervention Comparison Outcome (PICO) can help you narrow down your search.

Using your resources is also important. Even though I used to work in the Library, I still sought input from the nursing librarian when I was writing my thesis. Another resource I wish I had used when I was an undergraduate was the residential writing center. As a grad student, I have used the graduate writing center multiple times and found their feedback very helpful and informative.

Finally, have the grit to stick with your thesis topic when you get tired and bored. If you pick a topic meaningful to nursing and yourself, the laborious process will be well worth the effort.

Overcoming Test Anxiety

Test anxiety is like a insidious weed that grows like kudzu in the fertile ground of nursing school. Like a contagious disease it spreads rapidly from one student to another. One student voices their concerns about how they will do on their upcoming test; another says she heard from a senior that this is the hardest test of junior year; yet another says she spent 20 hours studying for this test but still doesn't feel ready, and the rest who hadn't studied even half as long suddenly are gripped with the fear of failure because they do not measure up to their friend's rather excessive preparation. I've seen it all before and have been apart of similar conversations and felt the real effects that test anxiety can have.

Some of us Anne of Green Gables fans can sympathize with her sentiments shared in a letter to Diana in which she expressed her anxiety over an upcoming exam. She confided, "Oh Diana, if only the geometry examination were over! But then, as Mrs. Lynde would say, the sun will go on rising and setting whether I fail in geometry or not. That is true but not especially comforting. I think I'd rather is didn't go on if I failed!" We've all been there--believing our entire fate rested on a single test. But I'd like to share how I came to realize that my fate does not rest on a "what" but a "Who".

When I was in high school, my youth pastor used to get down on his knees before the classroom, lift up his hands to God and pray a prayer that has impacted my approach to tests and my whole approach to life. He prayed something along the lines of, "God, I humble myself before You, and admit I cannot do anything apart from You. Give me the grace I need to preach this message." By his example, I started praying my own prayer before every exam, "Lord, I humble myself before You and admit I cannot do anything apart from You. Please give me Your grace and supernatural ability to do well on this test for Your glory not mine." By that prayer, I surrender the outcome into God's hands. When I try to do anything in my own strength, whether I pass or fail, the credit belongs to me. Therefore, the best way to overcome test anxiety is not only preparing well by spending sufficient time studying but to surrender the outcome to God and ask Him for His help. James 4:10 promises this: "Humble yourselves before the Lord and He will exalt you" (ESV). We have a God in Heaven Whose pleasure it is to shower blessings upon us (Lk. 11:13, Rom. 8:32, Js. 1:17). We don't have to live weighed down by cares and concerns (Matt. 11:29-30). In 1 Peter, we are commanded to "Cast all your anxiety on Him for He cares for you" (5:7, NIV).

A special thanks to the junior nursing student who asked me to write this post. I hope you will be as encouraged by it as I was in writing it.

Everyone Has Those Days

Those days when you feel like giving up are some of the hardest ones you can experience as a nurse. Usually caused by short staffing and a multiplicity of circumstances that lead to you having a hard day, discouragement can often try to bring you down and take your eyes from why you came here in the first place. A few days ago I had one of these days. I was over-stressed and had a lot of things going on simultaneously with my patients. I was on the brink of tears by the time 3:45 pm rolled around I hadn't had lunch yet. When I finally got lunch, I asked the Lord for His grace to do whatever came next when I walked out the door of our break room. Even after lunch, I still faced difficulties, but something was different. I was not as stressed by them. The Lord had given me the peace that prevailed in every circumstance (Phil. 4:7).

Later when I got in my car to go home, I unconsciously took a big sigh of relief. It had not been an easy day, but as I sat in my driver's seat pondering all that had taken place, I was reminded of the goodness of our God. He had helped me get through the day. It was by His grace, not my ability, that all my patients were taken care of (2 Cor. 12:9).

I want to encourage all the nurses and nursing students reading this blog to remember where our strength comes from--He is the source of our peace, our joy, and the grace we need every day. I was reminded this morning of a verse in Lamentations which says God's mercies are "new every morning" (3:23). Before our feet hit the floor on our next shift, let's take a moment and thank God for His faithfulness and the strength He is going to give us to be the nurses He's called us to be (2 Pt. 1:3).

"Cast your cares on the LORD and he will sustain you; he will never let the righteous be shaken." ~Ps. 55:22

Mid-Semester Reminders

About this time of the semester the days tend to run together starting with an early alarm that reads something like 0500 and clinicals that start shortly after that. I remember what that was like and, in fact, am reliving those times now as I am working full-time and taking a graduate statistics class while studying for the GRE. While late nights and early mornings are all too familiar for many nursing students, I want to encourage you to not lose sight of the One Thing, the thing that is necessary. Now is not the time to neglect our quiet time with the Lord. I know it's hard to find time. Believe me, I'm right there with you, but think about all the other things we miraculously always find time to do...ahem...like check Facebook, Instagram, and other social media outlets. I know I have come home after a long shift at the hospital, done both of those things, and then realized that I hadn't read my Bible yet. It's times like these that I have to examine the quality of time that I'm giving to the Lord. Am I giving Him my best? Or my left-overs? Let's strive to give the Lord our best in our time. When we put Him first, He promises to reward us and to take care of the rest.

"But seek first the kingdom of God and His righteousness, and all these things will be added to you." ~ (Matt. 6:33, ESV)

Why I Love Charge Nurses

When you graduate from nursing school you have a few months that you spend with a preceptor, but then you are released and are virtually on your own, or so it feels much of the time. During my orientation, I was intimidated by my charge nurses. I erroneously thought that they were too busy and important for me to bother. Boy was I wrong! If you need help or simply have a question, your charge nurses are your biggest resource. I love all of the charge nurses I work with. They each have their own special gifts, and all are extremely helpful.

Charge nurses typically have many years of experience and are the "experts" Patricia Benner describes in her book, Novice to Expert. They are the nurses you can call when you need a second opinion before you call Rapid Response to come for a nurse consult or page your physician about a change in patient status. As a new grad, I know that I, and other new grads, sometimes need this second assessment by a senior nurse to validate our own assessment and give us confidence before we recommend the physician to escalate care.

My advice to recent grads in the December 2014 class who are becoming the latest proud group of RNs to graduate from Liberty University is to make friends with your charge nurses. Your charge nurses are the ones you can call when you are swamped with STAT labs, meds, patient care, and have no way of getting it all done yourself. Charge nurses want you to succeed as much as you do. Don't be afraid of asking for help. One of the most important lessons you will learn as a new nurse is, when you need help, ask.

Note of Encouragement: To Nursing Students

I can hardly believe that Christmas break is over and school is back in session. I remember the mixed feelings of excitement, dread, and anticipation which would overwhelm me at the beginning of each semester. Before life gets crazy, I would like to encourage some LU nursing student out there who is reading this right now to keep first things first. I know it's easy to get caught up in the busyness of school and clinicals, but always remember why you are here. Seek Him. Know that He loves you.

I know sometimes being driven and a go-getter can be lonely and sometimes discouraging when we find ourselves falling short of what we hoped for and expected of ourselves. One of the biggest lessons and best pieces of advice came to me by the mouth of Ms. Drohn after I felt that I had failed and the world was ending because I realized I wasn't perfect, which sounds as ridiculous as it was. She told me that there is only One person who's perfect, and if you're Him we've got bigger problems on our hands. Now that made me smile through my tears, but it really is true. Perfectionism is a good thing insofar as it pushes us to excellence, but it can be a burden and a hindrance if it causes us to rely on ourselves instead of Him alone who IS perfect. Now I don't know if any of that is helpful for you, but if it's not maybe you'll be able to use it to encourage someone else in your program.

Keep up the good work, LU nursing student! You can do all things through Him who gives you strength. Lean on Him. He has you in His hands.

Q&A with an LU Nursing Grad

Recently I was contacted by Emily, a current junior in the nursing program at Liberty. She had a lot of great questions that I remember asking some of the seniors when I was a junior. I’m sharing them here in the hope that they will help other nursing students with similar questions.

Q: What advice do you have for applying to externships?

A: My advice about applying to externships is tailor your resumes and cover letters to each application. Use some of the key words that they use in the job posting in your resume/cover letter. Be concise but show the nurse recruiters why you're the best. I would also recommend using Liberty’s Career Center as a resource. You can electronically send your resume into them for critique and even schedule a mock interview.

Since you are filling out applications now, this will probably apply more to your future applications to new grad jobs, but I would recommend seeking out opportunities to serve (CSER is a great option) that will look good on your resume (esp. those related to nursing). It's rewarding in two ways. First you're serving God, which is the most important, but second, serving without pay is something unique that shows that you want to give back to your community not just be a consumer. Employers want employees with a service mentality because they know that A) it makes them look good B) you get personal satisfaction from helping others, which causes you to C) be a better employee as a result (less burn-out). Some service opportunities I would suggest are volunteer nursing lab worker, Patho/MedSurg tutor, and community nursing educator (I taught a class on drug addiction to women at a local Teen Challenge in my community).

When you are in your interview, be confident. You can look on the Liberty Career Center website for typical questions that interviewers ask and then formulate some responses. Think of a 7 or so nursing or work-related stories that highlight some of your personal qualities that they are seeking (compassion, caring, integrity, critical thinking, ability to work with difficult people, etc.). Once you get to Leadership (NURS 490), you will learn how to write a “critical incident” that highlights your skills and abilities which are exemplified in a particular patient care situation. This seems like a difficult assignment sometimes, but it helps you to go through the process of picking a situation you experienced and then examining it for every area and decision you made that shows that you are a caring, compassionate, hard-working Liberty nursing student who has what it takes to be the best nurse/nurse extern--one that they would love to hire.

Q: Can you tell me about the process of getting into the Adult CCCP?

A: First of all, once you've completed your application, Mrs. Akers, the director of the Adult Critical Care Certificate Program (CCCP), will be speaking with your clinical instructors about you and getting their feedback about your performance in the clinical setting. This is when having established a strong relationship with your clinical faculty really pays off. They will be able to tell her your strengths and weaknesses. (FYI when I was in the running for the program, taking part in the Richmond program was an extra point in the point system for calculating who is selected).

When I applied to the program, I had to submit the last patho of the semester. I didn't realize this at the time, but those who read the pathos submitted in the application really pay attention to these pathos. My understanding is that they look for attention to detail and overall comprehension of the material.

After the preliminary selection is made, a list will be posted in the nursing office of those selected for panel interviews. You will have to sign up for a time slot. I remember everyone (including myself) kinda freaking out about the interviews for the Crit Care program. But remember to take a deep breath and relax.

This is a professional interview so you will want to dress like you are going to a job interview for your first real nursing job. (I think I wore slacks, heels, and a nice blouse). One of the most helpful things I did was go to Mrs. Akers alone and talk with her about the questions I had about the program prior to the interview. She is super sweet and caring and loves talking to students about her passion for critical care nursing.

I don't know if Mrs. Akers and Dr. Kennedy will offer this to your class, but even if you don't make it into the first selection of those in the Crit Care program, there are usually those who don't get a high enough grade in NURS 460 and have to drop out of NURS 465 (which is the CCCP class). If you're put on the waiting list, you can still get in if there's an opening. Also, last year Mrs. Akers and Dr. Kennedy taught an ACLS class for those who were interested and got an A (and maybe even a B) in NURS 460.