This paper examines the key implementation challenges facing a Doctor of Nursing Practice (DNP) evidence-based project designed to reduce pressure ulcers in elderly, bed-bound nursing home patients through two-hour turning and repositioning protocols. The discussion covers methodological concerns such as controlling for the many risk factors associated with pressure ulcer development, logistical barriers to recruiting multiple nursing home facilities, staff resistance to protocol changes, and ethical complexities surrounding research consent for patients with dementia. The paper also addresses the broader problem of inadequate attention and funding for nursing home populations and underscores the growing public health burden of pressure ulcers, arguing that these obstacles must be overcome given the serious clinical and financial consequences of the condition.
The paper demonstrates problem–response structuring: each barrier is identified and then contextualized with supporting evidence or a proposed rationale for why it can be addressed. This technique, common in applied health sciences writing, moves the paper beyond mere problem-listing toward a practical, solution-oriented argument.
The paper opens by distinguishing evidence-based research from evidence-based practice and situating the DNP project within that distinction. It then works through overlapping categories of challenge — sample size and recruitment, staff compliance, ethics and consent, and funding gaps — before closing with a brief but forceful conclusion linking clinical and financial imperatives. The progression is roughly problem-to-consequence-to-call-for-action, which suits the advocacy purpose of a DNP capstone discussion.
Evidence-based research, as opposed to evidence-based practice, is defined as "research [that] is generating new knowledge about a phenomenon or validating existing knowledge… Although evidence-based practice may have opinion — expert opinion, but opinion still — woven in, research is built in such a way to avoid bias" (Evidence-based practice and avoiding confusion, 2014). Experiments must have controlled variables to ensure that extraneous data does not influence the result.
In the case of this DNP project — examining the use of two-hour turning and positioning to decrease pressure ulcers in elderly bed-bound patients in nursing homes — one clear issue is the extent to which patients' poor health could influence outcomes. Nursing home patients can have a variety of conditions that may impact results, and both experimental and control groups must be carefully balanced. As Lyder and Ayello (2008) note, "More than 100 risk factors of pressure ulcers have been identified in the literature. Some physiological (intrinsic) and nonphysiological (extrinsic) risk factors that may place adults at risk for pressure ulcer development include diabetes mellitus, peripheral vascular disease, cerebral vascular accident, sepsis, and hypotension."
Controlling for such a wide range of risk factors ideally requires a large sample size to limit the influence of extraneous variables. Obtaining permission from multiple nursing homes to implement the experiment could pose a significant logistical hurdle, however. Socially, there may be resistance to allowing patients to serve as research subjects, both from staff and from patients' families. Some pushback may arise if patients are placed in the control group and there is a perception that they are being denied a beneficial treatment.
When healthcare policy currently validates a less demanding turning schedule, soliciting participation may be especially challenging. As Haynes and Haines (1998) observe, "National healthcare policies are often moulded by a range of non-evidence-based factors including historical, cultural, and ideological influences. Moreover, when national guidelines or healthcare policies encourage clinicians to perform procedures that are not evidence based, the unnecessary work acts as a barrier to the implementation of other well-founded knowledge." Simply because something is widely regarded as policy or classified as common sense does not mean it constitutes a best practice.
Staff may also be resistant to changes in their routines. Organizational barriers include an unwillingness of staff to adhere to proper protocols, particularly when they cannot be observed at all times. The research study's design requires compliant staff, given the demands of a two-hour turning process. It would be physically impossible to supervise all staff members, particularly across multiple facilities. One reason that longer turning intervals tend to be more common in practice is simply that they are easier for staff to manage. Persuading staff to take on more frequent turning for the sake of a speculative study can be a difficult proposition.
Patients' families may also be reluctant to allow their loved ones to participate in any clinical trial, regardless of the potential benefit. The combined effect of institutional inertia, staff workload concerns, and family hesitation represents a substantial organizational barrier that any implementation plan must directly address. Change management research consistently shows that buy-in at multiple levels of an organization is essential for protocol adherence, making early and transparent communication with all stakeholders critical to the study's success.
Despite the obstacles presented to this research study, these challenges can and must be overcome because of the problems inherent to the epidemic of bedsores in nursing homes today. If the seriousness of the issue can be impressed upon staff members, a wide enough range of nursing homes can become involved in the study for the data to be meaningful. Preventing pressure ulcers is not only a humanitarian imperative — it is also a significant financial one. Even a single pressure ulcer case can cost upwards of $37,800 to treat (Lyder & Ayello, 2008). In today's financially constrained healthcare environment, that cost is simply unacceptable, and it provides a compelling argument for investing in prevention research now.
Evidence-based practice and avoiding confusion. (2014). Health Leader's Media Council.
Haynes, B., & Haines, A. (1998). Barriers and bridges to evidence-based clinical practice. BMJ, 317(7153), 273–276.
Lyder, C., & Ayello, E. (2008). Chapter 12: Pressure ulcers: A patient safety issue. In Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality.
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