Nursing Research

Nursing Research

NUR2300:  Assignment 2 Outline 2015

Introduction
Daytime sleepiness in aged care residents is a significant problem that needs to be addressed. To overcome the adverse health effects of daytime sleeping, there are three key recommendations that I wish to explore. These include treating sleep deprivation without medication, re-designing the current medical unit to be more accommodating for promoting night time sleep and adapting individual care-plans so specific schedules can be implemented for the needs of each resident. Through the analysis and collection of research literature various points of importance reflect these key findings. By engaging these recommendations and implementing each of the three key changes in practice, effective solutions will improve quality of life.

Part 1 Identifying Recommendations for Practice (approx. 1, 500)

Key findings:

Across the literature

The prevalence in sleep deprivation

Sleep is optimal cognitive function

Key findings and recommendations    CHECK 500 WORDS ONLY

Poor sleep patterns, including excessive daytime sleeping affect the patient in a negative way, as cited by (Woodward, p. 131) “Long term deprivation can have severe adverse health consequences indicating the essential nature of this stage.”  Woodward is referring to the compromise in attaining maximum rapid eye movement (REM) sleep, which is associated with dreaming and the consolidation of memory.  REM sleep is essential for overall physiological balance and wellbeing. Quality REM sleep is critical for optimal cognitive function. Added to this evidence, Keage says, “Poor sleep can lead to various cognitive impairments in elderly people,” (Keage et al., p. 886; Blackwell et al).

Geriatric sleep complaints include “insomnia, difficulty falling asleep, and difficulty maintaining sleep” (Missildine et al. p. 263; Hellstrom et al. p. 1). Issues in geriatric sleep patterns commonly stem from daytime sleepiness and napping, leading to nighttime sleep disturbances. Reyes states, “This may be directly related to poor health, increased risk of falls and mortality” (Reyes et al., p. 175). The importance of research is being increasingly recognized and is essential in addressing the problems in practice (Manian & Manian, p. 56). Keage et al., recognizes that sleep deprivation and daytime napping are all “modifiable behaviors open to intervention strategies,”.

Some intervention strategies to improve quality sleep could include increasing physical activities during the day such as walks around the facility grounds and participating in physical grous activities provided by the aged care facility .  Spending time in sunlight is beneficial and also engaging in social intellectual activites like playing cards, chess, computer games benefits the resident sby balancing day time acitivity with  exercises and prmotoing a restful sleep model.  Social intell .    acti… promote  the memory and mental activity and also maintains social contacts and communication.  Making these recommendations vital for normal sleep architecture.  Sleep architure (the cycle of REM and non REM sleep) and achieving the optimum balance benefiting the resident.

.  reflective by  the various day time activity modifications, is crucial in the balance of day time activity and stimulation with nighttime sleep architecture  improving   quality of life for the  residents

(p. 886) (maybe need to add in recommendations- other there any other reccomendations on the literature?)

have any recommendations been mentioned in more than one article?

Mannian et al., p 56 : Interventions at improving sleep quality in this patient population seem warranted.

What areas for nursing practice that could be changed or improved or strategies implemented

Medication

Another key recommendation to combat geriatric sleep deprivation explores  treatment without medication (Woodward, pp. 137-9). Currently a method of combating sleep deprivation is to give patients sedatives. Woodward is critical of this approach. “It is relatively easy to immediately prescribe a hypno sedative such as benzodiazepine (BZD) yet the published literature is often critical of such an approach.”… Medication does not necessarily combat the problems of sleep deprivation and therefore an accurate diagnosis is needed to determine what strategies should be used in it’s place. As a result, alternate methods should be incorporated into nursing practice to address the use of sedatives. Woodward lists various alternatives to sedatives including psychological approaches, educational methods, light therapy and utilizing non – pharmacological approaches.  Psychological treatment approaches have proved effective for the management of daytime sleepiness. These include approaches such as relaxation therapy and cognitive behavioral therapies (CBT) which can be administered by trained health professionals. Woodward states that the benefits of these methods have been established through two meta-analyses and systematic review, and therefore, would be worthwhile implementing in practice. (p. 138). This alongside other methods including education of sleeping patterns, light therapy and non- pharmacological approaches are strategies that could be used in place of  sedatives. Hellstrom also identifies the benefits of using a non-pharmacological first stage response, finding that social intellectual activities were beneficial for sleep (Hellstrom et al, p. 10).
(There is a range of sleep assessment tools. A two week sleep diary designed by the American Academy of Sleep Medicine can be useful. The individual records use of stimulants such as coffee, taking medications, alcohol use and exercise. They record the time they go to bed and when they believe they fell asleep, and record whether they were asleep or awake throughout the 24-hour day. It is important to emphasize that they do not fill it in throughout the night. This diary, most importantly, can combat the mistaken perception that they are having very little sleep for instance it may reveal that they are having 14 hours in bed overnight and while awake for 7 hours they are still having 7 hours sleep. It can also reveal excessive use of stimulants late in the day and insufficient exercise, amongst other useful information.) (Woodward p. 136)
These new improvements to aged care facilities will help overcome daytime sleepiness in the first stage response by making this first hand approach individualized to the patients needs and focusing on alternative methods. Woodward states “treatment without medication should almost always be the first approach.” (p. 145). Health care in nursing practice can thus be improved by considering alternative to sedatives. Instead assess and individualize health care needs and then you can identify key problems in relation to an individuals sleeping patterns.  By documenting these new improved suggestions which are non-pharmecautial and recording the results in the care plan, sedatives use may be reduced and other options considered.
Woodward states that sedatives have been associated with a greater risk of hip fractures and falls in older adults, and therefore by using alternate approaches the rate of falls in the aged care facility can be reduced. (Woodward, p. 145) and therefore by introducing these alternatives along with an individualized approach this issue may e reduced.
Ideally an aged care facility needs to reevaluate their system and put a process in place that will enable an individual-focused approach. One method of achieving this is to implement an interview process for when the patient first arrives to assess what is best suited for their immediate and ongoing care.

However, there may be challenges to implementing alternative practices, especially when sedatives are an easier alternative. The challenges to the implementation in the first stage response are how to ensure that treatment is sufficiently catered to the individual. It may be a difficult task to oversee that the nurse has sufficiently assessed the patient and isn’t over reliant on giving sedatives as an approach, but rather that they should be used a last resort. Woodward states that pharmacological management still has a place in the management of sleep disorders. (Woodward, p. 139) Therefore, despite it being a last resort it should not be disregarded altogether.

With the new changes to the aged care facility ethical considerations also have to be adapted and changed. Ethics, in nursing homes especially, are essential in ensuring that health professionals provide sufficient care to the patient. Therefore, any change in the procedures has to take into account ethical considerations and ensure they will be adhered to. One major ethical consideration in relation to these changes is the patient has a right to choose their treatment. By expanding first response methods the patient will be able to choose between a variety of methods that the nurse can recommend which is best suited for their care. As a result of increasing the choices the nurse should be aware of the patients right to either adhere to the new methods or to choose another alternative method that they may not necessarily be the best option.

•    Sources for ethics?
•     ‘Self Perceived Resources for Good Sleep’ has a lot in it about the patient being able to choose for themselves and technically they should not have their rights taken away

How recommendation could change the way nurses deliver care

Strength of the evidence that supports to recommendation

What outcomes of interests could be evaluated?

How to embed research into practice

p. 58

Re-designing of medical units     500 WORDS ONLY
Age old thing we do certain things at 6 or 7- changing – Missildine et al.

The next recommendation addresses the environmental physical surroundings impacting sleep cycles.  Many aged care facilities are  not designed to cater for low soft lighting and reduced noise from nursing staff activities.  The setting is often rather hospital like in design.  Looking at alternatives and redesigning units  to  promote quality sleep and a full sleep cycle of 90 minutes would allow patients to experience less fragmented sleep. Suggesting that staff should be encouraged to “reduce light and sound levels at night” (Missildine et al., p. 270) would be beneficial for the resident.  It is argued that staff interruption making staff activities of central importance.

Pain and anxiety are the most commonly cited reasons for unsound sleep (Manian & Manian p. 59).  By increasing staff numbers to care for these issues would promote better sleep management and a better outcome for the resident.

They don’t really recognise sleep patterns for patients they don’t get sleep because they have to take care of them they cannot just sleep residents rarely asked about at encounters with health professionals (Woodward p. 2) it was noted that few
It has been recommended that staff and GP’s take into account the impact of psychological barriers to sleep. These include Type 1 (non-psychological barriers, e.g. pain and noise), Type 2 (worry about actual situation and future) and Type 3 (traumatic memories) barriers (Hermann & Flick, pp. 484-6).

Feelings of being along, worrying at night, less staff to care for their phyciolgoical nees.  Expand this.

What are the improvements?

How could this lead to improvements?
•    Individualized
•    Focused
•    Fostering that type of care

What is eproblem 1?

How could it be implemented into the practice setting

Any challenges or barriers?

•    They still have a place?

Any ethical considerations

How recommendation could change the way nurses deliver care

Strength of the evidence that supports to recommendation

What outcomes of interests could be evaluated

How to embed research into practice

Care plan     5OO WORDS ONLY

Care plan should be developed with the sleep quality part of the plan being a high priority. On an individual basis – puts everyone
Catered for the individuality- different meal times, sleep time- living in your home all your life want to go to bed early and then cant because you might have to eat when you want to go to bed- hard transitioning to an institution

Addressing Poor health and sociological barriers to sleep

Effectiveness of sleep management of agencies

Association between sleep deprivation and leisure activities

Cognitive leads to increased fall risk- this is a major health risk in elderly people and needs to be preventative

Preventative plan- it is no less important that we need to do activities to stay healthy- make sure it happens in those settings

Staffing issues

What are the improvements?

How could this lead to improvements?
•    Individualized
•    Focused
•    Fostering that type of care

What is eproblem 1?
•    Contributing to the increased rate of falls
•    Physical activity

How could it be implemented into the practice setting

Any challenges or barriers?

•    They still have a place?

Any ethical considerations

How recommendation could change the way nurses deliver care

Strength of the evidence that supports to recommendation

What outcomes of interests could be evaluated?

How to embed research into practice

Ethical considerations

Across the research literature it has been identified that poor sleep patterns in the population lead to a number of detrimental health issues. Stone et al. asserts that “as many as 50% of older adults report sleep problems” (p. 299). Koch et al. argue that “older adults are prone to increased night awakening and sleep fragmentation” (p. 1268), it has been found that the prevalence of sleep deprivation in the population can range between 64%-69% (Herrmann & Flick, p. 482).
Woodward maintains the first recourse to action in combating geriatric sleep deprivation should be treatment without medication (pp. 137-9). Nonetheless, the risk of hypnotic agents may be acceptable when compared with the dangers of “undertreated sleep disturbance” (p. 145). In accordance with a non-pharmacological first stage response, it was found that social intellectual activities are beneficial for sleep (Hellstrom et al, p. 10).
Stone et al. found that “actigraphic short sleep duration and lower sleep efficiency” were positively related to recurrent falls in the population (p. 303). It was concluded that there was an association between poor sleep and the risk of falls, factors leading to this may include, “impaired cognitive function, depression, balance problems, and use of medications” (p. 304). Woodward reaffirms the position that a greater risk of falls is associated with insomnia/sleep deprivation (p. 135). Cumbler et al. (p. 580) highlighted the importance of a growing literature that emphasises the increasing occurrence of falls in patients/community dwellers receiving sedative medication. Based on the analysis of the chosen articles it is possible to argue that cognitive and functional impairments, developed through sleep deprivation, will have an increasing probability in the occurrence of falls in the target population.
Missildine et al. recommended the redesign of unit activities to revolve around a full sleep cycle—90 minutes—to allow patients to experience sufficient sleep. Suggesting that staff should be encouraged to “reduce light and sound levels at night” (Missildine et al., p. 270), it is argued that staff interruptions—making staff activities of central importance—pain and anxiety are the most commonly cited reasons for unsound sleep (Manian & Manian p. 59). It has been recommended that staff and GP’s take into account the impact of psychological barriers to sleep. These include Type 1 (non-psychological barriers, e.g. pain and noise), Type 2 (worry about actual situation and future) and Type 3 (traumatic memories) barriers (Hermann & Flick, pp. 484-6).

Part 2: Strategies to Facilitate Research Utilisation (500)

Part 3: Identifying and Evaluating Outcomes(300)

Part 4: Disseminating Evidence-Based Practice Outco

Conclusion (100)

Given the prevalence of daytime sleep disturbance problems in aged care importance of good quality sleep to overall physical and psychological well-being, it is imperative that the most effective sleep assessment, diagnosis and management strategies be implemented in aged care facilities.

Sleep disorders are a major clinical issue in aged care although advances have been made in diagnosis and management, there is still a major need for effective approaches to safely treat the spectrum of sleep problems. The dangers of under- treated sleep disturbance may outweigh the risk of adverse effects of the hypnotic agent, but treatment without medication should almost always be the first approach.
Socio intellectual activities are beneficial for sleep. Physical activities, such as strolling in the country or gardening,
Excessive daytime sleepiness was related to fall risk, Future studies using comprehensive objective measures of sleep should confirm the interrelationships between sleep characteristics to determine whether they contribute independently to risk of falls. Further research into daytime sleepiness is clearly warranted

FOOTNOTE MORE INFO FOR THE WRITER
•    Assignment 2 is considering what key nursing recommendations come from the evidence, patient and nursing outcomes that would be the focus of any interventions, strategies on how to embed research into practice and finally how to evaluate potential evidence-based practice change and then how findings could be disseminated

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Research Methods for Nursing
Assessment ebook

11 Assignment 2 Rationale
Rationale:
The purpose of this assignment is for you to demonstrate your knowledge and skills in
relation to:
1) analytical skills in the critical appraisal of the research evidence and applicability of
research evidence in the provision of nursing care
2) written communication skills, inciuding analysis and synthesis of information, and
appropriate use of language and literacy
3) an ability to synthesise research evidence and consider applications within clinical
practice using an EBP process
Assignment Links to Evidence-Based Practice Steps:
This course has been structured around the 7 steps of evidence-based practice. This
assignment is focused on the following key stages:
1. Critically Appraising the Evidence
2. Integrating Evidence into Practice
3. Evaluating the Outcomes of Practice Decisions based on Evidence
http://usqstudydesk.usq.edu.au/m2/mod/book/view.php?id=305744&chapterid=16684 28/ 04/201 5