Foundations of Inquiry

4. Synthesizing the Evidence: The team then synthesizes the findings from the appraised evidence, looking for consistent patterns, strengths of evidence, and any conflicting results. This involves summarizing the key findings and determining the overall body of evidence's strength and direction in relation to the EBP question.

5. Implementing the Evidence into Practice: Based on the synthesized evidence, the interprofessional team develops a plan for implementing the evidence-based change in clinical practice. This plan should consider the feasibility, resources required, potential barriers, and strategies for overcoming them. It also involves clear communication and collaboration among all involved disciplines.

6. Evaluating the Impact: After implementing the change, the team evaluates its impact on patient outcomes, processes of care, and organizational factors. This involves collecting data relevant to the outcomes identified in the EBP question and analyzing it to determine if the implemented change has led to the desired improvement. The evaluation findings then inform further adjustments to practice or the identification of new clinical problems.

This iterative process emphasizes collaboration, critical thinking, and the integration of the best available evidence with clinical expertise and patient values to achieve optimal patient care.

B. Impact of a Clinical Practice Problem: Delayed Ambulation Post-Surgery

Clinical Practice Problem: Delayed ambulation (walking) in adult patients following major abdominal surgery.

Impact on the Patient:

Delayed ambulation after major abdominal surgery can have significant negative impacts on patients:

• Increased Risk of Complications: Prolonged immobility increases the risk of developing postoperative complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, atelectasis, and pressure ulcers. These complications can lead to increased morbidity, prolonged hospital stays, and even mortality.
• Delayed Functional Recovery: Early ambulation is crucial for regaining strength, mobility, and independence. Delayed ambulation can lead to muscle weakness, reduced cardiovascular fitness, and a slower return to pre-operative functional status.
• Increased Pain and Discomfort: Immobility can exacerbate pain and stiffness, making it more difficult for patients to participate in other recovery activities like coughing and deep breathing.
• Prolonged Hospital Stay: The development of complications or a slower functional recovery due to delayed ambulation often necessitates a longer hospital stay, increasing the burden on the patient and the healthcare system.
• Negative Psychological Impact: Prolonged bed rest and dependence can lead to feelings of frustration, anxiety, and depression, hindering the patient's overall recovery and well-being.

Impact on the Organization:

Delayed ambulation also has significant implications for the healthcare organization:

• Increased Healthcare Costs: Longer hospital stays, treatment of postoperative complications, and readmissions associated with delayed ambulation significantly increase healthcare costs.
• Decreased Bed Turnover: Prolonged hospital stays reduce the availability of beds, leading to decreased bed turnover and potential delays in admitting new patients.
• Lower Patient Satisfaction: Patients experiencing complications, prolonged stays, and slower recovery are likely to have lower satisfaction with their care.
• Increased Risk of Penalties and Reduced Reimbursement: Healthcare organizations are increasingly being penalized for high rates of preventable complications and readmissions, which can be linked to delayed ambulation.
• Strain on Staff Resources: Managing patients with postoperative complications and providing prolonged care due to delayed recovery places a greater burden on nursing and other healthcare staff.

B.1. PICO Components:

Based on the clinical practice problem of delayed ambulation post-surgery:

• P (Patient, Population, or Problem): Adult patients who have undergone major abdominal surgery.
• I (Intervention): Implementation of a standardized early ambulation protocol (initiated within 24 hours post-surgery).
• C (Comparison): Standard postoperative care without a standardized early ambulation protocol (ambulation initiated based on individual assessment and tolerance, often later than 24 hours).
• O (Outcome): Reduction in postoperative complications (DVT, PE, pneumonia, atelectasis, pressure ulcers), shorter length of hospital stay, improved functional recovery (e.g., time to first independent walk, pain levels), and increased patient satisfaction.

B.2. Evidence-Based Practice (EBP) Question:

In adult patients following major abdominal surgery (P), does the implementation of a standardized early ambulation protocol initiated within 24 hours post-surgery (I) compared to standard postoperative care without a standardized early ambulation protocol (C) result in a reduction in postoperative complications and a shorter length of hospital stay (O)?

C. Evidence Appraisal of a Research-Based Article

Selected Research-Based Article:

O'Connell, M., Gardner, S., Betihavas, V., & Keogh, J. B. (2019). Early mobilisation within 24 hours of abdominal surgery: A systematic review and meta-analysis. Surgery, 165(2), 301-309.

C.1. Background or Introduction (Purpose):

The background of this systematic review and meta-analysis highlights the established benefits of early mobilization in preventing postoperative complications and promoting recovery after various surgical procedures. However, the authors note that the optimal timing and specific protocols for early mobilization following major abdominal surgery remain less clearly defined. The purpose of their research was to systematically review and synthesize the evidence from randomized controlled trials (RCTs) to determine the effect of early mobilization (initiated within 24 hours post-surgery) on postoperative outcomes in adult patients undergoing abdominal surgery.

C.2. Research Methodology:

This study employed a systematic review and meta-analysis methodology. The researchers systematically searched several major electronic databases (e.g., MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) for RCTs that compared early mobilization (initiated within 24 hours post-surgery) to later or standard mobilization in adult patients undergoing abdominal surgery. They defined early mobilization as any form of physical activity such as sitting out of bed, standing, or walking initiated within the first 24 postoperative hours. The researchers then critically appraised the included studies for methodological quality and extracted relevant data on various postoperative outcomes. Finally, they performed a meta-analysis to statistically pool the results of the comparable studies to determine the overall effect of early mobilization on the outcomes of interest.

C.3. Level of Evidence (Johns Hopkins Nursing Evidence-Based Practice Model):

Based on the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, a systematic review or meta-analysis of RCTs is considered Level I evidence. This level represents the highest quality of evidence due to the rigorous methodology of systematically synthesizing findings from multiple well-designed studies.

C.4. Data Analysis:

The researchers analyzed the extracted data using statistical methods appropriate for meta-analysis. For dichotomous outcomes (e.g., presence or absence of complications), they calculated risk ratios (RR) and 95% confidence intervals (CIs). For continuous outcomes (e.g., length of hospital stay), they calculated mean differences (MD) and 95% CIs. They used random-effects models for the meta-analysis to account for potential heterogeneity between the included studies. Heterogeneity was assessed using the I² statistic. The researchers also conducted subgroup analyses and sensitivity analyses to explore potential sources of heterogeneity and assess the robustness of their findings.

C.5. Ethical Considerations:

As this study is a systematic review and meta-analysis, it does not involve direct human subjects research. Therefore, it would not have required specific ethical approvals such as informed consent or institutional review board (IRB) review at the level of this study itself. However, the researchers would have relied on the ethical conduct and approvals obtained by the primary researchers of the included RCTs. The authors of this systematic review should have ensured that the included studies reported adherence to ethical principles relevant to human subjects research, such as informed consent, protection of privacy, and minimization of harm. This would typically be mentioned within the methodology sections of the primary studies they reviewed. If the included studies did not address ethical considerations, this would be a limitation noted in the systematic review's appraisal of the evidence base.

C.6. Quality Rating (Johns Hopkins Nursing Evidence-Based Practice Model):

To determine the quality rating according to the JHNEBP model, we would need to evaluate the methodological quality of the included RCTs and the systematic review process itself. Based on the description provided:

• Systematic Review Process: The researchers systematically searched multiple databases, defined inclusion and exclusion criteria, critically appraised studies, extracted data, and performed a meta-analysis. This suggests a rigorous systematic review process.
• Methodological Quality of Included RCTs: The quality rating would depend on the specific appraisal of each included RCT based on criteria such as randomization, blinding, attrition rates, and reporting of results.

Assuming the researchers used a recognized tool for quality assessment of RCTs (e.g., Cochrane Risk of Bias tool) and reported the findings, and that the systematic review methodology was sound, the overall quality rating for this systematic review and meta-analysis would likely be High (A) if the majority of included studies were of high quality and the synthesis was conducted rigorously with consistent results. If there were significant methodological limitations in the included studies or inconsistencies in the findings, the rating might be Good (B) or even Low (C). Without the specific quality assessment results from the article, we can infer a likely rating based on the study design (meta-analysis of RCTs being inherently strong)

A. The Process of Data Collection, Analysis, and Implementation of Evidence in Interprofessional Practice

The process of data collection, analysis, and implementation of evidence to improve clinical practice from an interprofessional perspective is a cyclical and collaborative endeavor. It involves healthcare professionals from various disciplines working together to identify a clinical problem, formulate a focused question, systematically search for and critically appraise relevant evidence, synthesize the findings, implement the evidence into practice, and evaluate the impact of the change.

1. Identifying a Healthcare Problem: The process often begins with a recognized gap between current clinical practice and desired patient outcomes. This might arise from direct observation, quality improvement data, patient feedback, or new research findings. An interprofessional team, including nurses, physicians, pharmacists, therapists, and others, collaborates to clearly define the problem and its scope.

2. Developing an Evidence-Based Practice (EBP) Question: Once the problem is identified, the team formulates a specific and answerable EBP question, often using the PICO (Population, Intervention, Comparison, Outcome) framework. This structured question guides the search for relevant evidence.

3. Reviewing Selected Evidence: The interprofessional team then conducts a systematic search for the best available evidence. This includes research-based evidence (e.g., randomized controlled trials, systematic reviews, meta-analyses, cohort studies, case-control studies, descriptive studies) and non-research-based evidence (e.g., clinical practice guidelines, expert opinions, organizational experience, patient preferences). The team critically appraises the selected evidence for its rigor, relevance, and applicability to the specific clinical context. This appraisal involves evaluating the study design, sample size, methodology, findings, and potential biases.