Running head: CLINICAL QUESTION PAPER
Clinical Question Paper
Adam Ratliff
Ferris State University
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Abstract
The nursing profession is one that is continually evolving to reflect the most up-to-date
research findings. Through the identification of a clinical problem in current practice,
followed by the development of a clinical question, using the PICOT format, as well as a
critique of three supportive nursing research articles has been conducted and included in
this paper to help emphasize the importance of needing to understand how nursing
practice is developed and disseminated among the profession. The need for nurses to be
able to integrate current best practice recommendations into everyday clinical practice is
of utmost importance to help aid in the promotion and improvement of quality and safety
of nursing care.
Keywords: Pain management, PICOT question, preoperative education, falls, total
joint replacement
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Clinical Question Paper
The nursing profession is one that is ever changing. As a profession that is created
and based upon scientific research, the way in which nursing care is delivered is
continually being modified and altered to reflect the latest and most up-to-date evidence
based research findings. However, not all research findings are going to be applicable or
appropriate for integration into nursing care. Consequently, the ability for nurses to be
able to interpret and understand these research findings is also important, in order to
make the most informed, educated, and knowledgeable nursing decisions before
integrating such research findings into clinical practice. Therefore, the purpose of this
paper is to reflect on how nursing knowledge is dispersed and disseminated in both
personal and professional nursing practice.
Clinical Question
When in comes to enacting a possible change in nursing practice, a clinical
problem or issue needs to be identified. Once a problem has been acknowledged, the
process towards change is one that involves a multifaceted approach. The development of
a clinical question is the first step in the process. In the nursing profession, this question
is typically constructed using the PICOT format. Developed by Fineout-Overholt and
Johnston, this five-letter acronym stands for: P = patient or population, I = intervention or
issue of interest, C = comparison intervention or current practice, O = outcome desired,
and T = time need to achieve the outcome (Nieswiadomy, 2012). The reason the PICOT
format is utilized is because it allows for a consistent, and systematic way of identifying
the main components of a clinical problem, which in return helps to conduct a quick and
efficient method when conducting a search for evidence (Stillwell, Fineout-Overholt,
Melnyk, & Williamson, 2010).
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More than 600,000 total joint replacements are completed every year in the
United States, ranking it as one of the top 15-inpatient surgeries throughout the entire
United States (Centers of Disease Control and Prevention, 2013). As a nurse on an
inpatient orthopedic unit, fall prevention and pain management are two highly stressed
areas when it comes to providing postoperative care. With the healthcare industry
stressing the importance of providing more patient centered and focused care, while
trying to maintain and promote patient involvement throughout the entire care spectrum,
the area of patient education has gained increased attention. Therefore, because fall
prevention and pain management are so significant following a total joint replacement,
the clinical question that has been developed is: In patients undergoing total joint
replacement surgery (P), how does the use of preoperative patient education (I) compared
with no preoperative patient education (C) affect clinical outcomes in regards to fall
prevention and pain management (O) postoperatively (T)?
Through answering the formulated question, that is stated above, patient safety
and quality of care would be improved. Conducting a thorough research analysis of the
current literature, and evaluating the results for validity and applicability into current
practice would help to improve nursing knowledge, which in return would help increase
the quality of nursing care provided. Patient safety would be improved by offering and
promoting preoperative education classes to all patients electing to have total joint
replacement surgery, making them aware and attentive to possible complications, such as
pain expectations and their increased risk of falls.
Methodology
In order to answer the proposed PICOT question, a thorough literary review
needed to be completed. This review was done using Ferris State University’s online
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library, FLITE. This source allowed for access to be achieved to multiple different
databases including CINHAL, PubMed, Cochrane Library, as well as the Agency for
Healthcare Research and Quality. Numerous different keywords and phrases were
entered into each database to help populate and generate results. Keywords and phrases
such as orthopedic patients AND preoperative education AND outcomes, preoperative
education AND joint surgery, orthopedic surgery AND preoperative education AND
benefits, are a few examples that were used when searching for supportive evidence to
help answer the PICOT question.
While gathering articles and evidence to help answer the PICOT question on
whether or not preoperative patient education affects fall prevention and pain
management in patients undergoing total joint replacement procedures, only nursing
research articles were selected and reviewed. Because the clinical question involves a
potential change directed towards nursing practice, utilizing evidence that is nursing
based helps to strengthen and solidify the nursing issue at hand, whether it be in support
or denial of the proposed idea or change. By choosing to utilize only nursing specific
resources, safety and quality standards of nursing care is maintained, the knowledge base
of the profession continues to expand and develop, but most importantly it helps to
promote evolution and growth within the profession itself.
Before selecting the nursing articles used to answer the proposed clinical
question, each article was evaluated and ranked using its level of evidence. The American
Association of Critical Care Nurses (AACN) has established a level of evidence or
grading system to help aid in the determination of a sources strength. Two different levels
of evidence, the original scale, ranking sources on a roman numeral scale, and a
modified, new evidence leveling system, rankings sources on an alphabetical scale were
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created by the AACN (Armola et al., 2009). On the numerical scale, a level I indicates
the lowest level of evidence, and a level A on the alphabetical scale represents the highest
level of evidence (Armola et al., 2009). Therefore, the higher the level of evidence an
article possesses, the stronger, sounder presence it has, which ultimately indicates a
greater level of credibility and validity.
Discussion of Literature
A literature review of the current evidence was completed. Through completing
this review, not only were resolutions found to help answer the proposed clinical
question, but it also helped to facilitate and expand the knowledge base of the author.
Three articles were selected and a short article review was completed. The results were
evaluated and discussed and can be found below.
Article One
The first article selected, descried the impact that preoperative education has on
pain management (Sjoling, Nordahl, Olofsson, & Asplund, 2003). The article qualifies as
nursing research as it involved a topic that is pertinent to nursing practice, listed a
registered nurse as one of the main authors and contributors, as well as it was published
in an interdisciplinary journal in which nursing is apart of. The study was approved by an
ethics committee and was given the green light to proceed. The articles purpose statement
was clearly identified in the articles abstract, an in depth literature review was completed,
and a reasonable amount of references were included on the articles reference page.
Orem’s theory of self-care was used as a framework for this study, and a prospective
experimental study design using two parallel groups of equal size (control and treatment
group) was utilized classifying the study as possessing a level C ranking on the new
evidence leveling system. A total of 60 participants were involved. Data was collected
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using questionnaires that were distributed both preoperatively and postoperatively. The
visual analog scale was also utilized to help collect the participants stated pain levels.
The results of the study concluded that by providing preoperative information to
patients having total joint replacement surgery, it does in fact influence the experience of
pain after surgery. The postoperative pain declined much faster in the treatment or
experimental group, and participants in this group also admitted to being more satisfied
with postoperative pain management.
Article Two
The second article focused on whether providing preoperative education would
have any impact towards reducing or eliminating the occurrence of falls following a total
knee replacement (Clarke, Timm, Goldberg, & Hattrup, 2011). The facilities institutional
review board approved the retrospective, cohort study. The purpose statement or
objectives of the study were distinctly found in the articles abstract. The authors
conducted a comprehensive literary review, and multiple references were utilized and
evident on the articles reference page. No framework was identified. A total of 244
participants were involved throughout the studies entirety. Two groups, a control and
experimental group were established. The experimental group involved 72 patients, all of
whom had the same surgeon, and 172 patients were part of the control group. Basic
demographic information, use of peripheral nerve blocks, details of the falls and any
resulting injuries from the fall was collected when a fall occurred. The Hendrich II Fall
Risk assessment tool was utilized to help identify patients at increased risk for fall, this
was conducted every 12-hours by nursing personnel. This study qualifies, as being
worthy of being deemed as nursing research in that two of the four authors are registered
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nurses, and the main topic or point of interest, falls, is a nursing sensitive outcome. This
article would rate as a level B on the new evidence leveling system.
The results of the study were quite shocking. Of the 72 patients who received
preoperative education, not one participant had a reported fall while hospitalized
following their total knee replacement. On the control group, a total of eight falls were
recorded, and three of the eight falls resulted in serious injuries in which required repeat
surgery. Based on the author’s findings, fall reduction education was consequently
incorporated into the institutions preoperative informational program.
Article Three
The final article that was selected was in regards to the effects that preoperative
education has on patient outcomes following a joint replacement surgery (Kearney,
Jennrich, Lyons, Robinson, & Berger, 2011). The level C article was published in a
nursing journal, written by nurses, and is about a nurse sensitive outcome, therefore
qualifying the article as nursing research. The purpose statement was clearly visible as it
was the first sentence in the articles overview. An institutional review board approved the
study prior to it commencing. A total of 150 participants were involved in the descriptive
comparative study. The authors completed an extensive literature review and included
relevant and current resources in their study. Data was collected via surveys pre and
postoperatively, and chart reviews were completed. A follow-up phone call was also done
after discharge.
The results of the study suggested that those who attended the preoperative
education class reported not only feeling better prepared for surgery but also felt better
and more equipped to control their pain following surgery. The authors then concluded
that the knowledge gained from the preoperative class had a direct and positive impact on
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the participant’s experiences. This in return should help to increase the participants’
comfort and sense of control in the immediate postoperative period, helping to improve
the overall experience.
Significance to Nursing
When it comes to nursing practice, quality and safety are two major areas of
interest and focus. According to the Quality and Safety Education for Nurses (2014),
nurses need to be able to improve the quality and safety of the healthcare systems in
which they practice. This assignment has showed how to do so. All three articles
attributed preoperative education as a successful tool in reducing the occurrence of falls,
as well as helping to improve pain management among postoperative total joint
replacement patients. By integrating the findings of these articles into clinical practice,
both quality and safety are improved. Educating patients on ways to help prevent falls
following surgery, such as mobility techniques, and the importance of using an assistive
device, as well as addressing the importance of keeping ahead of pain and reassuring that
all types of treatment modalities are utilized, such as pain medications, ice application,
and repositioning are examples of educational teachings that could be integrated into
preoperative classes to help promote, improve, and ensure quality and safety.
According to the American Nurses Association (ANA), nursing exists to help
improve the health and well being of all individuals, communities, and populations by
ensuring that the most up-to-date and evidence based care is provided (ANA, 2004).
Based on the results of all three articles, the need to provided preoperative education
classes to patients undergoing total joint replacement surgery is imperative as it has
shown to help reduce fall rates as well as improve pain management. Therefore based on
the statement made from the ANA, nursing needs to enact change to current policy to
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help reflect the evidence found in all three articles, in order to ensure that evidence based
nursing care is being delivered. Although the integration of preoperative classes would be
costly upfront, the institution would eventually gain increased reimbursement in the long
run due to the fact that hospitals are now funded or reimbursed based on patient
satisfaction and perception of care. Decreased falls and excellent pain management would
eventually help increase patient satisfaction, which would then in return increase funding
and reimbursement to the facility, ultimately helping to offset the cost of providing theses
preoperative educational classes.
In conclusion, the nursing profession is one that is continually being molded and
modeled to reflect the most current and up-to-date evidence based research. Therefore the
need for nurses to be able to integrate and incorporate such research into clinical practice
is imperative. By being able to identify a problem, develop a clinical question; perform
and evaluate current literature, and then integrate and adapt one’s nursing care to reflect
such changes promotes evidence based nursing practice, improves quality and safety, and
helps grow and expand the knowledge base of the nursing profession.
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References
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Clarke, H. D., Timm, V. L., Goldberg, B. R., & Hattrup, S. J. (2012). Preoperative patient
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Orthopaedics and Related Research. doi:10.1007/s11999-01101951-6
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