NKU: DNP-PROGRAM

NKU- DNP Peers’ Posts Needing Responses
Kayla Tackett
1A. Evidence based practice is utilized in all aspects of nursing. For example, I work in an academic institution working closely with healthcare community partners.  Although we are not working directly with patients in the institution, we still follow evidence-based practice daily in our setting.  The example of evidence-based practice we utilize in my work setting is wearing masks while the community spread is high for COVID-19.  A systematic review conducted by the World Health Organization (WHO), concluded that citizens that wore masks on every outing had a 70% reduction in the likelihood of becoming ill with COVID-19 (Howard et al, 2021).
1B&C. There are many different strategies to evaluate research that is conducted.  There are two specific types of research that can be conducted to study practice.  This is qualitative and quantitative research.  Quantitative research evaluates a specific piece of practice by utilizing results numerically with a major control over the experiment and research.  For example, in quantitative results, the researcher may compare two different control groups to determine which is a greater outcome.  Qualitative research evaluates a specific issue/phenomenon where the researcher gathers true information in the field by looking at the situation holistically from the patient view (Melnyk & Fineout-Overholt, 2019).  For example, a researcher may study reactions or statements of certain groups to compare the results of the two.
2A. The problem that I am considering utilizing for my DNP project is increasing the rates of colorectal cancer screenings for patients aged 50-75 years old at the primary care level. The number of colorectal cancer diagnoses and the number of screenings among this age group is nowhere near the number it should be, especially in the hometown in which I work.  There is a low incidence rate of asking and encouraging this age group to follow through with this screening as many see this is “embarrassing” or “unnecessary” if the patient does not have problems related to this.
2B. According to Wheeler et al (2020), the most cost-effective way for patients to have access to the colorectal cancer screening tools was to send the testing through the mail. This would encourage the patients to do this in their own home without having the unnecessary embarrassment.  However, it was also discovered that for most patients, it was important that primary care providers reiterate the importance of the testing and follow-up on the progress.  This could easily be provided upon initial assessment and intake in a primary care clinic.
2C&D. The research design for this particular article was a well designed random controlled trial  (RCT) where the authors reviewed the most cost-effective way for patients to obtain colorectal cancer screenings through Medicare.  This level of research would be at a level III as the patients were not randomized (Melnyk & Overholt, 2019).  The patients presented in the article were all Medicare recipients.  This type of RCT was not randomized and considered quasi-experimental.
2E. Some questions that arose after reading this quantitative RCT study is the basic study design valid for a randomized controlled trial? Yes, the Medicare recipients can be utilized as a RCT.
What are the results?  The results are that the patients were more likely to utilize the cancer screening protocols when shipped directly to their home.  Most of these patients were not asked about the screening process during their primary care visits (Wheeler, 2020). Will the results help locally?  The results will absolutely assist in ensuring that this age group of Medicare patients is receiving the most preventive care possible.  As of right now in Kentucky, only about 50% of patients are being screened adequately for colorectal cancer (CDC, 2021).
2F. From this chosen article, I can utilize the research conducted on this age group specifically to determine what is needed to motivate these patients to successfully be screened for colorectal cancer. As a result, I plan to utilize this to incorporate a checkbox for each patient that is screened during intake.  When the patients’ vital signs are being obtained along with other frequent questions being asked, this question will be included.  The patient will be encouraged to participate in the screening and have the screening process be sent directly to the patients’ home as an incentive.  The primary care clinic will follow-up on the screening one week after the patient received the testing.
References
Centers for Disease Control and Prevention (CDC). (2021). Colon cancer in Kentucky. Retrieved from https://www.cdc.gov/dhdsp/maps/gisx/mapgallery/ky_coloncancer.html
Howard, J., Huang, A., Tufekci, Z., Zdimal, V., Delft, A., Price, A., Fridman, L., Tang, L., Tang, V., Watson, G., Bax, C., Shaikh, R., Questier, F., Hernandez, D., Chu, L., Ramirez, C., & Rimoin,A. (2021). An evidence review of face masks against Covid-19. Proceedings of the National Academy of Sciences, 118(4). https://doi.org/10.1073/pnas.2014564118
Melnyk, B.M. & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare. A guide to best practice. (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
Wheeler, S., O’Leary, M., Rhode, J., Yang, J., Drechsel, R., Plescia, M., Reuland, D.,& Brenner, A. (2020). Comparative cost-effectiveness of mailed fecal immunochemical testing (FIT)–based interventions for increasing colorectal cancer screening in the Medicaid population. American Cancer Society, 126(18), 4071-4258. https://doi.org/10.1002/cncr.32992

Raphaelle Molas
1A.)  Share an example of evidence-based practice from your work setting.
The use of evidence to support clinical practice is a critical undertaking to ensure that clinicians are providing patients with high quality care. It is important for clinicians to use best-practice decisions that is scientifically based and that has been replicated in repeated research and application (Zaccagnini & White (2014). The clinician’s ability to critically appraise research for use in practice is crucial in ensuring that the patients receive optimal care and improve healthcare outcomes. An example of evidence-based practice (EBP) from my work setting would be utilizing sodium-glucose contransporter-2 inhibitors (SGLT 2 inhibitors) for patients with Diabetes Mellitus II with chronic kidney disease (CKD) and eGFR greater or equal to 30mL/min who are already being treated with antihyperglycemic medications. Kidney Disease Improving Global Outcomes (KDIGO), a global organization that develops and implements evidence-based practice guidelines in kidney disease, has put out a 2020 Clinical Practice Guidelines for diabetes management in chronic kidney disease.  Initiation of SLGT 2 inhibitor therapy among diabetic, CKD patients have proven effective not only in lowering serum glucose levels, but certain choices of SLGT 2 inhibitors, also have documented kidney and cardiovascular benefits. It is widely known that patients with DM II and CKD are at increased risk of both cardiovascular events and progression of kidney failure. According to KDIGO, there is substantial evidence that support that SLGT-2 inhibitors provide both renoprotective and cardioprotective benefits in these patients. Three large random control trials (RCTs) (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose [EMPA-REG] trial, CANagliflozin cardiovascular Assessment Study [CANVAS], and Dapagliflozin Effect on CardiovascuLAR Events [DECLARE-TIMI 58] trial), had reported efficacy for primary cardiovascular outcomes and secondary kidney outcomes. Multiple meta-analysis trials were conducted that yielded efficacy in management of CKD, providing both primary and secondary kidney benefits in diabetic patients with GFR greater or equal to 30mL/min. Currently, the safety and efficacy of SGLT2 inhibitors among patients with GFR less than 30mL/min are less established and currently being studied. Based on the above clinical guidelines, use of empagliflozin in DM II and CKD patients with GFR >30mL/min is now widely used  at the Cincinnati VA by our clinical pharmacists, nephrologists and even cardiologists in the management of DM, CKD and heart failure for select patients.

1B&C.) Describe how qualitative and quantitative research results can be used to solve practice problems. This is known as translational research.
Nursing research is the systematic inquiry using disciplined methods to develop and expand knowledge about issues that impact the practice of nursing (Polit & Beck, 2017). In quantitative research, deductive reasoning using a systemic set of procedures is used to generate predictions. Evidence is rooted in objectivity, and gathered through the senses. Data is usually concrete and analyzed statistically. Quantitative research answers questions regarding prevalence of a phenomenon, the factors related to that phenomenon, underlying causes, or predicting an outcome of a phenomenon under certain conditions, or if the phenomenon can be prevented or controlled. An example of a quantitative research would be evaluating the efficacy of using SGLT-2 inhibitors for diabetic patients with CKD. The limitation of quantitative research is that it does not capture a wide breadth of the human experience (Polit & Beck, 2017). According to Zaccagnini & White, quantitative research builds on prior results or evidence, and provides a basis for future research and discovery (2014).
Qualitative research on the other hand, emphasizes the complexity and the understanding of the human experience in relation to a phenomenon. Information is obtained through an inductive process, and the researcher integrates the information to develop a theory that helps shed light on the phenomenon being studied (Polit & Beck, 2017). According to Zaccagnini & White, qualitative research “allows the nurse to consider the context of a situation while connecting with patients and noting individual differences” (2014). Limitations include the reliability of the tools used to collect data (often subjective and fallible), and are often limited to a small group of participants, thus reducing generalizability (Polit & Beck, 2017).
Quantitative research generates factual, scientific based data that are usually generalizable to larger populations. Qualitative research on the other hand, produces a rich, and detailed process emphasizing the complexity of the human experience. It can help clinicians better understand clinical phenomena with emphasis on patient experience (Melnyk & Fineout-Overholt, 2019). Both research designs provide the clinicians with evidence that can be used to improve healthcare outcomes especially when they are both integrated into practice. The factual results of quantitative studies integrated with the holistic aspects of qualitative studies (mixed method research) enables the clinicians to translate the evidence generated from both, and use in clinical practice.

Refer back to last module’s discussion board item #4 in which you identified one or two potential problems that you are considering for your DNP Project.  As we move into the building blocks for evidence, try to think about what you want to improve through your DNP project.
State the problem that you are considering for your DNP project.
After further careful deliberation and discussions with my project mentor and colleagues, I decided to change my proposed problem for my DNP project. The problem I now choose is: Cancer screening among post-renal transplant patients at the Cincinnati VA Medical Center.
Find a peer-reviewed quantitative research article that addresses this problem. C & D. State the type of research design and the associated level of evidence in the article.
In 2008, Wong, Chapman & Craig, published an article for the American Society of Nephrology, reviewing cancer screening guidelines among post-renal transplant and general population using standard criteria. They noted consistent evidence that shows renal transplant patients are approximately three times more likely to develop cancers than the general population, and the extremely poor prognosis in advance stage cancer among transplant recipients. They appraised screening guidelines among the general population vs post renal transplant patients, reviewing RCT evidence that earlier intervention is effective, evaluating accuracies of the screening tools, cost effectiveness and harms vs benefits of the screening. They focused primarily on solid organ post-transplant malignancies such as breast, cervical, colorectal, skin, renal, lung, hepatocellular, and prostate cancer. They conducted an extensive literature search from reputable databases such as Medline, Embase, and the Cochrane Library for articles published between 1950 and 2006, including bibliographies of the retrieved articles to recover additional articles relevant to the topic. They determined inclusion criteria: clinical practice guidelines of cancer screening in the general and renal transplant population that were restricted to English-language articles, and those that applied to the average-risk adult participants. Cancer screening guidelines in other solid organ transplant, other than kidneys were excluded from the analysis. Based on the comprehensive review of multiple studies, this quantitative research utilized the pinnacle of evidence hierarchy: systematic review, incorporating multiple randomized control trials/studies and articles relevant to the topic.

E. What critical appraisal questions did you use to critique this article from Melnyk Chapter 5? Please list both the question and the answer to each question. (Use the questions that match the research design in the article).
Rapid Critical Appraisal Questions for Systematic Reviews: (Melnyck & Fineout-Overholt, 2019)
Are the results of the review valid?
Are the studies contained in the review? Yes, for each solid organ cancer screening article review, the authors referred to their studies in the bibliography section of the study reviewed.
Does the review include a detailed description of the search strategy to find relevant studies? The authors noted inclusion criteria for their search such as clinical practice guidelines for cancer screening among post renal transplant patients and the general population, restricted to English-language articles and those that applied to the average risk population. They also noted that their search did not include cancer screening guidelines in other solid-organ transplant populations such as lung, liver and heart. They also stated that their extensive literature search spanned from articles published between 1950-2006 using terms such as “kidney transplantation”, “neoplasms”, and “mass screening” and publication types “clinical guidelines.”
Does the review describe how validity of the individual studies was assessed? For instance, under the cervical cancer screening review, the authors noted that they reviewed observational studies based on historical data across the U.S. and Europe that demonstrated significant reduction in the incidence and mortality of invasive cancer since the introduction of the PAP test. Another instance, is upon review of the use of guaiac FOBT in detecting early colorectal cancers and precancerous polyps using four large RCTs. They noted the test sensitivity variability ranging from 46% (unrehydrated) and 92% (rehydrated) and specificity between 97% (unrehydrated) and 90% (rehydration) of the screening tool.
Were the results consistent across the studies? Based on their search, there was inconsistent findings in their literature review. For instance, in evaluating the test accuracies of the prostate specific antigen (PSA) and digital rectal exams (DRE) for prostate cancer screening, the authors noted that most of the observational studies were flawed with verification biases wherein only those with elevated PSA’s or positive DRE findings were investigated via prostate biopsies. Also, findings from meta-analysis studies with a PSA cut off level of >4ng/mL revealed inconsistencies: ranging from 72.1, 93.2 to 25%.
Were the individual patient data or aggregate data used in the analysis? Aggregate data from multiple studies and sources were used in this study.
What were the results? Cancer is at least a three-fold risk among post-renal transplant patients due to chronic immunosuppression, and comorbidities. Screenings of all cancers mentioned in this study among the transplant population has not been thoroughly assessed, and that clinicians should carefully assess the applicability of cancer screening routinely used among the general population towards their post-transplant counterparts.
How large is the intervention or treatment effect? The authors reviewed multiple RCT’s and meta-analysis studies among post renal transplant patients and the general population to conduct their study, thereby proving a vast population of patients effected. For instance, RCT of screening that earlier intervention works among 306,370 participants who perform biennial mammography for all women older than 50, reducing cancer-specific mortality by 20-24%.
How precise is the intervention or treatment effect? The authors used sensitivity and specificity analyses for cancer screening tools mentioned in the article.
Will the results assist me in caring for my patients? The results have shed light on the importance of cancer screening among my post renal transplant patients compared to the general population.
Are my patients similar to the ones included in the review? Some of my patients are similar to the ones included in the review, however many of my other patients with multiple comorbidities do not fall within the average risk population used in this study.
Is it feasible to implement the findings in my practice setting? It is feasible to implement cancer screening among post-renal transplant patients as part of routine preventative care.
Were all clinical important outcomes considered, including risks and benefits of the treatment? In this study, the authors not only noted the clinical benefits of early cancer detection, they also discussed the risks and harms of cancer screening as well as the financial costs involved. For example, for breast cancer screening, they noted that potential harms included psychological distress, pain and discomfort with mammographic screening. Economic analyses performed determined from RCT and population studies revealed that breast cancer screening is relatively cost effective in the general population.
What is my clinical assessment of the patient and are there any contraindications or circumstances that would inhibit me from implementing the treatment? This would be an important question to keep in mind when implementing preventative screening for my post-renal transplant patients, including questions regarding their goals of care. For instance, in this study the authors note that surgical intervention and intensive chemotherapy in cancer diagnoses among post-transplant patients are limited by comorbidities such as cardiovascular disease. Additionally, due to the complex nature of the post-transplant population, determining risks versus benefit along with their pre-existing comorbidities and patient’s preference should be kept in mind.
What are my patient’s and his or her family’s preferences and values about the treatment under consideration? According to the authors, these guidelines for the general population should be assessed for applicability to the post-renal transplant population due to their complex medical and social needs. The clinician should use an individual approach in determining the appropriateness of cancer screening to each post-transplant patient, bearing in mind the individual’s cancer risk, existing comorbidities, overall life expectancy, and preferences for screening.
How can you use this evidence from your chosen article to solve your clinical problem?  (Relates to MO1,2,3,4)
With the evidence generated by this systematic review, recommendations to perform cancer screening among renal transplant recipients who pose a much higher risk of morbidity and mortality due to chronic immunosuppression will help guide my clinical practice in disease prevention, and promoting improved health outcomes in this vulnerable population. Early cancer detection, not only reduces morbidity and mortality among renal transplant recipients, it also substantially reduces health care costs by preventing serious, detrimental health related injuries associated with advanced malignancies.

References:
Kidney International.  2020. KDIGO 2020 Clinical Practice Guidelines for Diabetes Management in Chronic Kidney Disease. Retrieved August 29, 2022 from https://kdigo.org/wp-content/uploads/2020/10/KDIGO-2020-Diabetes-in-CKD-GL.pdf (Links to an external site.)
Melnyk, B. M. & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare. A guide to best practice. (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
Polit D & Beck, C. (2017). Nursing research generating and assessing evidence for nursing practice. (10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Wong, G., Chapman, J.R., & Craig, J.C. (2008). Cancer Screening in Renal Transplant Recipients: What is the Evidence? Clinical Journal of the American Society of Nephrology. (3)2, 87-100. https://doi.org/10.2215/CJN.03320807 (Links to an external site.)
Zaccagnini, M.E, & White, K.W. (2014). The Doctor of Nursing Practice Essentials: A new model for advanced practice nursing. (2nd ed). Burlington: Jones & Bartlett.

Jace Sama
Evidence-based practice is used widely throughout the nursing profession. As nurses, we base our care and interventions from the works of evidence-based practice. An evidence-based practice that is used at my work setting is the use of a ventilator-associated pneumonia (VAP) bundle. The VAP bundle includes interventions that are implemented once a patient is intubated. These interventions include the use of an oral suction care kit that is used every two hours, turning the patient every two hours, maintaining the patient’s head-of-bed at 30 degrees or greater, endotracheal suctioning every four hours, assessment of lung sounds every 4 hours and also ordering a chest xray if pneumonia is suspected. Ventilated patients are also placed on weaning trials once they meet criteria. It is hopeful that the intubated patient will not develop pneumonia once the interventions are implemented.
The VAP bundle that is utilized at my workplace is supported by factual evidence. According to Kallet (2019), interventions related to the prevention of VAP may include: patient positioning, oral care and reducing the time spent on a ventilator.
Melnyk and Overholt (2019) describe that information gathered from quantitative and qualitative studies can be used to impact clinical practice. Qualitative research can be used to solve practice problems that are related to the patient experience (Melnyk & Overholt, 2019). The use of observation and descriptions can be utilized to solve practice problems. An example can include the use of “quiet time” on an inpatient unit to promote rest for the patient. The nurse leader may have reviewed an article that performed qualitative research based on patient experiences with quiet hours. This review can aid in solving the practice problem. Through the use of quantitative research results, the nurse leader may have read a review on how many patients gained restful sleep through the use of quiet hours. By reviewing results of patient experience or quantitative results of how many patients benefited from quiet hours, the nurse leader can make a decision to implement the practice or not, to solve their problem.
The problem that I am considering for the DNP project is nurse burnout in the inpatient setting. The article, “Burnout among Nurses Working in Ethiopia” (2020) used a systematic review to conduct research. The level of evidence associated with the article is level one.
1. Are the results of the review valid?
a. Are the studies contained in the review RCTs?
Review randomized controlled trials were not discussed in the article.
b. Does the review include a detailed description of the search strategy to find all relevant studies?
The review does include a detailed description of the search strategy. Researchers included the search engines used and key terms (Hailay et al., 2020)
c. Does the review describe how validity of the individual studies was assessed?
The article informed that two reviewers utilized a tool to evaluate the likelihood of bias in the studies (Hailay et al., 2020). The Newcastle-Ottawa scale was used to evaluate the methodological quality of the studies (Hailay et al., 2020).
d. Were the results consistent across studies?
Seven studies were validated and included in the review. Six of the studies were highly qualified as one study was only moderately qualified based on the Ottawa scale (Hailay et al., 2020)
e. Were individual patient data or aggregate data used in the analysis?
Data was collected from each individual study. A random-effects meta-analysis was then used to estimate an overall prevalence of burnout (Hailay et al., 2020).
2. What were the results?
a. How large is the intervention or treatment effect?
From the review, it was calculated that 39% of nurses in Ethiopia experience burnout (Hailay et al., 2020). This is significantly higher than the global percentage of 11% of nurses that experience burnout (Hailay et al., 2020).
b. How precise is the intervention or treatment effect (CI)?
The CI was 27% to 50% (Hailay et al., 2020).
3. Will the results assist me in caring for my patients?
a.  Are my patients similar to the ones included in the review?
Patient characteristics were not discussed in the review.
b. Is it feasible to implement the findings in my practice setting?
The review did not discuss the implementation of an intervention to relieve burnout. It did discuss the prevalence of burnout in the clinical setting in Ethiopia.
c. Were all clinically important outcomes considered, including risks and benefits of the treatment?
These were not considered as they were not discussed in the review.
d. What is my clinical assessment of the patient and are there any contraindication or circumstances that would inhibit me from implementing the treatment?
A clinical assessment is unable to be generated as the review did not include patient data.
e. What are my patient’s and his or her family’s preferences and values about the treatment under consideration?
The patient’s preferences and values were not discussed in the review.
When reviewing the article and the critical appraisal questions answered above, it is evident that the review did not include an intervention to my clinical problem. The article did address the issue, its relevance and that this is a significant issue in the clinical setting. This article can be used to support the significance of the issue. The article does inform that the country has a higher rate of nurse burnout globally (Hailay et al., 2020). Further research can be conducted to identify if a solution or intervention was developed to decrease the percentage. That solution, if viable, can be considered when developing the DNP project.
References
Hailay, A., Aberhe, W., Mebrahtom, G., Zereabruk, K., Gebreayezgi, G., & Haile, T. (2020). Burnout among nurses working in Ethiopia. Behavioral Neurology, 2020. https://doi.org/10.1155/2020/8814557
Kallet, R. (2019). Ventilator bundles in transition: From prevention of ventilator-associated pneumonia to prevention of ventilator-associated events. Respiratory Care, 64(8). https://doi.org/10.4187/respcare.06966
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare. A guide to best practice. (4th ed.). Philadelphia: Lippincott Williams & Wilkins.