NURS 6052 Essentials of EvidenceBased PracticeFrank BashumikaWalden UniversityMarch 30 2019Course Project Part

NURS 6052: Essentials of Evidence-Based PracticeFrank BashumikaWalden UniversityMarch 30, 2019Course Project: Part 2 — Literature Review Problem AnalysisThe use of seclusion and restrictions (SR) in psychiatric care has continued, worldwide, despite the well-documented physical and psychological harm to patient outcomes (Goethals, Dierckx, and Gastmans, 2012; Hamers & Huizing, 2005). Various studies have established that these measures are not effective in preventing or containing patient aggression, and, therefore, their use is not evidence-based (Kaucic, 2017). Acting on the study findings, regulatory authorities and professional bodies such as the American Psychiatric Nurses Association (APNA, 2014), Centers for Medicare and Medicaid Services (CMMS, 2012), American Nurses Association. (2015), and Mental Health America (MHA, n.d.) have recommended alternative patient aggression control skills and eventual elimination of SR use. This paper examines five existing primary studies with a view to understanding the different types of available alternative interventions and any barriers to their implementation. MethodFive recent primary research publications (not older than five years) were reviewed. As dictated by the nature of the problem under investigation, the review covered only those studies which had investigated the experiences and attitude of the populations that are most affected by the practice of SR towards the interventions: patients and nurses. The guiding previously formulated (PICOT) question was: “In psychiatric patient care (P), what is the most effective method of promoting alternative interventions (I) with a view to ending the use of SR (C, O) in the least time possible (T)?P= psychiatric inpatients I= SRC= alternative interventions O= abolition of SR useT= the least time possible This question guided the critical examination of the various studies to identify their outcomes, in/consistencies, and to determine any need for further research on the topic.The five publications were accessed in the Walden Library through a search of the following databases: CINAHL Plus with Full Text, MEDLINE with Full Text, and Cochrane Library database. The search was restricted to these databases because they contain filtered information (Levels 1- 3 of the Evidence Pyramid) which is the best evidence for practice. The key search words were: seclusion, restraints, reduction, elimination, barriers, psychiatric, and alternatives. ‘Seclusion’ and ‘restraints’ were the common search words in all searches. Initial search generated more than 100 publications which were sieved down to 35 by excluding those that did not bear full text (mostly from MEDLINE database). Upon examination of the abstract of the remaining 35 publications, only ten were found to have close relevance to the question under investigation. They were further trimmed by reading them and selecting those with the highest relevance.Literature ReviewThe reviewed publications, a mix of qualitative and quantitative studies, consistently reported the patients’ and nurses’ distaste for SR use. Patients distasted the interventions because they violated patients’ human rights – autonomy and access to basic needs. Studies found that patients did not see the need for the use of SR (Kontio et al, 2012). Nurses on their part were reported to be in a state of ethical dilemma, for whereas they too distasted SR use, they could not help applying them due to ‘lack of alternatives’. The studies, thus identified nurses’ general ignorance of available alternative patient aggression management skills (Muir-Cochrane, Baird, and McCann, 2015). This was presented as the key barrier to the implementation of alternative interventions although Kontio et al (2010) suggested that the barrier could be overcome. The publications reported various alternative interventions including de-escalation methods, sensory modulation, and time-out (Bowers et al, 2012; Godfrey et al, 2014). Other studies promoted formal alternatives: the Safewards model and Six Score Strategies (Bowers et al, 2015; Wieman et al, 2014; and Guzman et al, 2016). All the alternatives, but especially the formal ones, which took into consideration patients’ attitude and perceptions, were reported to improve patient satisfaction with care for de-escalating patient aggression without resorting to the use of SR (Bowers et al, 2015; Bowers et al, 2012; Godfrey et al, 2014). ConclusionThe literature reviewed confirmed the availability of alternatives that may be applied to either decrease or eliminate SR use. The consistency of findings establishes the reliability and validity of the information presented by the studies. They present strong support for a change in practice although further research may be desirable to determine the feasibility of each of the alternative interventions. Further research may identify the most effective alternative(s) and establish best practice in the actual intervention implementation. ReferencesAmerican Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/DocumentVault/Ethics -1/Code-of-Ethics-for-Nurses.htmlAmerican Psychiatric Nurses Association. (2014). APNA position statement on the use of seclusion and restraint. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageid=3728Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomized controlled trial. International Journal of Nursing Studies, 52(9), 1412 -1422. doi:10.1016/j.Bowers, L., Ross, J., Nijman, H., Muir-Cochrane, E., Noorthoorn, E., & Stewart, D. (2012). The scope for replacing seclusion with time out in acute Inpatient psychiatry in England. Journal Of Advanced Nursing, 68(4), 826 – 835 10p. doi:10.1111/j. 1365-2648.2011.05 784.x.Centers for Medicare and Medicaid Services, HHS. (2012). Condition of participation: Patients’ rights (CFR Title 42 Section 482.13). Washington, DC: U.S. Government Printing Office.Davies, K.S. (2011). Formulating the evidence-based practice question: A review of the frameworks for LIS professionals.  Evidence Based Library and Information Practice 6(2):75-80. Retrieved March 10, 2019, from https://www.researchgate.net/publication/229115669_Formulating_the_Evidence_Based_Practice_question_A_review_of_the_frameworks_for_LIS_professionalsDavies, K.S. (2011). Formulating the evidence-based practice question: A review of the frameworks for LIS professionals.  Evidence Based Library and Information Practice 6(2):75-80. Retrieved March 10, 2019, from https://www.researchgate.net/publication/229115669_Formulating_the_Evidence_Based_Practice_question_A_review_of_the_frameworks_for_LIS_professionalsGodfrey, J. L., McGill, A. C., Jones, N. T., Oxley, S. L., & Carr, R. M. (2014). Anatomy of a transformation: A systematic effort to reduce mechanical restraints at a state psychiatric hospital. Psychiatric Services (Washington, D.C.), 65(10): 1277 – 1280. doi:10.1176/appi.ps.201300247.Goethals, S., Dierckx de Casterlé B., Gastmans, C. (2013). Nurses’ decision-making process in cases of physical restraint in acute elderly care: A qualitative study. Int J Nurs Stud, 50(5):603-12. doi:10.1016/j.ijnurstu.2012.10.006. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23123034Guzman-Parra, J., Aguilera Serrano, C., García-Sánchez, J. A., Pino-Benítez, I., Alba-Vallejo, M., Moreno-Küstner, B., & Mayoral-Cleries, F. 2016). Effectiveness of a multimodal intervention program for restraint prevention in an acute Spanish psychiatric ward. Journal of the American Psychiatric Nurses Association, 22(3), 233 – 241. doi:10.1177/107839031664 4767.Wieman, D. A., Camacho-Gonsalves, T., Huckshorn, K. A., & Leff, S. (2014). Multisite study of an evidence-based practice to reduce seclusion and restraint in psychiatric inpatient facilities. Psychiatric Services, 65(3), 345-351. doi:10.1176/appi.ps.201300210 LITERATURE REVIEW SUMMARY TABLE CitationBowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International Journal of Nursing Studies, 52(9), 1412 -1422. doi:10.1016/j. Type of StudyPrimary study Design Type Quantitative – cluster randomizedcontrolled trialFramework/TheoryIs the Safewards model effective in reducing the number of S/R incidents? Setting31 psychiatric wards at 15 hospitals within 100 km of central London. Key Concepts/ VariablesIndependent variable/control conditionLITE:Implementationof a package of interventions directed at improving staff physical health (expected to have no impact on conflict and containment; Dependent variable/experimental condition: Implementation of the Safewards model interventions. FindingsRelative to the Control intervention, when conflict events occurred the Safewards intervention reduced the rate of conflict events by 15.0%.“The trial Intervention proved to be effective in reducing both conflict and containment.” Hierarchy of Evidence LevelCitationBowers, L., Ross, J., Nijman, H., Muir-Cochrane, E., Noorthoorn, E., & Stewart, D. (2012). The scope for replacing seclusion with time out in acute Inpatient psychiatry in England. Journal Of Advanced Nursing, 68(4), 826 – 835 10p. doi:10.1111/j. 1365-2648.2011.05 784.x. Type of StudyPrimary study DesignQualitative & quantitative – Retrospective case Notes review.Framework/TheoryIn psychiatric Inpatients, how does the use of time out compare to the use of seclusion in terms of managing aggression, and what are the circumstances leading up to the use of this intervention? Setting 84 acute psychiatric wards and psychiatric ICUs in 31 hospitals around London, UK between June 2009 andMarch 2010 Key Concepts/ VariablesVariables: “patients subjected to timeout or seclusion in the first 2 weeks of admission were compared to those who were not” “those who experienced more than one time-out orseclusion were compared with thoseexperiencing only one episode” Findings39 participants were secluded once or more during first 2 weeks of admission; 81 were subject to time out once or more; time out was more likely to be used repeatedly with the same patient; “the most common start to a sequence of events leading to seclusion was aggressive behavior by the patient.”“Aggression was more prominent as a precursor of time-out than for seclusion.” Verbal aggression tended to result in time-out, while physical aggression was met with seclusion. CitationGodfrey, J. L., McGill, A. C., Jones, N. T., Oxley, S. L., & Carr, R. M. (2014). Anatomy of a transformation: A systematic effort to reduce mechanical restraints at a state psychiatric hospital. Psychiatric Services (Washington, D.C.), 65(10): 1277 – 1280. doi:10.1176/appi.ps.201300247. Type of StudyPrimary study, DesignQuantitativeFramework/TheoryWill policy change and staff education/training in de-escalation techniques reduce the occurrence of S/R use? SettingA 398-bed state psychiatric hospital in North Carolina from September 1, 2009, to July 31, 2012 Key concepts/ VariablesIndependent variable:implementationof interventions(staff training inde-escalationtechniques andpolicy change)Dependent variable:rate of mechanicalrestraint use Findings“The findings indicated that afterImplementing NVCI and the response team…the number of mechanical restraint incidentswas significantly reduced on bothservice units”“Mechanical restraint use decreased by 98% on AAU and by 100% on CTU”“We learned that committedleadership was essential fordeveloping and implementing such a plan”“Monitoring the performance of the response team and requiring approval for use of mechanicalrestraint provided a level of accountability for staff actions and encouraged staff to follow the de-escalation principles” CitationGuzman-Parra, J., Aguilera Serrano, C., García-Sánchez, J. A., Pino-Benítez, I., Alba-Vallejo, M., Moreno-Küstner, B., & Mayoral-Cleries, F. 2016). Effectiveness of a multimodal intervention program for restraint prevention in an acute Spanish psychiatric ward. Journal of the American Psychiatric Nurses Association, 22(3), 233 – 241. doi:10.1177/107839031664 4767. Type of StudyPrimary studyDesign:Quantitative – retrospective cohortFramework/TheoryIs this intervention effective in reducing the use of mechanical restraints? Setting42 bedacute psych wardof a universitygeneral hospitalin an urban areaof Spain over atwo-year period Key concepts/ VariablesIV: use ofinterventionprogramDV: use or notof restraintduring hospitalstay* The studyprovided a levelof control forcomparativeanalysis byexamining thedata on the useof S/R over aone year periodprior toimplementingthe interventionprogram, andcomparing thisdata to data froma one year periodfollowing theimplementationof theinterventionprogram FindingsIn 2012 (non-intervention year),there were 164episodes ofrestraint. In 2013(implementationyear), there were85 episodes ofrestraint. The totalpercentage ofrestrained patientsfell from 15.07%in 2012 to 9.74%in 2013 (a 35.37%decrease). Thisdecrease suggeststhat the programmay have beeneffective inreducing the needfor S/R to preventand controlescalatedsituations. “Withregard to thepatients’ conditionprior tomechanicalrestraint, in 2013the percentage ofagitated patientsincreased, whilethe percentage of Level IVCitationWieman, D. A., Camacho-Gonsalves, T., Huckshorn, K. A., & Leff, S. (2014). Multisite study of an evidence-based practice to reduce seclusion and restraint in psychiatric inpatient facilities. Psychiatric Services, 65(3), 345-351. doi:10.1176/appi.ps.201300210 Type of Study Primary studyDesignQuantitative – quasi- experimental Framework/ TheoryIn terms of fidelity and sustainability,how will theimplementationof the 6CSmodel, comparedto standard care,impact the use ofS/R in inpatient psychiatric care facilities? Setting43 inpatient psychiatric facilities in 8 states of the USA over a period of 4 years. Key concepts/ variables:IV: facility and patient characteristics, implementation of 6CS model DV: fidelity(“the extent towhich deliveryof an intervention adheres to theprotocol orprogram modeloriginally developed”),sustainability(“the extent towhich a newlyimplementedtreatment ismaintained orinstitutionalizedwithin a servicesetting’songoing, stableoperations”),rates of S/R Findingsa) Facilities that continued to implement changes, adding components, and maintaining adherence to the changes showed the greatest reduction in the percentage of patients secluded. b) Facilities that reached at least stable implementation rates (implement, slight decline, plateau above implementation threshold) showed reduced percentages of S/R use, S/R duration. c) Fidelity and sustainability at different facilities correlated with actual reduction of S/R use. Level III

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