Evidence Digest

Nursing Interventions to Improve Outcomesin Hospitalized Adults

Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAAN

The purpose of Evidence Digest, a recurring column inWorldviews, is to provide concise summaries of well-

designed and/or clinically important recent studies alongwith implications for practice, research, administration,and/or health policy. Articles highlighted in this columnmay include quantitative and qualitative studies, system-atic and integrative reviews, outcomes evaluation studies,as well as consensus statements by expert panels. Alongwith relevant implications, the level of evidence generatedby the studies or reports highlighted in this column (seeFigure 1) is included at the end of each summary so thatreaders can integrate the strength of evidence into theirhealth care decisions.

• Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical guidelines based on systematic reviews of RCTs

• Level II: Evidence obtained from at least one well-designed RCT • Level III: Evidence obtained from well-designed controlled trials

without randomization • Level IV: Evidence from well-designed case-control and cohort

studies • Level V: Evidence from systematic reviews of descriptive and

qualitative studies • Level VI: Evidence from a single descriptive or qualitative study • Level VII: Evidence from the opinion of authorities and/or reports

of expert committees

Modified from Guyatt & Rennie, 2002; Harris et al., 2001

Figure 1. Rating system for the hierarchy of evidence (fromMelnyk & Fineout-Overholt 2011).

AN INTERVENTION TO REDUCEVENTILATOR-ASSOCIATED PNEUMONIA

Bingham M., Ashley J., De Jong M. & Swift C. (2010). Im-plementing a unit-level intervention to reduce the prob-ability of ventilator-associated pneumonia. Nursing Re-search, 59(1S), S40–S47.

Purpose: The purpose of this study was to evaluatethe effectiveness of a unit-specific education intervention

Copyright ©2010 Sigma Theta Tau International1545-102X1/10

that emphasized hand hygiene, head-of-the-bed (HOB) el-evation and oral care on ventilator-associated pneumonia(VAP) rates and number of ventilator days.

Design: A pre-experiment with a one group pretest-posttest design in which an evidence-based education in-tervention was instituted and its impact was measured interms of clinician compliance with hand hygiene, HOBelevation, and oral care.

Sample/Setting: The study included a convenience sam-ple of clinicians and 100 patients at two military medicalcenters with beds totally 450. The burn, medical, surgical,and trauma ICUs at Medical Center 1 and the trauma ICUat Medical Center 2 participated in the project.

Methods: The educational intervention was designed toteach the clinicians about current evidence and strategiesto enhance clinical practice guideline (CPG) compliance.Staff education targeted standard-of-care practices relatedto hand washing, oral care and HOB elevation as well asincorporated strategies relevant for each individual ICU.The goal of the project was to instill a cultural change inthe units in how staff interacted and policed each other toimprove care across disciplines and units as well as to pro-vide resources for staff to stay current with best practicesand new evidence on VAP. The intervention was deliveredthrough a number of strategies, some provided to all unitsand some designed by and for individual units, including:(1) VAP information notebooks that were given to eachVAP team leader and available to all staff; (2) VAP aware-ness posters; (3) index cards with EBP reminders posted ineach patient room and at each electronic documentationstation, (4) a VAP Awareness week, (5) decorated candyjars and a Fun VAP Quiz, (6) a Power Point presenta-tion and video about EBP practices related to VAP, and(7) an education video about oral care of the intubatedpatient.

Outcomes included 2-hour observations of health careprovider behaviors related to mechanically ventilated pa-tients admitted to one of five ICUs. Patients eligible forobservation were those who were on continuous mechani-cal ventilation for at least 48 hours and did not meet criteriafor VAP.

Results: The mean age of the patients was 50 years (SD =23 years) with the majority being male. The most

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improvement observed was for hand washing where allunits except one showed increased compliance, however,compliance for hand washing before and after patient con-tact remained below targeted behavior rates. There was nota significant difference in hand-washing behaviors after theintervention. The HOB was in the correct position 70% ofthe time, with little change after the intervention. Seventypercent of the 100 patients observed had an order for oralcare. During observations, only 17% of the 100 patientsobserved received oral care with a toothbrush despite thefact that the nurses were responsible for writing oral careorders. Oral care improved for three units and decreasedin the other two.

VAP rates did not decrease during the project. In fact,the VAP rate increased in all ICUs except the trauma unitat Medical Center 2 during this time frame.

Commentary with implications for action in clinicalpractice and future research. VAP continues to be amajor source of morbidity and mortality in hospitalizedventilated patients and strategies to enhance adherenceto CPGs to decrease the rate of VAP are critical. De-spite educational and other innovative strategies to en-hance adherence to the VAP CPG in these units, adop-tion of the guideline was much slower than expected.Major barriers were encountered, including staff andnurse leadership turnover and deployment. In additionand very importantly, clinical nurse specialists wereunavailable to these units because they also were de-ployed or worked rotating shifts as a staff nurse. Clini-cal nurse specialists can often function as EBP mentors,who in prior research, have been reported to enhanceEBP in point of care staff (Melnyk 2007; Newhouseet al., 2007). In addition, beliefs/attitudes toward EBPand the CPG were not measured, so it is unknownwhether there was “buy in” from staff to adhere to theguideline. Cognitive beliefs about the value of EBP andthe individual’s ability to implement it have been shownto impact EBP behaviors in prior research (Melnyk et al.2004, 2008). Furthermore, manipulation checks werenot conducted in this study to assess whether staff trulyprocessed the educational interventions. In addition,the interventions were permitted to be individualizedbased upon the unit, and the dose that was actuallydelivered in the units is unknown. Data were also col-lected soon after the educational intervention. Finally,there may not have been enough time allotted for dif-fusion of the CPG among staff.

Although this was not a rigorously designed ran-domized controlled trial and, as a result, has major

limitations and threats to internal validity of the study,it is an important project that can inform future studiesto test strategies to enhance EBP behaviors in staff. The2-hour observations may have missed behaviors thatwere implemented at other times. However, there wereno changes in VAP after the intervention, which sug-gests adherence to the protocol was indeed problem-atic. Standardization of the intervention across unitsmay have led to improved outcomes.

Behavioral change is challenging in both patientsand clinicians. Thus, there is an urgent need for futureintervention studies that test strategies to enhance achange to EBP behaviors in point of care staff in orderto decrease the serious time lag between the generationof research findings and their translation into practiceto improve care and patient outcomes.

Level of Evidence: VI

NURSING CARE FOLLOWING APERCUTANEOUS CORONARY

INTERVENTION

Rolley J.X., Salamonson Y., Dennison C.R. & DavidsonP.M. (2010). Nursing care practices following a percuta-neous coronary intervention. Results of a survey of Aus-tralian and New Zealand cardiovascular nurses. Journal ofCardiovascular Nursing, 25(1), 75–84.

Purpose: The purpose of this study was to describethe nursing practice standards, workplace values, educa-tional needs and priorities of cardiovascular nurses’ carefor patients following a percutaneous coronary interven-tion (PCI).

Design: Descriptive survey.Sample/Setting: The participants were 148 registered

nurses working in cardiovascular settings.Methods: A 116-item Web-based survey was adminis-

tered to cardiovascular nurses through electronic mailinglists of professional cardiovascular nursing organizationsusing a secure online data collection system. The surveywas developed through an integrative literature review,a consensus conference with 41 participants who iden-tified priorities, and existing clinical practice guidelines.The survey had six sections, including PCI nursing prac-tice (4 items), health care delivery values (16 items), clin-ical practice standards (6 items), knowledge and capacity(14 items), adjustment and recovery (46 items), and clin-ical practice environment (30 items). Data were collectedfrom March 2008 to March 2009. Cronbach alphas of thefive survey areas were above .88 except for the six-item

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clinical practice standard subscale, which had an internalconsistency reliability of .65.

Results: Participants were a mean age of 42 years(SD = 9.8) and had an average of 12.3 years experience(SD = 7.6) in a cardiovascular setting. One hundredtwenty-one of the respondents were from Australia (81%).One hundred ten of the participants (74.3%) answered allof the survey items. A range of practice patterns existed inthe areas of: (1) ambulation time after percutaneous coro-nary artery intervention (2) methods of sheath removal,(3) pain relief, and (4) patient positioning. Psychosocialcare of the patient was consistently ranked a lower prioritythan other tasks and was identified as a knowledge deficit.The highest ranked need for further education was psy-chosocial aspects of care and the lowest ranked need wasfor cardiac rehabilitation.

Commentary with implications for action in clinicalpractice and future research. The findings from thissurvey support the widely recognized phenomena ofvariations in the delivery of care and the need fornursing-based clinical practice guidelines that are con-sistently implemented with patients. The lack of suchguidelines is a major factor in the variation of care. Inthis sample of nurses, there is a huge need for educa-tion regarding the psychosocial aspects of cardiovas-cular care as numerous studies have shown the linkbetween psychosocial and physical health outcomes.Patients undergoing PCI should be assessed for psy-chosocial morbidities (e.g., depression, anxiety) thatcould impact their health outcomes. Once a clinicalpractice guideline is developed for patients undergo-ing PCI, intervention studies should be conductedwith nurses to test strategies that enhance consistentimplementation.

Level of Evidence: VI

LIVE MUSIC TO IMPROVE PATIENTOUTCOMES

Sand-Jecklin K. & Emerson H. (2010). The impact of livetherapeutic music intervention on patients’ experience ofpain, anxiety and muscle tension. Holistic Nursing Practice,24(1), 7–15.

Purpose: The purpose of this study was to evaluate theeffects of live music as a holistic patient intervention onpain, anxiety, muscle tension levels, heart rate, pulse andblood pressure of patients admitted to a tertiary care centerfor an unplanned/emergent medical condition.

Design: Pre-experiment; one group pre-post test design.Sample/Setting: A convenience sample of 31 patients

admitted on an unplanned/emergent basis to an acute caremedical-surgical unit of an academic medical center lo-cated in the Southeast region of the United States. All buttwo of the patients were admitted for an emergent injuryresulting from a trauma, fall or auto accident. Seventy-onepercent had been previously hospitalized.

Methods: The music intervention included 20 minutesof Celtic Harp music played by a certified music practi-tioner (CMP) at the side or foot of the patient’s bed. Mea-sures included patient ratings of pain, anxiety and muscletension using a 0–10 pain scale as well as patients’ pulse,respirations and blood pressure, measured either manu-ally or with an electronic devise prior to the music session.The measures were taken prior to and after the music in-tervention. Patients also rated the helpfulness of the musicintervention. Subjects who remained in the hospital for24–48 hours after the initial music intervention sessionwere offered a second therapeutic music session. Thirty-one patients completed the first music intervention and 20completed the second session as 11 were discharged beforethe second session.

Results: The patients ranged from 18 to 86 years witha mean of 48 years. Seventeen were women and 14 weremen. Patient-reported pain, anxiety and muscle tensionwere significantly lower after the music intervention ses-sions for both sessions. Respiratory rate was significantlylower after the music intervention for both sessions andsystolic blood pressure was lower after the first music ses-sion. Eleven of the patients in the first session had re-ceived pain medication within 2 hours of the music session,which may have enhanced the beneficial effect of the musicon patients’ ratings of pain and anxiety. Mean participantratings for the helpfulness of the music on pain were 8 forboth sessions and 8.5 for anxiety. Most patients reportedthe length of the music intervention was about right. Pa-tients reported that they engaged in visualizing/thinking ofa peaceful place, relaxing/resting and just listening whilethe music was playing. Six percent of the participants re-ported that the music sessions were not long enough and3% reported that they did not like the disruption of havingto answer questions after being relaxed or sleepy from theharp session. Ninety-three percent of the patients reportedan improved mood during the music sessions and 69%reported less pain during the session. Thirty percent ofthe participants reported that the beneficial effects lastedfor over an hour and 35% reported 30 to 60 minutes. Allpatients indicated that the music was helpful and 68% re-ported that the timing was good. In addition, all patientssuggested therapeutic music should be given to all hospi-talized patients.

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Commentary with implications for action in clinicalpractice and future research. Findings from multi-ple studies and systematic reviews have indicated thatpatients who listen to recorded music have less pain.However, there are few studies that have reported onthe multiple effects of recorded and/or live music onpatients’ pain, anxiety, physiological outcomes and sat-isfaction.

The major limitation of this study is that it used a onegroup pre- and post-test intervention design. Therefore,the internal validity of the study is weak (i.e., beingable to say that it was the intervention itself that causeda change in the outcome variables). Despite this ma-jor limitation, the investigators included physiologicalvariables and patient feedback about the music, whichis helpful in strengthening the findings.

Health care providers often use medication todecrease pain without fully considering a holisticapproach to reducing pain and anxiety. Therefore, thefindings from this study are helpful in recognizingthat a live music intervention can be useful in ame-liorating pain, anxiety and physiological indicatorsof pain as well as improving patient satisfaction.Using music as an adjunct to medication may enablepatients to cope better with their hospitalizationand lessen their pain. Future research is needed thatemploys randomized controlled trial designs withattention control groups to strengthen internal validityand enhance clinicians’ confidence in the findings.

Level of Evidence: VI

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