NSG/302 Week 5: Evidence-Based Practice as a QSEN Competency, sample paper

Out of Bed on the Evening of Surgery: Evidence-Based Practice as a QSEN Competency, Traced Through an Early Mobility Change After Cardiac Surgery

[Student Name]

University of Phoenix

NSG/302: Professional Contemporary Nursing Role and Practice

Week 5 Assignment

[Instructor Name]

[Date]

The unit, its data and its staff are a composite written for a model paper.

Many nurses think of evidence-based practice as a skill that belongs to researchers and educators. QSEN places it among six competencies every nurse needs, and defines it as integrating the best current evidence with clinical expertise and patient and family preferences and values to deliver optimal care (Cronenwett et al., 2007). This paper explains what that competency requires and then follows one change on a cardiovascular intensive care unit, from a routine that had never been questioned to a new practice supported by evidence.

The Competency as QSEN Defines It

QSEN divides each competency into knowledge, skills and attitudes. For evidence-based practice, the knowledge includes understanding how research is designed, how the strength of evidence differs from one study design to another and where to find reliable sources. The skills include reading original research and evidence reports, basing a patient's plan of care on evidence along with the patient's values and clinical expertise, and taking part in collecting data for practice changes. The attitudes include valuing the concept of evidence-based practice, appreciating the strengths and weaknesses of scientific bases for practice, and questioning the reasons for routine approaches to care that produce poor results (Cronenwett et al., 2007). The attitude of questioning routine practice is where most evidence-based change begins, because a practice that has never been questioned cannot be improved.

The Routine: Bed Rest Until Morning

Until last year, patients on our unit stayed in bed from the time they arrived from surgery until the first postoperative morning, when physical therapy would sit them at the edge of the bed. The routine was not written anywhere as a policy. It came from a time when patients arrived later in the day, were extubated later and had more lines and tubes. Today most of our patients are extubated within six hours of arrival and have stable hemodynamics by evening, yet they still spent twelve to sixteen hours lying flat.

A night shift nurse questioned the routine after reading about enhanced recovery programs, which is the attitude QSEN describes. She noticed that the patients who were moved to a chair the next morning were often weak, dizzy and reluctant, and she asked whether moving them sooner would help.

The Evidence

The unit's practice council turned her question into a searchable one and asked the unit's clinical nurse specialist to help with the search. Two sources carried most of the weight. The first was the Enhanced Recovery After Surgery Society's consensus recommendations for cardiac surgery, which reviewed meta-analyses, randomized trials and large observational studies for each element of perioperative care and graded the quality of the evidence behind every recommendation (Engelman et al., 2019). It gave the council a framework: recovery is a pathway of many small decisions made before, during and after the operation, and each decision should rest on graded evidence rather than habit. The second was a meta-analysis that pooled six randomized trials with 391 patients after coronary artery bypass surgery and found that early mobilization, started on the first or second postoperative day, improved the distance walked in six minutes at discharge by about 54 m (Kanejima et al., 2020). The trials were small and differed from one another, which the council noted as a limit.

The council then considered the clinical expertise of the unit's nurses and physical therapists, who identified which patients were not safe to move early, such as those on high doses of vasopressors, those with an open chest or those with active bleeding. It considered patient values as well: several former patients on the unit's family council said that sitting up and seeing their families on the evening of surgery would have made them less afraid.

The Change and Its Results

The unit wrote a nurse-led protocol. Patients who met clear safety criteria, including extubation, stable blood pressure without escalating vasopressors, chest tube drainage below a set limit and a patient able to follow commands, were helped to sit at the edge of the bed and then into a chair on the evening of surgery, with a nurse and a patient care technician present. The protocol named the stopping criteria, such as a drop in blood pressure or new arrhythmia, and required documentation of each attempt.

The council measured the change for six months. It tracked the share of eligible patients mobilized on the evening of surgery, which rose from under 5% to 71%, the median time to first walk in the hallway, which moved from the second postoperative day to the first, and falls and unplanned line removals as balancing measures, which did not increase. The unit did not claim that the change shortened length of stay, because other changes happened at the same time and the data could not separate their effects.

What Made the Change Hold

A protocol on paper does not change practice by itself. Three things helped the new routine last. First, the night nurse who raised the question became the unit's mobility champion and taught the protocol at each shift huddle for a month, so the change came from a peer rather than from a memo. Second, the physical therapists trained the nurses and patient care technicians in safe transfers with chest precautions, which answered the most common worry, that moving a patient so soon after sternotomy might harm the incision. Third, the council posted the monthly results on the unit board, including the patients who could not be mobilized and why, so staff could see both progress and the limits of the protocol. When the rate dipped during a month with heavy agency staffing, the champion noticed it on the board and added the protocol to the orientation packet for temporary nurses.

Where the Competency Appeared

The knowledge part of the competency appeared when the council judged the strength of the guidance and the studies. The skills appeared when the evidence, the physical therapists' expertise and the patients' values were combined into one protocol, and when nurses collected the data. The attitude appeared first, in the night nurse's willingness to ask why the routine existed, and last, in the council's honesty about what its data could and could not show.

My Next Step

In Week 1, I rated myself weakest in evidence-based practice. This example shows me that the competency is not reserved for researchers. It begins with a question at the bedside, the kind I have asked privately many times without taking it further. My next step is to bring one such question, the timing of glucose checks after surgery, to our practice council with a search already done in CINAHL and MEDLINE.

References

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D. T., & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131. https://doi.org/10.1016/j.outlook.2007.02.006

Engelman, D. T., Ben Ali, W., Williams, J. B., Perrault, L. P., Reddy, V. S., Arora, R. C., Roselli, E. E., Khoynezhad, A., Gerdisch, M., Levy, J. H., Lobdell, K., Fletcher, N., Kirsch, M., Nelson, G., Engelman, R. M., Gregory, A. J., & Boyle, E. M. (2019). Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations. JAMA Surgery, 154(8), 755-766. https://doi.org/10.1001/jamasurg.2019.1153

Kanejima, Y., Shimogai, T., Kitamura, M., Ishihara, K., & Izawa, K. P. (2020). Effect of early mobilization on physical function in patients after cardiac surgery: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(19), Article 7091. https://doi.org/10.3390/ijerph17197091