Sarah Elser Evidenced Based Practice Proposal How did the planning process, where you thought about

what you wanted to change, prepare you for the EBPP? Where I work, physicians and nurses have their own opinion on certain practices, but no one really knows the reasoning/evidence that makes the best practice. Some physicians write an order for every one of their patients to have an IS at bedside, others leave it as a nursing intervention. Researching the evidence of using an IS postoperatively would eliminate any discussion as to whether or not it was best practice to reduce pulmonary complications. How did the peer evaluation process prepare you for the EBPP? The peer evaluation process prepared me for the EBPP in several ways. My peer evaluator helped me to see the flaws in my reasoning by raising questions that seemed obvious to me, but I had not expressed clearly. It also helped to clarify the actual questions that I was trying to answer. By evaluating others EOR, I was able to better understand the process and what aspects of the research/reasoning should be explored in each section. Do you feel you are prepared to elicit change in your practice with your proposal? How does it fit into quality health care? I do not know that I could elicit a complete change in my practice based on the research that I found. There were too many conflicting conclusions and research results; some of the articles that I found completely supported the use of an IS whereas some of the articles stated that there was no supporting evidence that using an IS actually decreased postoperative complications. What I did find, however, was that using an incentive spirometer did not cause harm or increase the risk of postoperative complications and could be considered one of several interventions that, when implemented together, would reduce the risk of complications. Considering this is the practice currently used in my workplace, it is reassuring that we are indeed using best practice procedures for our surgical patients. Promoting IS use in patients with an increased risk for postoperative complications, along with other interventions, will promote the best outcomes for the patient which is key in providing quality health care. What could you have done better? Had I known that there would be such conflicting conclusions on the use of the incentive spirometer, I would have included other interventions in my research to determine the best possible techniques to reduce the risk of postoperative complications. I also could have narrowed down my research to a specific type of surgery (abdominal or cardiac, for example) as many of the studies and research seemed to differentiate between specific surgical procedures. How well do you think you are using the EOR? Do they make sense to you (why or why not)? I think I am using the EOR fairly well, but there is definitely room for a great amount of improvement as I use the concepts more for evidence-based practice research. When I first started, it was very slow going and I struggled with what concepts and thoughts went where. It

was helpful to evaluate my peers EOR to think through the process using their ideas and research/information. It was almost like using the EOR backward, but helped to clarify the process for me. The information and concepts/ideas sections still tend to run together; I have to really think it through to separate which thoughts belong in which section. The same goes for the purpose and question sections; I am questioning something, which is my motivation for researching the subject and I am just rewording the questions into a statement to form the purpose. Once I thought through both mine and my peers, it is clearer and I believe it will only become more so with practical use.

Article annotation 1 Davis, S.P. (2012). Incentive spirometry after abdominal surgery. Nursing Times, 108:26, 22-23. Suja P. Davis, MSN, BS, BA, RN is a clinical assistant professor at the University of North Carolina. This article outlines the various pulmonary complications that can occur after abdominal surgeries, such as atelectasis, pneumonia, and decreased respiratory function and explains the benefits of using an incentive spirometer to reduce the risk of these complications. The author explains not only risk factors for developing pulmonary complications postoperatively but also the pathophysiology is described thoroughly. The information is simply explained, but basic nursing knowledge of the disease processes is useful to wholly comprehend the material. It is clear that the article is intended for nursing staff because there are also guidelines on instructing a patient to use an incentive spirometer along with the advantages and disadvantages of using one. Pulmonary complications are described only as related to abdominal surgeries, so it leaves one questioning the authors stance on using incentive spirometers for any other type of surgery. Article annotation 2 Qaseem, A., Snow, V., Fitterman, N., Hornbake, E., Lawrence, V., Smetana, G., & ... Owens, D. (2006). Clinical guidelines. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Annals Of Internal Medicine, 144(8), 575. Retreived from: http://0-web.ebscohost.com.libcat.ferris.edu/ehost/detail?sid=3e90b166441b-4980-99a4-cf4245bc2488%40sessionmgr111&vid=15&hid=123 This source is a peer-reviewed journal article written by physicians that are associated with the American College of Physicians. The information is presented with the assumption that the readers have a good knowledge base in medical terminology and methodology. The article very broadly describes the risk factors that patients may have which would increase their risk for postoperative pulmonary complications including patient-related risk factors (age, weight, medical history, etc.) along with procedure-related risk factors such as length of surgery, surgical site, and type of anesthesia used. The article then describes methods to reduce the risk of postoperative pulmonary complications, of which incentive spirometry is included; the amount of data in the article on incentive spirometry is limited, but it does state that there is good evidence to support its use. Overall from this article, one would conclude that using an incentive spirometer perioperative is a user-friendly and important intervention for preventing postoperative pulmonary complications. Article annotation 3 Lamar, J. (2012, January-February). Relationship of respiratory care bundle with incentive spirometry to reduced pulmonary complications in a medical general practice unit. MedSurg Nursing, 21(1), 33+. Retrieved from http://0go.galegroup.com.libcat.ferris.edu/ps/i.do?id=GALE%7CA280558224&v=2.1&u=lom_f errissu&it=r&p=AAON&sw=w

In this article, the author compares and contrasts several studies that were done previously involving the use of incentive spirometry perioperative. Lamar states that the results of her research are conflicting; several studies she examined provided convincing evidence that incentive spirometers decreased the risk of pulmonary complications in major abdominal and CABG surgeries. Other studies Lamar used found that there was no conclusive evidence in support of IS use postoperatively. The conclusion of the authors study stated that consistent hourly rounding by nursing staff including encouragement/reminders of IS use among other interventions significantly reduced postoperative complications. This study was done by nursing staff members of a general med/surg floor with the intended audience being nurses; the author of the article (Joanne Lamar, MSN, MSBA, RN) is the nurse manager of the med/surg unit of which the study was conducted, which may indicate a potential biased view of the results. Article annotation 4 Body, D. (2012). Physiotherapy for patients following coronary artery bypass graft (CABG) surgery: Limited uptake of evidence into practice. New Zealand Journal of Physiotherapy, 40(1), 35+. Retrieved from http://0go.galegroup.com.libcat.ferris.edu/ps/i.do?id=GALE%7CA303549559&v=2.1&u=lom_f errissu&it=r&p=AONE&sw=w In the study done which this article summarizes, a survey was conducted of the practices of physiotherapists in New Zealand in regards to practices with patients who recently underwent CABG procedures. While the information collected is interesting, it is not the most applicable source to my research, as it does not consider nursing intervention as a means to reducing the postoperative complications, only those of the physiotherapists. One problem that was stated in the article was that the physiotherapists were not able to adequately promote/encourage IS use as often as necessary to be effective, which nurses would most likely have a better chance of doing during their hourly rounds and with other interaction. The article concludes that early ambulation/mobilization actually helps prevent complications more than using an IS. The authors specific credentials could not be determined. Overall, this was not the most useful article I used in my research, but still presented interesting information in regards to my purpose/questions.

Table 1 1. Purpose (all reasoning has a purpose)

1-3 sentences describing your thoughts on the issue related to that element There is much debate at my workplace whether or not encouraging incentive spirometry use decreases post-op pulmonary complications. My purpose is to research the evidence available to determine if using an incentive spirometer postoperatively decreases the risk of pulmonary complications. Is using an incentive spirometer an important part of decreasing post-op complications? Is the coughing and deep breathing technique just as effective? Is its effectiveness dependent on the type of surgery the patient had?

2.

Questions at issue or central problem (all reasoning is an attempt to figure something out, to settle some question, solve some problem) 3. Point of view (all reasoning is done from some point of view; think about the stakeholders)

It can be very time consuming to constantly remind some patients to use their IS along with reviewing the proper steps with them, especially if it isnt effective. However, if it is effective in decreasing a patients risk of post -op pulmonary complications, then it is very much worth the time and effort of having the patient perform the exercise. The hospitals cost of providing surgical patients with an IS would be much less than an extended stay due to complications.

4.

Information (all information is based on data, information, evidence, experience, research) Concepts and ideas (all reasoning is expressed through, and shaped by, concepts and ideas)

5.

6.

Assumptions (all reasoning is based on assumptions-beliefs we take for granted)

I have found several sources discussing the effectiveness of using an incentive spirometer; however there is conflict within the sources whether or not it helps to prevent post-op complications. Some sources claim that it is effective depending on the type of surgery. I need to study the sources information more closely to determine their methods of data collection. As nurses, it is our responsibility to ensure that our patients have the best possible outcomes; therefore we should be consistently encouraging any behavior that could possibly decrease post-op complications for the patient. Using an incentive spirometer may help to decrease post-op complications, which can increase a patients length of stay, costs (both to the patient and hospital), and patient outcomes. I am assuming that physicians have a preference and want their patients to be using an IS. Not all physicians order this for their patients and sometimes it is implemented as a nursing intervention. I assume that patients are willing and physically/mentally able to use an IS when encouraged by nursing staff. Some patients may lack the cognitive and/or physical ability to use the device. I am assuming the hospital is willing to supply enough incentive spirometers to give to every surgical patient. I do not know the individual costs of the devices, but obviously using the coughing and deep breathing technique would be less expensive.

7.

Implications and consequences (all reasoning leads somewhere. It has implications and when acted upon, has consequences)

If using an incentive spirometer really is not effective in preventing post-op complications, or if the patient does not use the IS appropriately, nurses are wasting their time encouraging and reminding patients to routinely perform the exercise. Giving every surgical patient an incentive spirometer may become very costly to the hospital but if it is known to decrease complications, it would be less expensive in the long run. I can conclude from the information Ive gathered that using an incentive spirometer postoperatively may or may not always decrease the risk of pulmonary complication given the specific patient and surgical factors; however, encouraging IS use after surgery, along with other interventions, is an important part of recovery and should be included in my practice.

8.

Inference and interpretation (all reasoning contains inferences from which we draw conclusions and give meaning to data and situations)