NUR 675 Module 5 Milestone Two Example

Milestone Two: A Search and Appraisal Plan for Evidence on Preventing Inpatient Falls

[Student Name]

Southern New Hampshire University

NUR 675: MSN Seminar: Preparation for Practicum

Module Five Milestone Two

[Instructor Name]

[Date]

Milestone Two: A Search and Appraisal Plan for Evidence on Preventing Inpatient Falls

A practicum project is only as good as the evidence behind it. Students often begin by typing a broad topic into a search engine, collecting whatever articles appear and summarizing them without judging their quality. The result is a literature section that looks thorough but cannot support a decision. The student in this paper is planning a twelve-week practicum on a unit where most falls occur at night during unassisted toileting, often after sedating medications. This milestone plans the search and appraisal. It argues that a focused question, a documented search strategy, a clear hierarchy of evidence and systematic appraisal will produce evidence the unit can act on, and that reading the best synthesized evidence first can sharpen the question itself.

Building the Question

Richardson et al. (1995) argued that evidence-based decisions begin with a well-built clinical question that specifies the patient or problem, the intervention, a comparison and the outcome, a structure now known as PICO, often extended with a time frame as PICOT. A focused question makes searching efficient and makes it possible to judge whether an article is relevant. The student's first question, how can we prevent falls, was too broad to search. Her revised question reads: in adult medical-surgical inpatients at high risk of falling, does a nurse-led scheduled toileting and medication review program, compared with usual care, reduce the rate of falls during night shifts over a twelve-week period? The question is specific to the unit's pattern, names an intervention that could be tested within the practicum and specifies a measurable outcome.

Search Strategy

Three databases will be searched, CINAHL, PubMed for MEDLINE and the Cochrane Library, and the hospital librarian will check the strategy before it runs. Terms will combine subject headings and keywords for the population, such as inpatients, hospitalized and hospital units; the problem, such as accidental falls and fall prevention; and the intervention elements, such as toileting, rounding, medication review and deprescribing. Synonyms will be linked with OR, and separate concepts linked with AND. Results will be limited to adult studies in English from the last fifteen years, with older landmark studies added by hand. Reference lists of key reviews will be searched for additional studies, and the search terms, dates and number of results will be recorded so that the search can be reproduced.

Screening and Selection

Search results will be screened in two stages. Titles and abstracts will be reviewed first against inclusion criteria: studies of adult hospital inpatients, interventions that include toileting schedules, purposeful rounding, medication review or multicomponent programs containing these elements and outcomes that include falls or injurious falls. Studies in long-term care or community settings will be excluded from the main synthesis but noted if they offer useful detail about delivering an intervention. Full texts of potentially relevant studies will then be read to confirm eligibility. The number of records found, screened, excluded with reasons and included will be recorded in a simple flow diagram, following the approach used in systematic reviews, so that the preceptor and faculty can see how the final set of studies was reached. The preceptor, who has experience with quality improvement literature, will review a sample of decisions to check consistency.

Hierarchy of Evidence and Appraisal

Melnyk and Fineout-Overholt (2023) present a widely used hierarchy of evidence for questions about the effect of interventions, placing syntheses of randomized trials highest, with the next rung held by well-designed randomized trials, controlled trials without randomization, case-control and cohort studies, systematic reviews of descriptive and qualitative studies, single descriptive or qualitative studies and finally opinions of authorities and expert committees. The hierarchy guides where to look first and how much weight to give each finding. Each included study will be appraised with a standard appraisal tool matched to its design, and results will be entered in a synthesis table recording the design, sample, setting, intervention, outcomes, level of evidence and quality.

Beyond Published Research

Research is not the only evidence the project will use. National fall prevention guidance from professional organizations will be reviewed, the hospital's own fall policy and incident data will be examined and patients' perspectives will be gathered through brief conversations with five recent patients about what made them try to get up alone at night. These sources will not be ranked in the research hierarchy, but they will help translate the research into a change that fits the unit and its patients.

How the Best Evidence Reshaped the Question

Following the hierarchy, the student read the highest-level evidence first. Cameron et al. (2018), in a Cochrane review of interventions to prevent falls in older people in hospitals and care facilities, found that the evidence for multifactorial interventions in hospitals was of low certainty and that bed and chair sensor alarms probably made little or no difference to falls. This finding matters for the unit, where bed alarms were a central part of the current approach but were often not activated. It suggested that adding or enforcing alarms would be unlikely to help and that the project should focus on components aimed at the unit's specific pattern, scheduled toileting and review of sedating medications, and on whether staff could deliver them reliably. The PICOT question was confirmed, and a secondary question about adherence was added.

Timeline and Use of the Evidence

The search will be completed in practicum week two, screening and appraisal in weeks three and four and the synthesis table presented to the preceptor and falls committee at the end of week four, where it will inform the recommendation required by the second objective. Articles will be managed with the reference software the hospital library provides. The synthesis will be written for a clinical audience, stating what the evidence supports, where it is uncertain and what the unit would need to do to apply it.

Conclusion

A broad topic becomes a searchable, answerable question through the PICOT structure. A documented strategy across three databases, a clear hierarchy and standard appraisal tools will produce evidence the unit can trust. Reading the Cochrane review first showed that alarms, the unit's current focus, are unlikely to help and pointed the project toward toileting, medication review and reliable delivery, which is the kind of shift a good search should produce.

References

Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, (9), Article CD005465. https://doi.org/10.1002/14651858.CD005465.pub4

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing and healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

Richardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. A. (1995). The well-built clinical question: A key to evidence-based decisions. ACP Journal Club, 123(3), A12-A13. https://doi.org/10.7326/ACPJC-1995-123-3-A12