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Present your work as a portfolio consisting of the following five parts:
Part 1: Clinical scenario - Describe a clinical problem facing you and/or your colleagues. Be specific about why this is a problem and to whom
Part 2: Critically Appraised Topic (CAT) - From the above scenario construct a search question, identify search terms to locate research evidence

Part 3: Assessment for applicability to clinical practice - Provide an assessment of how applicable the evidence is to your area of clinical practice. Consider the feasibility, acceptability, cost, and anticipated benefits of the intervention.
Part 4: Barrier analysis - Identify barriers and enablers to implementing the evidence within your service/organisation. Focus on those relating to the key target behaviours and target groups that need to change for successful implementation. You are recommended to use a published model/framework for identifying barriers and available supporting evidence. Supporting evidence may include existing data relevant to your scenario such as survey and audit information, patient experience data, knowledge of staff opinion, or existing knowledge of effective implementation strategies/barrier analysis, but you are not expected to generate new data for the purpose of this assignment.

Part 5: Implementation plan - Construct a plan that describes the steps you plan to take for implementing the evidence appraised. Your plan should demonstrate consideration of core implementation principles, provide some rationale for the selected implementation strategies (i.e. why those selected to bring about change should address the barriers identified) and be specific to your work setting. You are recommended to use a published implementation model/framework as a guide.

Clinical Issue Faced by Nurses and Their Colleagues

Proximal femoral fracture is one of the most devastating results of osteoporosis as well as injurious accidental falls. There has been a high rate of mortality like up to about 35% where patients are found to die just within the year of the post fracture period (Parker, 2016). Only 40% of them are able to return to the pre fracture ability of mobility and 15% fail to gain independence to remain at residences. The researchers have provided evidences which show that the number of hip fractures cases will increase by 405 million in the year 2050 (Managano & Kenny, 2016).

Clinical issue faced by nurses and their colleagues:

In such a scenario, it becomes extremely important for a nurse to take active steps to ensure that patients can get back to their normal lives which will portray the best quality lives. However the case is not simple as after the surgery, condition of the patients becomes very fragile as they remain undernourished and even during routine care provided by the nurses; their dietary requirements are very less resulting in poor nutritional pool within the body (Flodin, 2015). Although the nurses try their best to help the patients eat proper food, however they deny as the pain, anxiety and depression engulf such individuals. Therefore, it becomes very difficult for the nurse to handle such situation as they are not being able to provide the correct nutrient which is exceptionally important for the fragile patients. With these situations, the patients develop mental apathy, muscle wasting and also reduced muscle power resulting in impaired cardiac function (Cosman et al., 2014). Hence the nurses often tend to get entangled in a series of burden of the patients which subsequently becomes strenuous for them. However, in the meantime the patients explore leading to mental pressure on the nurse. Hence, it has become excessively important for the nurses to develop interventions which would help them to meet the nutritional requirement helping in development of the conditions of the patients after fracture.

Critically Appraised Topic (CAT):

The search question here is “what is the most suitable intervention that can be applied by the nurses in order to meet the nutritional requirements of the old patients who have suffered hip fracture?”

In order to find the correct article that will have the evidence of the correct intervention that should be used by the nurses, some important key words need to be selected. These are “interventions to provide nutrition to old patients with fractures”, “interventions after hip replacement to meet nutrient requirements”, “ nutritional importance of old patients after hp surgery”, overcoming nutrition deficit in patients after hip fracture” and others. Some of the important databases that one should consider are the Google scholar, Cochrane library, cinahl library, pubmed, plos one and others as well.

Critically Appraised Topic (CAT)

On successful search, a number of articles have been found, out of which a particular article has been selected. This article is actually a systematic review on the different interventions that a nurse can use to provide the correct nutrition to the patients and maintain the correct nutrition level within the patients. By the application of the Casp tool one can analyze the entire systematic review and hence can evaluate the efficacy of the paper in solving the clinical problem faced by the nurses.

The Casp tool act as a screening tool where the first answer that it tries to find is the whether the article had addressed a clearly focused question. The article has been successful in reviewing papers that had correctly addressed the main concern regarding the correct interventions (Weaver et al., 2016). After the entire review, they have reached a conclusion that has correctly addressed the focus questions stating that the interventions they have used had helped in reducing the unfavorable conditions of patients and had increased nutrition pool within the patients.

Moreover the second question of the Casp tool helps to ponder over the fact that whether the authors have selected the right type of papers. The paper has collectively addressed this arena by selecting papers which are all based on randomized controlled trials and each of the paper had been based on specific interventions like oral interventions of nutritional supplements, se of nasogastric tube feeding, and also intravenous application of nutrition (Liu et al., 2014). Hence the papers chosen are apt and are significant to reach to a conclusion.

The third question asks whether the author had included relevant papers. The author had rightly searched proper databases called the e Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2008), MEDLINE and others like the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3) and many others. These databases published authentic nursing articles which are not only evidence based but also helps the nurses to develop their skill and knowledge. No non English papers were selected and all consisted of Proper English language, used to address the interventions. All the papers which were reviewed were published articles and had the information that helped to ponder over the main concern of the portfolio.

The next question that needs to be addressed is that whether the authors of the reviewed papers have done enough to assess the quality of the papers. The author of the systematic review stated that many of the trails that the authors were flawed in different ways. There were even some trials which did not contain the intention to treat basis procedure. There were even some studies which did not undertake the blinding of the participants that increased the risk of biasness and changes in result of the studies. There were many studies which even did not consider the placebo treatment. However, they were included as they provided information on the interventions and helped the authors get an idea of different interventions applicable (Goisser et al., 2015). Hence there were a mixture of both good quality and bad quality papers selected by the authors.

Finding the Correct Intervention for Elderly Patients with Hip Fracture

The fifth question is whether the results of the reviews have been combined and whether it was reasonable to do so. The review papers were categorized into different parts depending upon the interventions used and then they were clumped together. The papers portraying oral supplementation were taken together; those with naso-gastric interventions were taken together and so on. These helped in developing an idea that the papers wanted to provide us in each of the interventions and moreover each intervention has been properly addressed (Aldebeyan et al., 2017).

The sixth question was that whether the overall results of the review have been addressed or not. The systematic review has rightly concluded that the interventions although reduced unfavorable conditions associated with the patients’ condition but the efficiency is still questionable by the authors as they had not been satisfied and suggested more randomized trial to conclude effectively.

The seventh question is how much precise is the results. The results are quite precise helping in addressing the concerns of the clinical problem effectively and help the nurse to easily understand which are the best interventions and the success rates of each of the interventions precisely.

The eighth question helps in addressing that whether the results could be applied to the local population. The interventions can very well be applied to the local population of the aged patients who suffer hip fracture and get admitted to hospitals for surgery. In a way, the randomized control trials have been effective in including the correct population of old people who have faced poor quality life due to hip replacements (Peters et al., 2016).

The ninth question tries to confirm that whether all the important outcomes were considered. All the primary outcomes like morbidity, mortality and others were independently assessed while that of the secondary outcomes was clumped together and considered as unfavorable outcomes. Therefore one can consider this as an authentic way of addressing the outcomes and correctly linking the relation of the outcomes with that of the interventions applied.

 The last question asks that whether the benefits are worth the harms and costs. The benefits will definitely help in addressing the recent concern of a large number of old patients with hips fracture experiencing mortality within the year of the surgery. Although it will increase the cost due to introduction of new intervention but it assures that it will reduce the level of harms.

Evaluating the Efficacy of Nutritional Interventions

The introduction of the new intervention of using nasogastric tubes as well as oral supplements will require a new set up in the practice settings. Rise in cost is definitely associated with that of the introduction of naso-gastric tubes as well as oral supplements. Huge expenditure of the health care resources are associated but it would balance the lives of the people that would be saved by these procedures. In regards of the acceptability, it may create concerns. Any healthcare professionals always tend to be apprehensive about any new interventions as any new interventions always accompany large number of expenditure of energy, time and is always associated with risks (Morley et al., 2013). Moreover patients may also be apprehensive as they may feel discomfort in taking feeding tubes although oral supplementation creates no issues. In terms of  feasibility and benefits, the approach is found to be excessively helpful as evidences have shown this to reduce unavoidable outcomes and also reduces the mortality rates of patients. This is mainly because the combined approach is able to maintain the correct nutritional balance within the body of the patients with hip fracture (Bell et al., 2014). This in turn helps them in better development form the injury and makes recovery very fast. As a result, it had helped in gifting better quality lives to patients.

In case of older patients with hip fracture, post-operative management of patient is critical as they are vulnerable to short term complications like infection, delirium, cardiovascular events and pressure ulcers. They are also vulnerable to long-term adverse outcome of worsening ambulation or functional status. In such condition, providing appropriate nutrient supplementation is important for nurses to promote recovery and prevent complication (Calvani et al., 2014). In relation to the clinical problem of nurse’s inability to identify appropriate nutritional supplementation needs for elder patient, it has been proposed that post operative oral and nasogastric tube feeding might help to reduce complication after the hip fracture (Colón-Emeric, 2012). The critical appraisal of the research article by Avenell & Handoll, (2010) provide support regarding the efficacy of this intervention and this section provides regarding the enablers and barrier in implementing the evidence within daily nursing practice.

TDF template for barrier analysis in implementing the intervention

Table of findings by TDF domain

Target clinical behavior (S)

TDF domain

Barrier

Enabler

As malnutrition in older people hinders their recovery process after hip surgery, it is proposed to provide oral and nasogastric supplementation to them. To implement this intervention, nurse must have knowledge about nasogastric feeding requirement of individual patients as well the intake of oral meals by them. They should also have the knowledge about tube feeding decisions for elderly patients (Avenell & Handoll, 2010).

Knowledge

· Lack of knowledge in nurse about balancing oral and nasogastric supplements might act as barrier in providing the intervention.

· Lack of toleration of the feeding tube by patients might hinder effective delivery of the intervention.

· Training the nurse regarding oral and nasogastric tube feeding before placement may enhance the delivery of intervention.

· Giving nurse knowledge about condition that might hinder tube feeding will help to avoid discomfort to patient and avoid medical errors. Conditions like dyspagia requires other interventions first before introducing nasogastric tube feeding (Ogita et al., 2013).

In order to implement oral and nasogastric supplementation for hip fracture elderly patients, nurse must have all the skills for tube feeding practices in clinical setting

Skills related to competence, ability and interpersonal skills of nurse

· Nurse may face challenges in implementing the intervention if they are not aware about patients conditions that impeded the process. The conditions may include dysphagia and diarrhea in patient after surgery.

· Older patients may face eating difficulties and nurse may face challenges in taking decisions on complicated issues of patients.

· Lack of experience in tube feeding care might act as a barrier (Ogita et al., 2013).

· Nurse must have all the knowledge and skills regarding the selection of nasogastric tubes, nasogastric placement and care, administration of feeding and monitoring and management of complications (Metheny, 2014).

· Nurses who are aware of intervention needed before starting tube feeding might enhance the quality of the intervention.

·  The activity of providing information to patients about tube feeding promote management of tube feeding and reducing stress in patients.

· In addition care coordination with other colleagues is also important to protect patients during enteral feedings (Majka et al., 2014).

Nurses must be accountable for care of elderly patients by getting involved in the care of patients. They must have the commitment to engage in safe patient care practices and identifying risk while delivering the intervention. Patient centered collaborative care also enhances outcome in patient (Ignatavicius & Workman, 2015). 

Professional role and identity dependent on professional confidence, organizational commitment and group identity

· Ignorance of nurse in fulfilling the nutritional needs of patients may impede the intervention process.

· Lack of tolerance of enteral feeding by older patients may create problems in carrying out professional responsibility.

· Lack of appropriate guidelines of tube feeding protocols may cause risk to patients and act as barrier in coordination of service (Christie et al., 2015). 

· The major professional goal of nurse while delivering the intervention should be to enhance the quality of living in elderly with eating problems.

· The decision making of nurse regarding the tube feeding for particular patients and prevention of complications should be based on patient-centred care approach (Graham et al., 2014.

As elderly patients may have many other complications apart from pain associated with hip fracture, they may resist in accepting nasogastric feeding, in such scenario nurse must have behavioral control and patiences to handle patients. They must use their therapeutic skills to overcome barriers in practice and explain patients about the importance of intervention for their health needs (DiCenso et al. 2014). 

Beliefs about capabilities: Self-control and perceived behavioral control in task

· Lack of appropriate supportive resource in organization act as barrier and decreases the motivation level of nurse in practice.  

· Lack of self-confidence in clinical skills impedes independent decision making by nurses (Pfaff et al., 2014).

· Poor relationship with multidisciplinary team and lack of understanding about indications for tube feeding may acts as barrier in implementing the intervention (Ogita et al., 2013).

· The enabling factors that can enhance the nurse’s self-confidence in practice include feeling competent about their role in care, utilizing their nursing skill in effective manner and getting adequate organizational support for improving performance.

· Environmental factors such as relevant clinical knowledge, clinical experience and relationship of nurse with other colleagues also improve self-confidence of nurses (Lean Keng & AlQudah, 2017).

The desired clinical behavior for nurse according to this domain is to resolve to adopt safe practices in oral and nasogastric supplementation to enhance the quality of care and engage in decision making

Intentions and goals

· Lack of knowledge regarding the management of nasogastric tube might impede the goals and intentions of providing the intervention.

· If the nurse cannot engage elderly patients in care, the intervention may not be effective. Nurse may give knowledge regarding the care needs while on enteral feeding

· The enablers for achieving the goal of intervention includes following the protocol for management of nasogastric tube feeding, starting from selection of feeding tube to administration of tube feeding and monitoring complications

· Feeding tubing selection and care of the tube is critical to providing high quality intervention

· In case of adults with swallowing disturbance, other options of care must be decided by nurse (Gomes et al., 2015).

To achieve the goals of the intervention, it is necessary that nurses are provided updated tools and manual to engage in evidence based practice for nutritional supplementation

Reinforcement

· Lack of quality improvement appoproaches create risk in providing nasogastric tube feeding.

· Use of outdate equipment may act as barrier in meeting nutritional requirements of elderly patients with hip fracture.

· All nurses must be provided the protocol for management of oral and nasogastric tube feeding to effectively implement the intervention in daily practice.

· Quality assurance in nasogastric tube feeding should be done to enhance the intervention.

· Incidence of misplaced tubes and complications during nasogastric tube feeding must be adequately reported (Lan et al., 2017).

According to the demand of this domain, the nurse must engage in critical reflection to identify any issues in practice and search for cues to solve those problems.

Memory and decision process

· Lack of motivation in professional and safe nursing practice may restrict nurse in engaging in this process.

· While delivering the intervention, the nurse must take care to identify all cased of complications during nasogastric feeding and takes steps to engage in corrective actions to enhance the delivery of care (Farrington & Townsend, 2014).

World health organization had provided a framework called the Knowledge-to-Action (KTA) Framework which helps in identification of the problem and thereby help in solving them with the help of proper scientific methods. The healthcare professional should search for solutions which may be either available in published researches and if not present, the professional should search out for new solutions through appropriate researches (Dyer et al., 2017). Often it has been seen that implementation of research based knowledge often accompanied various barriers in real life. Therefore, available research data need to be synthesized and then the knowledge needs to be contextualized before the implementation process is initiated. Moreover, it is very important to incorporate evidence based knowledge which should be also tailored to overcome different local barriers (Wakabayashi & Sakuma, 2014). Graham et al. has thereby provided the following framework giving a sequential idea about how knowledge can be incorporated in practice to properly implement the action plans to overcome the different barriers.                                                 

The first step of the cycle is identification of the problem and then reviewing and selecting the knowledge. The problem has been already identified where the nurses face issues in providing the correct nutritional requirement to the old patents with hip fractures. The patients are often malnourished for which their recovery is low and many even expire in the post operative phase due to improper nutrient pool. Hence, evidence based researches have been selected which states that the combined approach of nasogastric tubes along with oral supplementation of nutrients by the nurse is one of the best approach that can help decreasing the mortality rate of patients and hence increasing the quality of their lives.

On moving the cycle from the left side, the next two steps mainly involves the adapting knowledge to the local context followed by the assessing the barriers that the healthcare professional may face due while incorporating the intervention in real practice setting.

  1. While targeting the implementation of nasogastric tube feeding and also oral supplements, knowledge of the individual nurse can act as a barrier as the nurse may not be properly trained in nasogastric feeding to patients (Wyers et al., 2013). Moreover, proper knowledge also needs to be administered by them regarding the tube feeding decisions about the old patients.
  2. Another barrier that the healthcare professional may face is that besides, knowledge she may also not possess the specific skill that should be developed to handle such fragile patients during the period of naso-gastric tube feeding sessions as loss of skills may cause patients to lose balance, irritation and others.
  3. Another barrier that is often reported by nurses is that they often fail to provide accountability for the patient’s care and cannot ensure a safe environment of practice. They also fail to identify the different risks associated with it and also fail to establish collaboration among team members during team care (Goisser et al., 2015).
  4. Moreover as old patients are often suffering from a large number of diseases burden, they may not want to take another burden of tube feeding. Hence, in such patients it become difficult for the nurse to work against dignity and autonomy. However here they need to provide behavior control skills to overcome the barriers.
  5. The nurse should also have to take active part in desired clinical behavior development or adoption of safe practices to meet the intended goals. However enhancement of quality may get hampered while handling the other aspects (Iddress et al, 2015).
  6. The nurse may not be provided with significant tolls and manual which may act as barriers in their evidence based knowledge.
  7. Often lack of motivation in professional as well as safe nursing practice in the healthcare environment may act as barriers also.

The next two steps mainly involve selecting, tailoring as well as implementing the important interventions which is followed by another step called the monitoring of knowledge

  1. The implementation plan would include steps that would help to overcome the different barriers and provide the best care to the patients. The first plan to overcome the barriers include proper arrangement of training programs for nurses regarding provision of knowledge about systems of naso-gastric tube feeding (Liu et al. 2015). It will also help the nurses to gather knowledge about the conditions which might hinder successful tube feeding and also derive knowledge about how to avoid any sort of discomfort of patients and also avoid making of any errors.
  2. The next implementation plan include conducting of practical sessions in the practice settings, attending of workshops and trained mentors who would guide the nurses to develop their skills in correct selection of naso-gastric tubes and its proper managements. The nurses should also develop knowledge and skill about how to educate the patients before administration of naso-gastric tubes so that they do not go through stressful condition and can prevent them from opening the tube again and again. Moreover, the management should introduce active plan where they will enable a team work spirit which help every nurse to discuss their work and provide the best treatment to patients (Singh et al., 20140.
  3. The implementation plan should help the nurse in policies and rules that will help them in remodeling their major professional goals while they will deliver the intervention to the patients. These policies should help them in incorporating ways which will help in enhancement of the quality of living in such elderly patients especially during their feeding times. A proper guideline should be provided so that it would help the nurse in choosing the right type of naso-gastric tubes for different patients by a patient centered approach.
  4. Motivational talks weekly should be organized by the healthcare sectors where the self confidence of the nurses should be boosted. Moreover the talks should be such that the nurse can feel competent about their role in care with the help of proper nursing skills. Discussion meetings should be implemented weekly which will induce collaborative meetings among different team members where they will also point out both the positive and negative aspects of their clinical experiences (Myint et al., 2013). It will help the others to learn from the experiences of others and in turn develop their own practices.
  5. Another important steps required to implement in order to provide the correct treatment to old patients include is another workshop which would be conducted to teach the nurses the specific types of feeding tubes that will be selected for different patients. Moreover they should also be taught how to handle tricky situations when a patient denies taking in such tubes. They would be taught proper behavioral changing tools which they can apply to the patients in order to change their feelings for eating the naso-gastric tubes.
  6. The management should implement protocols regarding quality assurance in nasogastric feeding along with oral supplementation. It should also cover the reporting of any cases of misplaced tubes and complications that arise during applying the interventions in practice settings (Anbar et al., 2014). This will help in turn to look over the incidences and take steps for correction of such practices so that no such incidences occur in the future.

The last two steps that complete the cycle comprises of evaluation of the outcomes followed by the step of sustenance of knowledge use. The implementation of the steps should be monitored and the results should be evaluated. The evaluation of the steps can be done by eminent experienced healthcare officials. They should try to measure the efficacy of the interventions by analyzing the clinical behavioral skills that are developed by the nurses after the different steps are implemented. Moreover evaluation of the outcome can be done by measuring the fall in rate of mortalities in the number of old age patients after surgery of hip fractures. Moreover the complaint number should be checked as it is a very good indicator of the responses of the treatment that the patients are getting from the nurses. Moreover feedback responses from both the patients as well as from the nurse’s should be correctly analyzed to see how the interventions have affected them physically as well as negatively (Flodin et al., 2015). The health of the patients should also be monitored in order to check that the interventions which are provided are indeed helping them to overcome the condition of malnourishment. Once the evaluations are done, care should be taken that in order to sustain the knowledge use, the positive aspects should be strengthened and the negative aspects would be altered towards betterment.

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