Respond  using one or more of the following approaches:

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.

                                                  INITIAL POST 

             Using evidence-based practice (EBP) is an essential tenant of nursing  practice. Therefore it is imperative to develop the skills necessary to  gather, interpret, and evaluate scientifically based data. To begin my  research for this week’s assignment, I first did a Google search of  nursing research topics to help myself generate ideas and narrow down a  problem that interested me. After considering several topics, I decided  to write about delirium in acutely ill patients.  Acute Delirium is  something that I have a lot of experience with, both personally and  professionally. The aim of my research will be to find out how  non-pharmacological interventions compare to pharmacological treatment  of acute delirium.

Search Results Analysis

             Once my topic was selected, I went to the Walden library to search for  evidence-based literature on delirium management. According to Walden  University (2018), the levels of evidence pyramid determines the quality  and amount of evidence available. The top three sections of the pyramid  are referred to as filtered results. Filtered results are comprised of  systematic reviews at the pinnacle of the pyramid, followed by  critically appraised topics, and critically appraised individual  articles. The next three sections of the pyramid are referred to as  unfiltered results and include randomized controlled trials, cohort  studies, and case-controlled studies. Background information and expert  opinions make up the base of the pyramid (Walden University, 2018). 

           I began searching for resources from the top of the evidentiary  pyramid, systematic reviews. I used the Joanna Briggs Institute EBP  Database, and then limited my search results to systematic reviews, and  set a date range of 2014 to current. I used the keywords “delirium” and  “interventions” this search yielded four systematic reviews. When I  search the term “acute confusion” I found three results. I also utilized  the Cochrane Database of Systematic Reviews, and found two systematic  reviews by searching for “delirium” in the first text box, and “nursing  interventions” in the second text box, again searches were limited to  full text with a date range of 2014 to current. I also used the Joanna  Briggs Institute EBP Database to search for critically appraised topics.  My search for “delirium interventions” yielded just one result.  However, when I searched for “delirium” I found ten results. I also  searched those same terms on Guideline Central and found four critically  appraised topics results. Finally, I searched for critically appraised  individual articles using the Evidence Alerts database, and the terms  “delirium and acute confusion” this search yielded 23 critically  appraised individual articles.

Next,  I searched for nonfiltered resources utilizing the CINAHL Plus  database. I first looked for randomized controlled trials by searching  for the terms “delirium” and “nursing interventions” in the first and  second text boxes respectively; this search query yielded four  randomized controlled trials. To find cohort studies, I typed “delirium”  in the first text box, “interventions” in the second text box, and  “cohort studies” in the third text box, this search resulted in 27  articles. I searched for case studies using the same search terms in the  first and second text boxes and limited the publications to case  studies, this search yielded 56 results.  However, when I adjusted the  filters to include case studies published within the past five years,  the number of results reduced to 14 case studies.  

Comparative Value

             I found congruency between the evidentiary pyramid and my  search results; the further down the pyramid, the more resources I  found; but, the quality of the information decreased concurrently. While  the systematic reviews were not as numerous, they are superior in terms  of scientific rigor and evidentiary support. Moreover, the information I  found within the systematic reviews were very consistent with my chosen  topic compared to information further down the period like cohort and  case studies. When search terms were altered, for example, searching for  “delirium” versus “acute confusion,” the results remained more  consistent when searching for the higher level filtered results whereas  alteration of search terms would create a wide variation in results  further down the pyramid, in the unfiltered resources. 

Polit  and Beck (2017), contend that systematic reviews are the best resources  for EBP because they contained synthesized information about a topic  from numerous evidenced-based studies. However, it is important to  recognize that the quality of evidence can vary significantly regardless  of its position within the evidentiary hierarchy (Pilot & Beck,  2017). Overall, I found greater quality and consistency of information  within the systematic reviews and critically appraised topics and  articles. Nonetheless, I found several high quality randomized  controlled trials and cohort studies that provide high-quality  information for making a comparison between pharmacological and  non-pharmacological interventions for managing delirium. 

Helpful Tips for Literature Reviews

             I found the course guide for this discussion post extremely helpful. I  followed the guide to conduct my searches, find my articles, and  evaluate the information. I also like to use Google Scholar because the  search algorithm pulls a lot of information, it does have some  drawbacks, the main one being that the articles are not always available  in full text. But, it is very user-friendly, and because it casts a  wide net, I can easily find pertinent information. If I see an article  that peaks my interest that is not available in full text, I copy the  title or other vital information and then plug that information into the  Walden University Library. I have always been able to find the article I  want using this method. I also find it helpful to organize my search  results within folders, and to tag my articles with the types of  studies. I also find that the National Center for Biotechnology  Information (2019) is a great resource for locating free, full text,  peer-reviewed, scholarly articles (National Center for Biotechnology  Information, 2019). If I find a study I know that I definitely want to  use in my work, I will create a citation and save it in a word document.  When I begin writing, I can use my reference list that I started during  my literature review as a guide. I have found that this method of  source organization is both helpful and time-saving. 

References 

National Center for Biotechnology Information. (2019). Retrieved March 4, 2019, from https://www.ncbi.nlm.nih.gov/

Polit, D. F., & Beck, C. T. (2017). Nursing research generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer.

Walden  University. (2018). Evidence-Based Practice Research: Levels of  Evidence Pyramid. Retrieved from  https://academicguides.waldenu.edu/healthevidence/evidencepyramid#s-lg-box-8700027

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Respond to the post bellow in one or more of the following ways:

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.

Offer and support an alternative perspective using readings from  the classroom or from your own review of the literature in the Walden  Library.

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 insights or contrasting perspectives based on readings and evidence.

                                             Main Post

 An Intervention Program to Promote Health-Related Physical Fitness in Nurses

             This quantitative, quasi-experimental study conducted by Yaun et al.  (2009) aimed to determine the effects of an exercise intervention on  nurses’ health-related physical fitness. The researchers also expressed  an explicit interest in the relationship between physical fitness and  the incidence of musculoskeletal disorders. Taiwanese nurses from five  different units volunteered to be part of the study. The participants  were divided into two groups with 45 nurses in the experimental group  and 45 nurses in the control group. There was no randomization, but all  the participants gave written informed consent (Yaun et al., 2009). 

Internal Validity 

             According to Polit and Beck (2017), internal validity pertains to the  empirical relationship between the independent variable and the final  results. Researchers must establish that the intended cause created the  effect, and that it was not influenced by other variables (Polit &  Beck, 2017). After all, correlation does not equal causation, and an  astute researcher will adeptly identify and control convoluting  variables. Further, Andrade (2018) asserts that internal validity  assesses whether the design of the study, the conduct of the  researchers, and the analysis of the results answer the research  question without bias (Andrade, 2018). 

Consequently,  the research conducted by Yaun et al. did have some issues that  negatively impacted the internal validity of their research. Firstly,  convoluting variables were not adequately controlled. The exclusion  criteria consisted of cardiovascular disease, diabetes, hypertension,  renal disease, pulmonary disease, severe musculoskeletal aches, and  pregnancy. However, other significant variables such as age, gender,  marital status, educational level, or other medical issues. It is worth  noting that the diet and exercise habits of the participants were not  limited by the researchers.

Moreover,  the nurses in the experimental group worked a fixed schedule whereas  nurses in the control group worked alternating shifts. Secondly, the  lack of randomization coupled with the fact that the participants worked  for the same organization could have contaminated the results. Thirdly,  while the results of the research showed the exercise intervention  improved the physical fitness of the participants in the experimental  group, participants were not evaluated for musculoskeletal  improvements.   

Recommendations to Strengthen Internal Validity

A  different research design would have strengthened internal validity.  Randomization is the most effective way to control individual  characteristics of participants. Randomization also eliminates for the  Hawthorne Effect, which occurs when participants behave differently  because they know they are being studied. Moreover, a cross-over design  is highly effective when groups are being compared to one another.  Although, this design is subject to carryover bias, in which an effect  carries over from one experimental condition to another (Polit &  Beck, 2017). 

I  contend that a randomized control trial with a cross over design would  have increased the strength of the internal validity in this study. In a  cross-over design participants serve as their own control group, which  would negate the convoluting variables that influenced the results of  this study, and would more accurately gauge changes resulting from the  exercise intervention. I would also add a metric to assess the  musculoskeletal status of the participants. To limit the effects of  carryover bias, the health metrics of the participants would be obtained  before the exercise intervention to establish a baseline, then after  the exercise intervention, and finally, after a wash-out period, the  metrics should be re-recorded.

The Impact of Changes on Other types of Validity 

In  contrast to internal validity, statistical validity is not concerned  with the causal relationship between variables, but rather measures the  mathematical correlation of all relationships that occur between the  variables (Polit & Beck, 2017). The randomized control, crossover  design would improve statistical validity because the participants would  serve as their own control group making statistical analysis more  powerful. Construct validity determines if the outcome measured  corresponds to the theoretical construct of the study (Polit & Beck,  2017). In this research, the theoretical construct was Pender’s health  promotion model. Construct validity also would have been improved by  changing the design of the study. The same health promotion strategy  yields different outcomes for different participants based on individual  differences. The modification of the study’s design would have negated  these individual differences. External validity indicates if the results  of the research will remain the same when applied to other people or  settings (Polit & Beck, 2017). Again, a change in the design of this  research would optimize external validity which would increase the  likelihood of the results influencing evidence-based practice.

Failure to Consider Validity in Research

Failing  to properly account for and control variables threatens the validity of  the results yielded from the research. The rigor of the research design  may be the most important factor in strengthening or weakening  validity, as evidenced by the hierarchy of research studies in the  evidentiary pyramid. Other elements such as biased statistical analysis,  unreliable implementation of an intervention, carryover bias, and the  Hawthorne Effect are just a few variables that can threaten the validity  of a research study (Polit & Beck, 2017). Since research guides  evidence-based practice, failure to ensure the validity of results  directly affects patient outcomes; unfortunately, the effects of poorly  executed research impacts all research. People are inherently inclined  to remember negative consequences over positive outcomes. Improper  research regarding vaccines has created an anti-vaccination movement  that is highly problematic. Big tobacco companies produced improper  research that may have resulted in people continuing to smoke longer  than they otherwise would have. The failure to appropriately consider  validity in research is a grave mistake that should be avoided at all  costs. 

References 

Andrade, C. (2018). Internal, external, and ecological validity in research design, conduct, and evaluation. Indian Journal of Psychological Medicine,40(5), 498. doi:10.4103/ijpsym.ijpsym_334_18

Polit, D. F., & Beck, C. T. (2017). Nursing research generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer.

Yuan,  S., Chou, M., Hwu, L., Chang, Y., Hsu, W., & Kuo, H. (2009). An  intervention program to promote health-related physical fitness in  nurses. Journal of Clinical Nursing,18(10), 1404-1411. doi:10.1111/j.1365-2702.2008.02699.x

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Respond using one or more of the following approaches:

Ask a probing question, substantiated with additional background information, and evidence

Offer and support an alternative perspective using readings from the classroom or from your own review of the literature in the Walden Library.

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Reference:

Skloot, R. (2010). The immortal life of Henrietta Lacks. New York, NY: Crown Publishing Group.

                                                            MAIN POST

INITIAL POST

            Research drives innovation in health care and establishes evidence-based practice. The medical community relies on research to promote better practice, develop new technology, work more efficiently, and to develop life-saving medicines and treatments. The standards that guide research are of paramount importance. Research must be carefully planned, rigorously executed, replicable, and above all else, it must be ethical. Fouka and Mantzorou (2011) contend that within the context of research, ethics must be applied to the daily work of the study, the protection and dignity of research subjects, and to the publication of research. The primary ethical issues involving research are informed consent, beneficence, non-maleficence, respect for anonymity and confidentiality, and respect for privacy (Fouka & Mantzorou, 2011).

Lenzer (2016) reports that The Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) was a study that aimed to analyze the effects of extending work hours for first-year internal medicine residents on patient mortality and negative outcomes at a 30-day interval (Lenzer, 2016). Shea et al. (2018) maintain that the study analyzed several patient safety issues including readmission rates, prolonged length of stay, various medical complications, and overall costs associated with care. The iCompare research study was a randomized control trial conducted in the 2015-2016 academic year. It was funded by the National Institute of Health and included resident-subjects from 40 medical programs that agreed to sign an Institutional Affiliation Agreement. The University of Pennsylvania served as the institutional review board for all the participating medical programs. The researchers randomly assigned residents to work in one of two groups. Residents belonging to the first group worked a maximum 16 consecutive hours, which is the maximum number of hours allowed by the Accreditation Council for Graduate Medical Education, while residents belonging to the second group worked as many as 30 hours consecutively (Shea et al., 2018).  

Ethical Breaches in the iCOMPARE Study

Informed Consent

While it is true that the various academic institutions agreed to participate in the iCOMPARE study, and even assisted in facilitating the research, the residents nor the patients were informed that they were active participants in the iCOMPARE study (Lenzer, 2016). Informed consent is arguably the primary ethical issue for research that involves human participants. Informed consent requires that “a person knowingly, voluntarily, and intelligently and in a clear and manifest way, gives his consent” (Fouka & Mantzorou, para. 8, 2011). In order for informed consent to occur, research participants must be provided with an introduction of the study as well as the risks and benefits. Moreover, in denying informed consent the residents and patients were also denied autonomy and self-determination (Fouka &Mantzorou, 2011).

Matthew Alvin (2017) was a resident participant in the iCOMPARE research study. While he admits he did not give informed consent, he asserts that he gave implied consent to participate in the study. Alvin bases his assertion on the fact that prospective medical students were sent information about the iCOMPARE research study via email during the months in which they interviewed for residency assignments. And, that by participating in the residency program itself, he consented implicitly to any and all integral components of the academic program (Alvin, 2017). I respectfully disagree with Dr. Alvin’s assessment of implied consent, and would argue that information about a potential research study sent via email is informal and does not meet the legal or ethical litmus test for implied consent. Furthermore, the patient participants received no such informal email communication. They were not provided any information about the research, nor were the risks and benefits explained to them. The iCOMPARE study exposed both residents and patients to unnecessary risks and denied both groups the option of opting out of the study. The gross disregard for informed consent in the iCOMPARE study violated the very foundation for which reliable research is based.

Beneficence and Non-Maleficence 

Beneficence and non-maleficence are ethical principles which require researchers to have good intentions for the welfare of participants when conducting research. These principles require researchers to above all else, do no harm (Fouka &Mantzorou, 2011). The researchers in the iCOMPARE study showed blatant disregard for the ethical principles of beneficence and non-maleficence. Inexperienced first-year residents were pushed to the physical limits of exhaustion, working more than double the hours allowed by the Accreditation Council for Graduate Medical Education. This undoubtedly had both physical and psychological implications. Errors made by residents during this research could have potentially impacted the perceived quality of their residency experience, and contributed to internalized feelings of self-doubt. Moreover, Patients’ lives were put in the hands of residents who were purposely overworked simply to find out if fatigue contributes to medical errors. I did not find any data which corroborated or eliminated any undue harm incurred by either residents or patients during the iCOMPARE research study.

Suggestions for the iCOMPARE Study

Because ethical standards were not upheld during this research, the validity of the study is questionable. The designers of this research should have facilitated informed consent with the resident-participants, since some of them were working more hours than recommended by the Accreditation Council for Graduate Medical Education. Obtaining informed consent from the patient-participants is more of a gray area, because technically, medical residents are supervised by attending physicians who are ultimately responsible for the care provided. However, since the aim of the research was to determine if fatigue played a significant role in patient mortality and medical errors, I believe that patients had a right to be informed of the study.

It is likely that the researchers did not provide informed consent to the participants because they believed the participants, especially the residents would have behaved differently had they known they were part of a study, this phenomenon is known as the Hawthorne Effect (Poilt & Beck, 2015). Had the residents been provided with informed consent, they would have known which experimental group they were based upon the hours they were assigned, essentially negating any attempt at randomization. Nonetheless, these reasons are not significant enough to violate research ethics. The researchers should have chosen a quasi-experimental design for this study because it lacks randomization, and would have facilitated informed consent (Polit & Beck, 2017). When research is being conducted on sensitive issues, researchers should choose a design that maintains ethical standards, even if that design ranks lower on the evidentiary pyramid.

The researchers of iCOMPARE, leaders of 40 graduate medical programs including John Hopkins, The National Institute of Health, and an institutional review board at the University of Pennsylvania were all complicit in violating the ethical principles of informed consent, beneficence, and non-maleficence. The iCOMPARE study not only violated ethical principles and exposed medical residents and patients to potential dangers; it also compromised the value of any conclusions or statistical information deduced from the results of the study. Ethically flawed research negatively impacts the medical profession. The iCOMPARE study violated the relationship of trust which must be maintained between patients and medical providers. And, although Dr. Alvin believes implied consent is applicable to the participating residents in this case, he cannot speak for the countless other residents, nor the patients who unwillingly participated in this research study.  

References

Alvin, M. D. (2017). ICOMPARE: An interns perspective. Journal of Graduate Medical Education,9(2), 261-262. doi:10.4300/jgme-d-16-00711.1

Fouka, G., & Mantzorou, M. (2011). What are the major ethical issues in conducting research? Is there a conflict between the research ethics and the nature of nursing. Health Science Journal. Retrieved from http://www.hsj.gr/medicine/what-are-the-major-ethical-issues-in-conducting-research-is-there-a-conflict-between-the-research-ethics-and-the-nature-of-nursing.php?aid=3485

Lenzer, J. (2016). Groups call for “dangerous” trial of doctors’ working hours to stop. Bmj,I1070. doi:10.1136/bmj.i1070

Shea, J. A., Silber, J. H., Desai, S. V., Dinges, D. F., Bellini, L. M., Tonascia, J., . . . Asch, D. A. (2018). Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: A protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine. BMJ Open,8(9). doi:10.1136/bmjopen-2018-021711

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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.

                                                          INITIAL POST

            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).

Managing Delirium

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)?

Organizational Critique

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.

Organizational Barriers

            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.  

References

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/.

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