When using the free-cash flow model, cash flows are discounted at the weighted average cost of capital (WACC) and when using the dividend discount model, dividends are discounted at….
Respond using one or more of the following approaches:
Ask a probing question, substantiated with additional background information, and evidence.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Validate an idea with your own experience and additional sources.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional strategies for addressing barriers to EBP based on readings and evidence.
Evidence-based practice is the standard that guides clinical practices within the nursing profession. Adams (2010) asserts that evidence-based practice “is defined as the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making” (Adams, 2010, p. 274). Polit and Beck (2017) maintain that there is no consensus about what does or does not constitute evidence. There are, however, agreed upon sources of evidence which exist within a hierarchy. Systematic reviews are at the pinnacle because information is derived from multiple sources. Randomized controlled trials are next, followed by cohort studies, single case-control studies, cross-sectional studies, qualitative studies, and finally expert opinion reports. Knowledge translation is the process of using evidence to evoke systemic change within the clinical practice (Polit & Beck, 2017).
While working on a busy surgical floor, I was caring for a confused, combative, elderly patient with a urinary tract infection who had fallen and broken her hip. During report, the night shift nurse told me that she gave the patient multiple doses of haloperidol and lorazepam which were ineffective. The patient continued to be confused and agitated, and because she was a danger to herself by continually trying to get out of bed, the night shift nurse obtained an order for soft restraints. Springer (2015) contends that the nurse should determine if the utilization of restraints is appropriate based on the patient’s current behavior, and should only be used when all other options such as distraction and de-escalation are exhausted (Springer, 2015). Because I was not there, I must assume that the nurse used evidence-based practice to decide that the restraints were necessary.
When I went in to assess the patient, she was sleeping; and in my professional opinion, the restraints were no longer appropriate. I removed the soft restraints and put the patient on one to one observation with a nursing assistant. Not long into the shift, the light for that room came on, and I heard staff in the patient’s room yelling. I walked in to find the patient screaming and striking the nursing assistant as he was attempting to change the patient. It was clear that the patient was still experiencing acute delirium. However, the television was on, the blinds were open, and every light in the room was on. Instead of using a chemical or physical restraint, I turned off the television, lights, and closed the blinds. I sat down beside the patient, spoke softly and attempted to reorient her. Although she was still confused, she was calm.
Bull (2015) asserts that nursing interventions to manage delirium include providing a therapeutic environment, frequent re-orientation, anticipating the patient’s needs, ensuring sensory assistance devices such as glasses or hearing aids are in use, observing the patient’s response, and proceeding accordingly. Non-invasive interventions should be exhausted prior to restraining a patient chemically or physically (Bull, 2015). In this case, the patient responded to non-invasive interventions. I continued to use the one to one observation to ensure safety throughout the shift but did not need to escalate to using chemical or physical restraints. By implementing evidence-based practice, I kept the patient safe without using restraints.
Background and PICOT Question
Background questions are broad, generalized questions that focus on a clinical issue (Polit & Beck, 2017). In this case, my background questions would be: what is delirium? And, what causes delirium? The acronym PICOT (population, intervention, comparison, outcome, and time) is a format used to create a research question with the subsequent goal of finding evidence-based solutions to implement into clinical practice (Polit & Beck, 2017). My PICOT question is: in delirious patients (population), what are the effects of non-invasive management techniques (intervention), compared to restraints (comparative intervention), on patient experience (outcome) and does either intervention increase or decrease the recovery period (time)?
I work as a float nurse in my organization, with previous experience in critical care. As a float nurse, I have a unique perspective on organizational culture because I work in multiple units. Overall, my organization does facilitate a culture of safety that promotes an environment where nurses learn from mistakes and do not place blame on one another. Written policies and procedures are easily accessible on the intranet. Moreover, my organization utilizes nursing shared governance which has a special committee devoted to practices and standards. Nurses are encouraged to bring practice issues to members of shared governance, and clinical practices are continually being updated and reviewed. If a nurse has an immediate question about a clinical practice situation, Clinical Nurse Specialists are available as a resource in addition to written policies and procedures.
Majid et al. (2011) report that most nurses have positive attitudes about evidence-based practice. However, some barriers which reduce the utilization of evidence-based practice include inadequate time to learn and implement evidence-based practice; nurses lack understanding of statistical terminology and research jargon, and technological deficiencies which inhibit informational searches (Majid et al., 2017). I believe that inadequate time is the primary barrier to evidence-based practice implementation within my organization. Time is finite, and working 12-hour shifts means nurses do not want to stay in late or come in early for any type of training. I propose that team nursing would provide individual nurses with the opportunity to attend training during regular working hours. Dickerson and Latina (2017) maintain that team nursing is the practice of nurses working in pairs to deliver patient care. A pair of nurses make up a team; both nurses get report on all patients shared by the team, Then, when one nurse needs to step away for a break, or in this case for training, their partner is already ready to take care of their patients.
Adams, J. S. (2010). Utilizing evidence-based research and practice to support the infusion alliance. Journal of Infusion Nursing,33(5), 273-277. doi:10.1097/nan.0b013e3181ee037e
Bull, M. J. (2015). Managing delirium in hospitalized older adults. American Nurse Today,10(10). Retrieved from https://www.americannursetoday.com/managing-delirium-hospitalized-older-adults/.
Dickerson, J., & Latina, A. (2017). Team nursing. Nursing,47(10), 16-17. doi:10.1097/01.nurse.0000524769.41591.fc
Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses perceptions, knowledge, and barriers. Journal of the Medical Library Association : JMLA,99(3), 229-236. doi:10.3163/1536-5050.99.3.010
Polit, D. F., & Beck, C. T. (2017). Nursing research generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer.
Springer, G. (2015). When and how to use restraints. American Nurse Today,10(1). Retrieved from https://www.americannursetoday.com/use-restraints/.