This week, we will discuss the research design and sample for your nursing clinical issue. The research design flows from the research question and outlines the plan for the study that will answer the research question. The design identifies the major components of the study. It is important to remember that there is no one best design for a research study.

1. After you review the designs, describe which research design you would expect to find when searching for evidence relevant to your own research question from Week 2. Why? Explain your answer.
2. The most common sampling method is the convenience sample; therefore, many of the studies that you find for evidence use this sampling method. What are the implications for using a convenience sample on the way you interpret and use the findings?

Please In 2-3 paragraph respond to this post : 

A Walk Through The Steps of a Nursing Research Study-2.docx 

What have you learned and will it make a difference?

In my welcome letter to you, I indicated that every class should change your thinking about the focus of the class. Again read the provided ” A Walk Through The Steps of a Nursing Research Study”.  This is the same document you were provided during Week 1. Has your ability to read with understanding changed? Briefly share your thoughts regarding this experience. In this discussion forum  from a “qualitative approach” briefly reflect on what you have learned about nursing research, evidence based nursing and its impact on you as a professional nurse earning a baccalaureate degree in nursing.  From a “quantitative approach”, reflect on your response to the scale of your reading and understanding of nursing research you identified in week 1. How has it changed? What activities most contributed to your enhanced knowledge base?  

Additionally, I would like you to discuss your preparedness to respond to the Institute of Medicine’s mandate that “Participants have set a goal that, by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence* (IOM, 2007).   What strategies can you personally implement to address this mandate on a personal/professional level beyond obtaining your baccalaureate degree in nursing? What is the state of your employing institution (no need to name your institution-just identify if it is an acute care setting, long term setting etc) in addressing this mandate since it was initiated in 2007 and with only 1 year left?  Will your employing institution meet the mandate? Initiate a discussion regarding this mandate with a managerial/administrative/ person in your employing institution to gain their perspective on evidence based practice. Here is a website that you can select to review to gain information on this directive. If possible, informally ask some of your nursing colleagues if they are aware of the mandate. What challenges do you foresee to the implementation of evidence-based nursing practice in your workplace?

http://www.ncbi.nlm.nih.gov/books/NBK52821/

Lastly, discuss how you would identify the “best available evidence” and what is the  significance of “Level of Evidence” as it relates to evidence that informs your nursing practice. 

It is expected in this forum that you use/implement the appropriate nursing research terminology. Hint: consider your words like research, prove etc. 

Also my initial respond about level of understanding of  article”A Walk Through The Steps of a Nursing Research Study-“from week 1 was: 

“I read the document ” A Walk Through The Steps of a Nursing Research Study”, my comfort level in reading and understanding this document was satisfying me since I got all explanation very organized and well formated that made it easy to read and get the idea.My knowledge base of nursing and all types of researches was my effective tool to understand most of the document. From quantitative approach I can rate my comfort level 8 out of 10, which I am still happy to this level of understanding.”

Now by the end of this course is expected that my level of understanding increased, so you know how to answer this question compare to my initial post from first week.

This article discusses how the critical social theory should be utilized as a framework for academic nursing practice.  The preface of critical social theory is that nurses must maintain a level of self-reflection to maintain the areas of practice without forgetting that patient problems are as important as treating the condition.  This includes being able to assess all of the dimensions utilized as nursing care is delivered.  This is bigger than locating a problem and instituting a solution it also involves a behavioral shift to utilize emotional and behavioral solutions as well.  They discuss how the nurses actions are dictated by actions other than the nurses original intentions such as; the manner the situation is being treated, the view regarding who should be in charge of the interaction, the center of commitment to the client, practitioner, organization, and the nature of communication that is appropriate for that specific interaction (Swartz, 2014).  They further discuss how the nursing profession is somewhat oppressed in that many advanced practice nurses feel that they are powerless without their physician backing them.  They also discuss how nursing has difficulty obtaining support to institute programs such as proper nutrition for cardiac wellness but there is significant backing for bypass procedures.  This is similar to the oppression discussed in the critical social theory.  The discussion of transpersonal learning through active participation from teachers and learners instead of the traditional forms of presenting material.  This learning format promotes respect and collaboration.  Utilizing the critical social theory to assess areas of oppression, in order to open the discussion for change and improvement would greatly benefit any nursing and education in nursing environment.  Empowering the nurses to be actively engaged in the process of change encourages commitment to the organization and allegiance to improvements. 

References

Swartz, M. K. (2014, May). Critical Theory as a Framework for Academic Nursing Practice. Journal of Nursing Education, 53(5), 271-276. https://doi.org/10.3928/01484834-20140408-01

Respond  of your colleagues who were assigned to a  different case than you. Explain how you might apply knowledge gained  from your colleagues’ case studies to you own practice in clinical  settings.

NOTE: Positive comment

                                          Main Post

The three questions this writer would as the patient are: 

Did your depressive symptoms worsen after the death of your husband? 

How many hours per night do you sleep on average? 

Do you sleep throughout those hours of sleep or do you wake constantly? 

Do you ingest any stimulants like coffee or chocolate before bed? 

Do you sleep during the daytime? 

The rationale behind question one is to gauge the timeline of the patient’s depression. She appears to have been suffering with untreated depression for a long time, however the additional symptoms of insomnia and tearfulness seemed to worsen after his death. With this information the nurse practitioner will know if her depression is in an acute state and the severity of her illness.The patient is reporting sleeplessness; however the nurse practitioner needs to gauge if the patient is participating in restful sleep. Sleep of two hours or less may only consist of REM sleep (Boland et al., 2020). If the patient is not getting restful sleep, she is not benefiting from the bodily repair that takes place during sleep (Fitzgerald et al., 2017).  This can place her at an increased risk for other illnesses and heighten depressive symptoms (Uchmanowicz et al., 2019).Knowing if the patient sleeps consistently throughout those hours of sleep will provide information to the nurse about the kind and amount of sleep the patient is getting. Ingesting certain stimulants like caffeinated drinks, coffee or chocolate can affects the client’s sleep by providing wakefulness (Ulke et al., 2017).  If the patient is sleeping during the daytime, her circadian rhythm could have been reversed where she will need less sleep during the night time hours (Fitzgerald et al., 2017).

The people this writer would interview are:

The patient’s aide 

The patient’s son 

The patient aide may be able to provide more information about observed sleepiness during the daytime. In addition, she will be able to provide information on the patient’s dietary patterns and physical activity. The questions to the aide would be:    

Does she easily nod off during the daytime? 

Does she easily become fatigued? 

Does she consume a well-balanced diet? 

Question one would illicit answers about her getting sleep. 

It appears that she in fact getting sleep but because of a revered circadian rhythm she is not able to get the sleep at the night which is the desired time.  Question two will help the nurse practitioner gauge the extent of the effects that non sleep has taken on the patient’s life. The patient, if constantly fatigued throughout the day has a life that has been highly impacted by the lack of sleep. The aide would be able to provide a clear, picture of the patient’s diet. The aide would be able to reveal if the patient consumes a vast amount of sugar or caffeine which could interrupt sleep.

Questions to the son would surround the family’s psychiatric history.  These questions will help the nurse practitioner construct the family history of the patient and rule out or consider familial history as a cause for her symptoms.

Can you recall any maternal family members with psychiatric disorders including depression and insomnia? 

Did the symptoms start after the death of the client’s husband?  

This would help the nurse practitioner rule out depressive symptoms as the cause of her insomnia.

Physical Examinations and Tests

Sleep Study:

Polysomnogram – The sleep study or polysomnogram measures the brain waves, blood oxygen, leg movements and breathing during sleep (Meghdadi et al., 2019). The Nurse Practitioner would be able to rule out physiological reason’s ad the cause for the patient’s insomnia.

Actigraphy: This is where a small device is worn on the wrist and it measures the person’s sleep wake cycle for a specified period (Meghdadi et al., 2019). This is convenient for this client and the Nurse Practitioner would be able to monitor the client’s sleep health and gauge the severity of the disruption of her sleep.The nurse practitioner could also physically examine the patient’s nares for septal occlusion.

Septal occlusion or deviation could lead to problems with sleeping even during sleep, this would be important for the nurse practitioner to evaluate as this could be interfering with the patient’s sleep.

Epworth sleepiness scale – assesses the patient’s tendency to nod off in various situations (Meghdadi et al., 2019).  For this client it would be necessary for the nurse practitioner to assess the severity of her nodding off during the day time especially at unexpected times like during eating and other activities that would put her safety at risk. 

Differential Diagnosis

G47.00 Unspecified Insomnia Disorder– The patient is experiencing insomnia at nighttime that could be related to several factors. She reports staying up late to watch T.V., depressive symptoms, restless leg syndrome, sleep apnea and sleeping during the daytime. Some of these factors have not been ruled out yet as the cause of her anxiety. 

G47.23 Persistent Irregular Sleep Wake type severe 

F32.9 Unspecified Depressive Disorder 

G25.81 Restless legs syndrome 

Medications:

Trazodone 50 mg – This medication would be the first choice as it offers antidepressant properties as well as promotes sleep in those diagnoses with insomnia. It is generally safe for the elderly population at low doses (Pagel et al., 2018). The Nurse Practitioner should monitor the patient and evaluate the needs to slowly increase or in some cases decrease the dose. 

Rozerem 8 mg- Is a nonbenzodiazepine hypnotic that promotes sleep. The patient would benefit from his, but an added benefit would be that she would be at a diminished risk of falls as this is a concern following the use of hypnotics in the elderly. This drug is reported as one that would prevent less falls from over sedation (Pagel et al., 2018).

Lessons Learned            

This writer has learned that it is important to conduct a complete evaluation of the patient and not just focus on the presenting symptoms. There are additional environmental and physiological symptoms that could be attributed to the patient’s insomnia. In this case the patient had several factors that could be contributing her insomnia and they needed to be ruled out. The cause of her insomnia could have been physiological from the sleep apnea or from her habits of staying up tool late at nights and sleeping during the daytime. It is also important to evaluate medications, social and economic factors before the resorting to pharmacological interventions. 

References

Boland, E. M., Vittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett, R. B. (2020). Is sleep disturbance linked to short- and long-term outcomes following treatments for recurrent depression? Journal of Affective Disorders, 262, 323–332. 

FitzGerald, J. M., O’Regan, N., Adamis, D., Timmons, S., Dunne, C. P., Trzepacz, P. T., & 

Meagher, D. J. (2017). Sleep-wake cycle disturbances in elderly acute general medical inpatients: Longitudinal relationship to delirium and dementia. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, 7, 61–68. 

Meghdadi, A. H., Popovic, D., Rupp, G., Smith, S., Berka, C., & Verma, A. (2019). Transcranial Impedance Changes during Sleep: A Rheoencephalography Study. IEEE Journal of Translational Engineering in Health and Medicine, Translational Engineering in Health and Medicine, IEEE Journal of, IEEE J. Transl. Eng. Health Med, 7, 1–7.  

Pagel, T., Seithikurippu R. Pandi-Perumal, & Jaime M. Monti. (2018). Treating insomnia with medications. Sleep Science and Practice, (1), 1. Uchmanowicz I, Markiewicz K, 

Uchmanowicz B, Kołtuniuk A, & Rosińczuk J. (2019). The relationship between sleep disturbances and quality of life in elderly patients with hypertension. Clinical Interventions in Aging, 155. 

Ulke, C., Sander, C., Jawinski, P., Mauche, N., Huang, J., Spada, J., Hegerl, U. (2017). Sleep disturbances and upregulation of brain arousal during daytime in depressed versus non-depressed elderly subjects. World Journal of Biological Psychiatry, 18(8), 633–640.