1 Evaluating the Evidence for Directly Obse.docx

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Evaluating the Evidence for Directly Observed Therapy in the
Treatment of Tuberculosis
Walden Student
Walden University
NURS 6052, Section 2, Essentials of Evidence-Based Practice
Dr. Trudy Tappan
May 7, 2016
2
Evaluating the Evidence for Directly Observed Therapy in the
Treatment of Tuberculosis
Tuberculosis continues to be an issue of concern in the United
States and around the

world. In 2014, there were 9.6 million people diagnosed with
tuberculosis and 1.5 deaths
worldwide (Centers for Disease Control and Prevention [CDC],
n.d.a). In the United States,
there were 9,421 new cases of tuberculosis that same year
(CDC, n.d.a). This paper will explore
the case management of tuberculosis in the United States,
focusing on the value of directly
observed therapy for tuberculosis clients. The purpose of this
paper is to explore the evidence
around the use of directly observed therapy in tuberculosis
clients. This will be accomplished by
formulating a researchable question, exploring the existing
research, and formulating a plan to
distribute the evidence to local public health nurses.
Part I - Identifying a Researchable Problem
Tuberculosis Treatment and Directly Observed Therapy
For clients who have been diagnosed with active tuberculosis
disease, appropriate
treatment is crucial. With proper medication, the majority of
tuberculosis cases can be
successfully treated (World Health Organization [WHO], 2016).
Without treatment, tuberculosis

is fatal in approximately two-thirds of all cases (WHO, 2016).
Recommended treatment for
tuberculosis involves treatment with antibiotics for 6 to 9
months (Centers for Disease Control
and Prevention [CDC], n.d.b). When clients with tuberculosis
do not take the medication as
prescribed either by skipping doses or by ending treatment
earlier than recommended, drug-
resistant tuberculosis can develop (CDC, n.d.b).
To increase successful tuberculosis treatment and decrease the
development of drug-
resistant tuberculosis, the Centers for Disease Control and
Prevention (n.d.c) recommends case
management of all tuberculosis cases. One component of case
management that the CDC
Comment [T1]: APA
Numbers:
Please make sure you are using numbers correctly. Review
pages 111-115 in APA to make sure you are apply the proper
rules governing the use of numbers in scholarly writing.

3
recommends is directly observed therapy (DOT). DOT involves
an individual, often a healthcare
worker, observing the client as the client takes his or her
medications (CDC, n.d.c). Including
DOT with all tuberculosis clients is standard care in many local
health departments in the United
States (CDC, n.d.c). At the local health department at which
I’m where I am employed, DOT is
most often performed in the client’s home.
The cost of performing DOT for tuberculosis clients includes
staff salary and travel
expenses. There are also costs to the client, including time and
inconvenience. Additionally,
there is often stigma attached to a diagnosis of tuberculosis
(Juniarti & Evans, 2011). It can be
difficult maintain a sense of privacy with frequent home visits
by local public health staff.
Because of the financial and personal costs involved with DOT,
it is important to evaluate
carefully the value of DOT.
Exploring Research Questions around DOT

Several research questions can be posed around the topic of
DOT and tuberculosis. The
first question posed is: does case management and directly
observed therapy lead to a higher cure
rate for clients diagnosed with tuberculosis? Although this is a
valid question, the topic is quite
broad. When conducting research, it is helpful to narrow the
topic to an appropriate level
(Walden University Library, 2012). The second question that I
posed was: is case management
without the use of directly observed therapy as effective as case
management with directly
observed therapy for clients with active tuberculosis disease?
This question focuses on the value
of case management in addition to DOT, and for this research
study, I want to limit my research
to the value of DOT. The third question I asked was: does
directly observed therapy cause an
increase in perceived stigma for clients being treated for
tuberculosis disease? Although this is
an important consideration around DOT, the question is quite
narrow. When questions are too
Comment [T2]: Writing refinement

It
Do not start a sentence with it.
This is not scholarly writing. It is an indefinite pronoun.
Starting a sentence with it causes your readers to pause
momentarily, while they figure out what it is. It makes your
sentences clumsy.
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narrow, there may not be sufficient research available (Walden
University Library, 2012). The
fourth question I asked was: is the use of remotely observed
therapy through the use of
technology as effective as in-person directly observed therapy
in clients being treated for active
tuberculosis disease? Again, this is a valid question, but more
narrow than I’d like my research
question to be. The fifth question I asked was: does directly
observed therapy increase

compliance with the medication regime for the entire course of
treatment in adults with active
tuberculosis disease compared to those who do not receive
directly observed therapy. This
question seems appropriate regarding the scope and is,
therefore, the question that will be
explored in the remainder of this paper.
PICOT Question
Composing a well-worded research question is an important
first step in conducting
research for evidence-based practice (Polit & Beck, 2012). The
acronym PICOT can be used to
frame research questions; PICOT stands for population,
intervention, comparison, outcome, and
time (Polit & Beck, 2012). The PICOT question that this paper
will explore is this: does directly
observed therapy increase compliance with the medication
regime for the entire course of
treatment in adults with active tuberculosis disease compared to
those who do not receive
directly observed therapy? The Population is adults with active
tuberculosis disease. The
intervention is directly observed therapy. The comparison

component is those who do not
receive observed therapy. The outcome is compliance with the
medication regime. The time
component is the entire length of treatment, which is typically 6
to 9 months (CDC, n.d.a). By
using the PICOT format, I assured the essential elements of the
research are address in the
research question.
Keywords
Comment [T3]: Contractions are not part of scholarly
writing.
Write "it is," never "it's." Write "do not," never "don't."
Write I am, not I’m – I’ve should be I have
Do not write "he'll" when you mean "he will"
Use should not, could not, would not, instead of the
contractions
5
Identifying search terms is another important step in searching
for research. The research
question identified will demonstrate which keywords to use in a

search. Keywords are often
based on the independent variables, dependent variables, and
population that are identified in the
question (Polit & Beck, 2012). When the research question is
written using the PICOT format,
the five key points of the PICOT question can be used to
identify keywords (Polit & Beck,
2012). Additional keywords can be identified after an initial
search by reviewing the subjects
area of a citation (Walden University Library, 2012). The
keywords that I used for my research
include tuberculosis, TB, directly observed therapy, DOT,
directly observed treatment,
antitubercular agents therapeutic use, tuberculosis drug therapy,
tuberculosis therapy, medication
compliance, and monitoring. I used a combination of keywords
in my search, including at least
one word or phrase to reference tuberculosis disease and
directly observed therapy in each
search. These keywords are based on the PICOT question, with
a focus on the population of
tuberculosis clients, the intervention of directly observed
therapy for tuberculosis treatment, and
the outcome of medication compliance. It was not necessary to

include the comparison or time
elements from the PICOT question to identify appropriate
resources for the research.
Part II - Literature Review
A good literature review provides the reader with a summary of
the current knowledge on
a subject or topic (Polit & Beck, 2012). This literature review
explores current research on the
effectiveness of directly observed therapy (DOT) on increasing
tuberculosis treatment
completion rates to help inform nursing practice in the United
States. To use the best available
evidence, I searched for filtered studies, specifically systemic
reviews.
DOT and Tuberculosis
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Cases of tuberculosis continue to occur in the United States
(CDC, n.d.d). Those
diagnosed with active tuberculosis disease need to take the full
course of medication, usually
involving six to nine months of treatment (CDC, n.d.b). DOT is
an intervention, recommended

by the World Health Organization, aimed at increasing
completion of the full course of treatment
for tuberculosis (Karumbi, 2015). Those who do not complete
the entire course of treatment are
at risk for reoccurrence of symptoms (CDC, n.d.b). The
research summary that follows will
evaluate the evidence to help answer the following research
question: does directly observed
therapy increase compliance with the medication regime for the
entire course of treatment in
adults with active tuberculosis disease compared to those who
do not receive directly observed
therapy?
Literature Review Summary
Karumbi (2015) published a recent systemic review of 11
studies in the Cochrane
Database of Systematic Reviews database. According to
Karumbi, the current research does not
support the routine use of DOT for tuberculosis clients.
Karumbi noted, however, that there was
value in DOTs when the management of the tuberculosis case
was limited to a monthly clinic
visit. Karumbi did not find support for DOTs when the client

had more frequent visits to a
healthcare professional.
The National Guidelines Clearinghouse (NGC) is a well-known
source for clinic practice
guidelines (Robeson, Dobbins, DeCorby, & Tirilis, 2010). NGC
guidance states that DOT is not
routinely recommended; DOT is only recommended for clients
that are experiencing
homelessness or near homelessness and for clients with a
history of noncompliance with
treatment (National Collaborating Centre for Chronic
Conditions, 2011). This guidance is
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similar to that suggested by Karumbi, however, the factors that
necessitate DOT be conducted
differ between the studies.
DOT may be conducted at a clinic and or in at a home or
community location (Wright,
Westerkamp, Korver, & Dobler, 2015). Wright, Westerkamp,
Korver, and Dobler (2015)
conducted a systemic review that addressed the differences
between DOTs conducted in a clinic

compared with those conducted in the community. Wright et al.
found that community-based
DOTs were more effective at improving tuberculosis treatment
success. Although this review
provides useful information, it has limited benefit because those
not receiving DOT were not
included in the review (Wright et al., 2015). Excellent
pointThis study was included in this
literature review because, in the United States, DOT can be
provided in community or home
locations for client convenience (CDC, n.d.c).
To have a broader understanding of the costs and benefits of
DOT from the client’s
viewpoint, this literature review includes a qualitative study.
Zuñiga (2012) conducted a case
study of a woman receiving DOT for tuberculosis. This case
study, conducted in the United
States, was chosen for inclusion in this literature review
because an understanding of the cost of
an intervention is needed to make an informed decision about
practice. Zuñiga found that the
client experienced psychological impacts from the DOT,
including stress and fear. Over time,

the stress and fear turned to paranoia, with the client feeling as
if she were continuously being
watched (Zuñiga, 2012). This study highlights the need to
consider quality of life issues when
assessing the cost and benefits of DOT.
The final study included in this literature review was cited in
the article by Zuñiga (2015)
as evidence supporting DOT. Chaulk and Kazandjian (2003)
conducted a systemic review
providing support to the use of DOT. This systemic review was
unique in two ways. First, it
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was based on studies conducted in the United States (Chaulk &
Kazandjian, 2003). The
systemic review by Karumbi (2015) and the guidance from the
NGC both were based on studies
carried out in numerous different countries (National
Collaborating Centre for Chronic
Conditions, 2011). Second, it classified DOTs into three
categories: patient-centered DOTs,
which included incentives along with DOTs; standard DOTs,
which included only incentives that

would cover transportation or treatment costs related to
tuberculosis; and modified DOT, which
only included DOT during hospitalization (Chaulk &
Kazandjian, 2003). Chaulk and
Kazandjian found that patient-centered DOT was the most
effective. Interestingly, Chaulk and
Kazandjian found that all three types of DOT were more
effective than unsupervised therapy,
although no incentives were provided for those receiving
unsupervised therapy.
Analysis of Findings
This literature review produced research with conflicting
information. In evaluating why
Chaulk and Kazandjian (2003) found DOT to be effective in
improving successful tuberculosis
treatment while Karumbi (2015) and others did not, a few
factors need to be evaluated. Chaulk
and Kazandjian’s study is over 12 years old and is based on
studies done in the United States.
Several studies had additional factors that were considered
when assessing the value of DOT.
Karumbi considered the frequency of medical or nursing care a
client received in addition to the
DOT. NGC’s recommendation was altered for clients that are

experiencing homelessness or
with a history of noncompliance with treatment (National
Conditions, 2011). Chaulk and Kazandjian considered the
benefits using incentives with DOT.
Zuñiga (2012) pointed out the need to consider the personal
costs of DOT to the clients.
Karumbi did not address quality of life issues in the review.
Chaulk and Kazandjian addressed
quality of life issues but focused on the added benefit of
incentives more than psychological
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impact of DOTs on clients. The differences between the
research findings reviewed here make it
difficult to draw decisive conclusions.
Preliminary Conclusion
Based on this literature review, it appears that additional
research is needed to answer
convincingly the question regarding the value of DOT in
improving tuberculosis cure rates.
Specifically, research is needed on the effectiveness of the use
of incentives without the use of

DOT. To be most useful to practitioners in the United States,
this research should be conducted
in the United States. None-the-less, the best and most recent
evidence points to the use of DOT
only with specific clients (Karumbi, 2015; National
Conditions, 2011).
Part III – Translating Evidence into Practice
PICOT Questions Significance to Nursing Practice
The PICOT question that this paper has researched is: does
directly observed therapy
increase compliance with the medication regime for the entire
course of treatment in adults with
active tuberculosis disease compared to those who do not
receive directly observed therapy?
This is a significant question for public health nurses who are
often responsible for conducting or
overseeing staff who conduct DOTs. With limited funding, the
wise use of public health nurses
time is vital. Controlling the spread of tuberculosis is an
important goal for public health nurses,
but it is important that the interventions are evidence based.

DOTs and Nursing Practice Supported by Evidence
The research cited in this paper supports the conditional use of
DOT. The conditions
under which it was supported varied between the studies.
Because the study by Karumbi (2015)
is a recent systemic review of 11 studies, those findings should
be heavily weighed. Karumbi
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found value for DOT only for clients who were infrequently
seen by healthcare providers. The
target population for this paper is tuberculosis clients who
reside in Minnesota; the standard
practice in Minnesota involves a weekly assessment visit
conducted or supervised by a public
health nurse (Minnesota Department of Health, n.d.).
Therefore, all tuberculosis clients in
Minnesota should be seen more than once per month.
Consideration should also be given to the
findings of Robeson, Dobbins, DeCorby, and Tirilis (2010) who
identified that clients
experiencing homelessness or near homelessness benefit from
DOT. Additionally, Chaulk and

Kazandjian (2003) found that when DOT is conducted, the use
of incentives increases treatment
compliance. When these studies are considered together, there
is support for limiting DOT to
clients that are high risk and using incentives whenever DOT is
utilized. Because public health
nurses can carefully assess their clients and determine who is at
high risk for non-compliance
based on a variety of factors, my recommendation based on this
research is that DOT is only
conducted with clients that are high risk for non-compliance,
including those experiencing
homelessness. I would also recommend the use of incentives
with all clients receiving DOT.
This approach allows for those who will most benefit from
DOTs to receive the service. It also
allows public health nurses to redirect some of their time from
DOTs on low-risk clients to other
valuable activities. This change in practice would benefit the
clients; those at high-risk would
receive the needed DOT, and those at low-risk would be spared
the inconvenience, stigma, and
intrusion into life activities that can come with DOT.
Disseminating Evidence and Influencing Practice

Research studies have limited value if the findings are not
made available to practitioners.
The findings from this literature review provide guidance on
practice changes that I want to
share with public health nurses in my unit. The first step in the
process is to share the research
Comment [T4]: Which ones specifically?
11
contained in this paper with my colleagues that perform or
oversee DOT visits. I have already
moved forward with this first step by talking about this research
to the supervisor of the nurses
who care for tuberculosis clients. The nursing supervisor
expressed interest in the research and
suggested the material be presented at a staff meeting. The
IMRAD format, which stands for
introduction, method, results, and discussion, can be used when
presenting findings at a meeting
(Polit & Beck, 2012). The following questions summarize the
IMRAD format: “why was the
study done…how was the study done…what was learned…[and]
what does it mean?” (Polit &

Beck, 2012, p. 682). I would use these questions to frame the
presentation to nurses about the
findings from this literature review.
The next step in the process would be determining if practice
changes should be made
and how those changes should be implemented. If the group
decided that they would like to
change the current practice of conducting DOTs on all clients
with active tuberculosis disease,
then a plan would be created to begin the implementation of the
change. The change in practice
would start small-scale (Cullen & Adams, 2012). If the change
was determined to be successful,
then the practice changes could be fully implemented. Cullen
and Adams (2012) discuss the
value of change agents, or champions, in changing nursing
practice. I would assess the interest
in this subject during the presentation and seek out respected
nurses to serve as champions for
this process. In addition to interest, I would consider
experience and knowledge level of nurses
recruited to fill the role of a champion (Aitken et al., 2011).
Those willing for to fill the role of

champion would be given training and tools to allow them to be
successful in their role (Aitken
et al., 2011). I would also seek support from senior leadership
as their support for evidence-
based practice changes can increase staff acceptance of the
change (Cullen & Adams, 2012).
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My local public health department is supportive of evidence-
based practice. The
department highly values education and scholarship. Making
changes within the organization is
supported by a Quality Improvement Council. The changes in
practice that have resulted from
quality improvement initiatives have been supported by senior
leadership and widely
communicated to staff throughout the health department. The
culture of this health department
supports the implementation of changes based on evidence.
This is good to hear!
Concerns would likely arise due to departing from standard
practice within the state. The
Minnesota Department of Health (n.d.) supports the use of DOT.
However, the Minnesota

Department of Health website states “DOT is especially critical
for patients with drug-resistant
TB, HIV-infected patients, and those on intermittent treatment
regimens” which supports
conditional use of DOT (para. 3). None-the-less, it would be
vital to ensure that this practice
change was in compliance with state rules and regulations.
Making this change would
necessitate careful communication between the local and state
health departments. I would
recruit supportive senior leadership to discuss this proposed
practice change with appropriate
state staff. It would be essential to report on the outcomes of
this communication with staff
nurses implementing the change.
I would anticipate some nurses would be more likely to
implement this practice change
than others. Cullen and Adams (2012) note that early adopters
of change can positively
influence late adopters. I would identify early adopters of this
practice change and ask them to
report on the impact on both the nurse and the client at a staff
meeting. I would also ensure that

all the nurses affected by this change would have access to the
research articles that support this
change (Cullen & Adams, 2012). This change would take
commitment, time, and clear
communication to be successfully implemented.
Comment [T5]: Interesting assessment
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Summary
This paper provides an overview of the process of developing a
research question,
conducting a literature review, and planning for implementation
of a practice change in the use
of directly observed therapy for clients with tuberculosis
disease. A research question was
formulated using the PICOT model. The question addressed in
this paper is: does directly
observed therapy increase compliance with the medication
regime for the entire course of
treatment in adults with active tuberculosis disease compared to
those who do not receive
directly observed therapy? The goal of this paper is to identify
evidence to support the nursing

practice of directly observed therapy (DOT).
A literature review was conducted on the effectiveness of DOT
in increasing the
tuberculosis medication compliance. Five studies were included
in this paper: three were
systemic reviews, one was a critically appraised topic, and one
was a case study. This paper
focused on filtered systemic reviews because they are the most
useful in informing practice (Polit
& Beck, 2012). The findings from the literature review
provided useful, although sometimes
conflicting, information on the value of DOT. Overall, the
research seemed to indicate that
DOTs are useful for specific population groups due to risk
factors for not completing
tuberculosis therapy. Future research on the effects of
incentives without the use of DOT would
strengthen the available evidence regarding the value of DOT
and be useful for informing
practice.
This paper includes a plan for disseminating the research and
using it to inform practice.
The research findings would be presented using the IMRAD

(introduction, method, results, and
discussion) format to nurses at a staff meeting. Support for the
proposed practice changes would
be sought from both senior leadership and staff who can
champion the change. An important
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component would be communication with the state health
department to ensure the change falls
within state requirements. The strong support for evidence-
based practice within my local health
department would increase the likelihood of this practice
change being successfully
implemented.
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References
Aitken, L. M., Hackwood, B, Crouch, S., Clayton, S., West, N.,
Carney, D., & Jack, L. (2011).
Creating an environment to implement and sustain evidence
based practice: A
developmental process. Australian Critical Care, 24(4), 244–

254.
doi:10.1016/j.aucc.2011.01.004
Centers for Disease Control and Prevention. (n.d.a).
Tuberculosis: Data and statistics. Retrieved
from http://www.cdc.gov/tb/statistics/
Centers for Disease Control and Prevention. (n.d.b).
Tuberculosis (TB) treatment. Retrieved
from http://www.cdc.gov/tb/topic/treatment/default.htm
Centers for Disease Control and Prevention. (n.d.c). Self-study
modules on tuberculosis.
Retrieved from
http://www.cdc.gov/tb/education/ssmodules/module9/ss9reading
2.htm
Chaulk, P., & Kazandjian, V. A. (2003). Comprehensive case
management models for
pulmonary tuberculosis. Disease Management & Health
Outcomes, 11(9), 571-577.
Retrieved from Walden Database
Cullen, L., & Adams, S. L. (2012). Planning for implementation
of evidence-based practice.
Journal of Nursing Administration, 42(4), 222–230. doi:
10.1097/NNA.0b013e31824ccd0a

Juniarti, N., & Evans, D. (2011). A qualitative review: The
stigma of tuberculosis. Journal of
Clinical Nursing, 20 (13/14), 1961-1970. doi:10.1111/j.1365-
2702.2010.03516.x
Karumbi, J. (2015). Directly observed therapy for treating
tuberculosis. Cochrane Database of
Systematic Reviews, (5).
doi:10.1002/14651858.CD003343.pub4
16
Minnesota Department of Health. (n.d.) Directly observed
therapy (DOT) for the treatment of
tuberculosis. Retrieved from
http://www.health.state.mn.us/divs/idepc/diseases/tb/lph/dot.ht
ml
National Collaborating Centre for Chronic Conditions. (2011).
Tuberculosis. Clinical diagnosis
and management of tuberculosis, and measures for its
prevention and control. London
(UK): National Institute for Health and Clinical Excellence
(NICE), 64 (Clinical
guideline; no. 117). Retrieved from:
http://www.guideline.gov/content.aspx?id=34833&search=direct

ly+observed+therapy+a
nd+directly+observed+therapy+and+tuberculosis
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating
and assessing evidence for
nursing practice (9th ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.
Robeson, P., Dobbins, M., DeCorby, K., & Tirilis, D. (2010).
Facilitating access to pre-
processed research evidence in public health. Retrieved from
Walden Database
Walden University Library. (2012). Evidence-based practice
research: Clinical question
anatomy. Retrieved from
http://academicguides.waldenu.edu/healthevidence/clinicalquest
ion
World Health Organization. (2016). What is TB? How is it
treated? Retrieved from
http://www.who.int/features/qa/08/en/
Wright, C. M., Westerkamp, L., Korver, S., & Dobler, C. C.
(2015). Community-based directly
observed therapy (DOT) versus clinic DOT for tuberculosis: a
systematic review and
meta-analysis of comparative effectiveness. BMC Infectious

Diseases, 15210.
doi:10.1186/s12879-015-0945-5
17
Zuñiga, J. A. (2012). A woman's lived experience with directly
observed therapy for
tuberculosis—a case study. Health Care for Women
International, 33(1), 19-28 10p.
doi:10.1080/07399332.2011.630118
18
Literature Review Summary Table
Citation Type of Study
Design Type
Framework/Theory
Setting Key
Concepts/Variables
Findings Hierarchy of

Evidence Level
Karumbi (2015)
Type of Study:
Systemic Review
Design Type: n/a
Framework/Theory:
None mentioned
This
systemic
review
included 11
separate
studies, all
of which
were
randomized
control trials
(RCT) or
quasi-RCTs.
Concepts:
Independent Variable:
DOT

Dependent Variable:
Tuberculosis cure rate
Controlled Variable:
Standard tuberculosis
care by health
professionals
This systemic review did not find
evidence that supports the use
of directly observed therapy
(DOT) to increase tuberculosis
cure rate. However, the
systemic review found a small
but statistically significant
increase in tuberculosis cure
rates when DOT was used in
clients with infrequent contact
with health professional (i.e.
once per month or less), as
demonstrated by two of the trials
included in this systemic review.
Level 1 –
Systemic
Review of RCT
and quasi-RCTs
National Collaborating
Centre for Chronic
Conditions. Tuberculosis.
(2011)
Type of Study:

Guideline Summary
Design Type:
n/a
Framework/Theory:
None mentioned
This
guideline
provides
guidance
based on
evidence for
the care of
clients with
tuberculosis.
Concepts:
DOT
Dependent Variable:
Tuberculosis cure rate
Standard tuberculosis
care by health
professionals

The use of DOT is not needed
for most cases of tuberculosis.
DOT may be recommended for
tuberculosis clients who are
experiencing homelessness or
who have a history of poor
adherence to treatment.
This article included
recommendations of ways other
than DOT to improve compliance
with treatment.
Level 2 –
Critically
appraised topics
19
Citation Study
Design Type
Framework/Theory
Setting Key
Concepts/Variables

Findings Hierarchy of
Evidence Level
Wright, Westerkamp,
Korver, & Dobler (2015)
Type of Study:
Systemic Review
Design Type: n/a
Framework/Theory:
None mentioned
This systemic
review
included
eight studies;
one study
was a RCT,
the remaining
seven studies
were none-
randomized
studies.
Concepts:
Independent
Variable:
Clinic based DOT
and community-
based DOT

Dependent Variable:
Tuberculosis
treatment success
and the number of
clients lost to follow-
up
Community-based DOT was
found to be better than clinic-
based DOT for improving
treatment success. This study
was limited in that there was only
one RCT. It was also limited in
that there was no comparison
with those not receiving any DOT.
Although community-based DOT
was more effective in improving
treatment success, there was no
difference in decreasing the
number of clients lost to follow-up.
Level 1 –
systemic review
Zuñiga (2012) Type of Study:
Case study
Design Type:
observational
Framework/Theory:

Phenomenology
This
qualitative
study
involved a
researcher
conducting
an interview
in a private
office with
one study
participant.
Concepts: This study
was based on the
lived experience of a
woman being treated
with DOT in the
United States.
Independent
Variable: n/a
Dependent Variable:
n/a
n/a
The DOT was found to have
negative psychological impacts
on the participant, including
stress, fear, and eventually
paranoia.

Level 6 – Case
Studies
(unfiltered)
Chaulk & Kazandjian
(2003)
Type of Study:
Design Type: n/a
Framework/Theory:
None mentioned
This systemic
review
examined
research
done on DOT
in the United
States.
Concepts:
Independent
Variable: Patient-
centered DOT (which
includes the use of
incentives), standard
DOT, modified DOT
(DOT only while
hospitalized), and
nonsupervised

therapy
Dependent Variable:
Tuberculosis
treatment completion
rates
Standard medical
treatment of
tuberculosis
This systemic review found
increased completion rates of
tuberculosis treatment with DOT
over nonsupervised treatment.
What the authors describe as
patient-centered DOT had the
best completion rates. Patient-
centered DOT included the use of
incentives along with directly
observed therapy. The
completion rates for unsupervised
therapy with incentives was not
included in this review.
Level 1 -
Systemic Review
20

Running head: SEPSIS LITERATURE REVIEW 1
Sepsis Literature Review
Student at Walden
Walden University
NURS 6052, Section 2, Essentials of Evidence-Based Practice
Please use portrait orientation for the paper, but place your
table in landscape. Find directions in doc sharing.
SEPSIS LITERATURE REVIEW 2
Sepsis Literature Review
Conducting a literature review is helpful to become familiar
with a topic of interest. The development of a clinical question
is
a necessary first step before searching for primary and
secondary literature sources (Polit & Beck, 2012, p. 96). Using
the databases
provided by the Walden University Library can be a helpful
resource while compiling a literature review. The purpose of
this project is
to conduct a literature review and, a synthesis of the studies

found. From this review, I will draw, and preliminary
conclusions about
the following PICOT question: In the adult population
diagnosed with severe sepsis or septic shock (P), is utilizing
early broad-
spectrum antibiotic therapy (I) superior to awaiting culture
results before antibiotic treatment (C), to reduce mortality rate
(O) during
inpatient hospitalization (T)?
Current State of Knowledge
The Journal of the American Medical Association (JAMA)
recently held a consensus to redefine sepsis and septic shock.
The
redefinition of terms stems from advances in diagnostics and the
need to clarify and simplify the stages of sepsis. The following
are
the definitions proposed by JAMA:
-threatening organ dysfunction caused by a
dysregulated host response to infection” (Singer & et al.,
2016).
y and cellular/metabolic
abnormalities profound enough to substantially increase
mortality” (Singer & et al., 2016).

Sequential Organ Failure Assessment (SOFA) scores are to be
utilized when diagnosing sepsis or septic shock. A SOFA score
of two
or greater is considered sepsis. Septic shock also has a SOFA
score greater than two, but the patient requires vasoactive
medications to
maintain an adequate blood pressure for organ perfusion and has
an elevated lactate level (Singer & et al, 2016).
More than one million Americans develop severe sepsis every
year. This life-threatening illness is frequently a result of a
bacterial infection that becomes serious enough to cause a
systemic inflammatory response syndrome (SIRS). Patients that
develop
sepsis are usually debilitated and often have other co-
morbidities (NIGHS, 2015). The risk of mortality increases if
sepsis is left
untreated. Symptoms of sepsis progress quickly from general
malaise to multisystem organ failure as seen in septic shock
(Leon, et al.,
2013). Studies suggest that one in four patients diagnosed with
sepsis will progress to severe sepsis or septic shock (Capp, et
al.,
2015). Early treatment of septic shock is essential to reduce
mortality rates (Gaieski, et al., 2010).

The Surviving Sepsis Campaign developed and published in
2013 an international guideline for the treatment of severe
sepsis.
The key features of the guidelines recommend that patients
receive resuscitative measures via intravenous fluids and
vasoactive
medications as necessary. Blood cultures are also to be drawn
from needed for patients that who are suspected to have severe
sepsis.
Furthermore, empiric antibiotics are to be administered within
the first six hours of the onset of the symptoms of sepsis
(Dellinger &
et al., 2013). The early administration of an empiric antibiotic
can improve the overall mortality rate of patients diagnosed
with severe
sepsis or septic shock (Ferrer, et al., 2009). Comment [T1]: Are
there more than one study that
concludes this? If so, cite them
Review of Literature Table
A review of literature table (RLT) is provided that provides
information related to the early administration of empiric
antibiotics to patients diagnosed with severe sepsis or septic
shock. Siddiqui & Razzak attempted a systematic review of
randomized

controlled trials (RCT) revealing no current RCT studies
(Siddiqui & Razzak, 2012). The study suggests that RCTs of
septic patients
would be unethical and that observational studies would be a
more appropriate approach to evaluate the relationship between
empiric
antibiotics and the mortality of septic patients (Siddiqui &
Razzak, 2012). There are, however, Oobservational studies
available that
suggest that the early administration of empiric antibiotics to
septic patients can reduce mortality (cite a few of those studies
here).
MacArthur, et al. conducted an observational study involving
2634 patients diagnosed with sepsis revealing a 43% mortality
rate of patients that did not receive appropriate empiric
antibiotics as compared to a 33% mortality rate for patients that
received
appropriate empiric antibiotics (MacArthur, et al., 2004).
Ferrer, et al. conducted an observational study of 2,796 patients
diagnosed
with sepsis revealing a 41.6% mortality rate of patients that did
not receive appropriate empiric antibiotics (Ferrer, et al., 2009).
Paul,
et al. conducted a meta-analysis of seventy prospective studies
that suggest that the appropriate empiric to septic patients
significantly

reduces overall mortality rates (Paul, et al., 2010). Studies with
fewer participants diagnosed with sepsis were conducted by
Gajeski, et
al., 2010 and Harbarth, et al., 2003 both suggesting that the
administration of early empiric antibiotics to septic patients
reduces
mortality rates. Comment [T2]: Excellent synthesis
Preliminary Conclusions
Systematic reviews or meta-analysis of RCTs summarize and
provide a high-quality synthesis of multiple RCTs and are
considered a gold standard in research (Polit & Beck, 2012, p.
30). Observational studies and reviews lack the randomization
of
groups found in RCTs. and They are prospective in design thus
decreasing the risk of unethical research. The utilization of a
prospective design was consistent with all the studies in the
RLT. The observational studies provided in the RLT represent a
small
group of patients, but there are significant findings suggest that
the administration of early empiric antibiotics to septic patients
can
reduce overall mortality (cite all studies that support this
conclusion). Continued research regarding the timing of empiric

antibiotics
can provide standards for evidenced based practice that can
reduce the mortality rates of patients diagnosed with severe
sepsis.
Summary
The purpose of this project was to conduct a literature review
addressing the PICOT question regarding the administration of
early empiric- antibiotics effects on the mortality rate of adults
diagnosed with severe sepsis. The findings of the literature
review
suggest that overall mortality is decreased when an appropriate
early antibiotic treatment is utilized for patients with severe
sepsis. The
main limitation of the studies is that RCTs is unethical. All
studies resorted to observational reviews of other RCTs that
included septic
patients who received antibiotics. Further study of the type and
timing of the administration of broad-spectrum antibiotics to
septic
patients’ needs to be evaluated. Comment [T3]: patients
References
Capp, R., Horton, C., Takhar, S., Ginde, A., Peak, D., Zane, R.,

& Marill, K. (2015). Predictors of patients who present to the
emergency department with sepsis and progress to septic shock
between 4 and 48 hours of emergency department arrival.
Critical Care Medicine, 43(5), 983-988. Retrieved from
http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/detail/
detail?vid=7&sid=ae3fe6e6-bd00-4cd7-b645-
27af89d436eb%40sessionmgr111&hid=125&bdata=JnNjb3BlPX
NpdGU%3d#AN=25668750&db=mnh
Dellinger, P., & et al. (2013). International guidelines for
management of severe sepsis and septic shock: 2012. Critical
Care Medicine
Journal, 41(2), 580-637. doi:10.1097/CCM.0b013e31827e83af
Ferrer, R., Artigas, A., Suarez, D., Palencia, E., Levy, M.,
Arenzana, A., . . . Sirvent, J. (2009). Effectiveness of
treatments for severe
sepsis. American Journal of Respiratory and Critical Care
Medicine, 180(9), 861-866. doi:10.1164/rccm.200812-19120C
Gaieski, D., Mikkelsen, M., Band, R., Pines, J., Massone, R.,
Furia, F., . . . Goyal, M. (2010). Impact of time to antibiotics on
survival
in patients with severe sepsis or septic shock in whom early
goal-directed therapy was initiated in the emergency
department.
Society of Critical Care Medicine, 38(4), 1045-1053.
doi:10.1097/CCM.0b013e3181cc4824

Harbarth, S., Garbino, J., Pugin, J., Romand, J., Lew, D., &
Pittet, D. (2003). Inappropriate initial antimicrobial therapy and
its effect
on survival in a clinical trial of immunomodulating therapy for
severe sepsis. The American Journal of Medicine, 115(7), 529-
535. doi:http://dx.doi.org/10.1016/j.amjmed.2003.07.005
Leon, A., Hoyos, N., Barrera, L., Rosa, G., Dennis, R., Duenas,
C., . . . Jaimes, F. (2013). Clinical course of sepsis, severe
sepsis, and
septic shock in a cohort of infected patients from ten Colombian
hospitals. BMC Infectious Diseases, 1-9. Retrieved from
http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfvie
wer/pdfviewer?vid=9&sid=8d0ed0c2-8f30-431c-8884-
77b4d709fa82%40sessionmgr102&hid=125
MacArthur, R., miller, M., Albertson, T., Panacek, E., Johnson,
D., Teoh, L., & Barchuk, W. (2004). Adequacy of early empiric
antibiotic treatment and survival in severe sepsis: Experience
from the MONARCS trial. Clinical Infectious Diseases, 38(2),
284-288. doi:10.1086/379825
NIGHS. (2015). Sepsis fact sheet. Retrieved from National
Institute of General Medical Sciences:

https://www.nigms.nih.gov/Education/pages/factsheet_sepsis.as
px
Paul, M., Shani, V., Muchtar, E., Kariv, G., Eyal, R., &
Leibovici, L. (2010). Systematic review and meta-analysis of
the efficacy of
appropriate empiric antibiotic therapy of sepsis. Antimicrobial
Agents and Chemotherapy, 54(11), 4851-4863.
doi:10.1128.AAC.00627-10
Polit, D., & Beck, C. (2012). Nursing research: Generating and
assessing evidence for nursing practice (Laureate Education,
Inc.,
custom ed.). Philidelphia, PA: Lippincott Williams & Wilkins.
Siddiqui, S., & Razzak, J. (2012). Early versus late pre-
intensive care unit admission broad spectrum antibiotics for
severe sepsis in
adults. Cochrane Database of Systematic Reviews. John Wiley
& Sons, Ltd. doi:10.1002/14651858.CD007081.pub2
Comment [T4]: I know this physician
Singer, M., & et al. (2016). The third international consensus
definitions for sepsis and septic shock (Sepsis-3). The Journal
of the

American Medical Association, 315(8), 801-810.
doi:10.1001/jama.2016.0287
Review of Literature Table
Citation Type of Study
Design Type
Framework/Theory
Setting Key
Concepts/Variables
Findings Hierarchy
of
Evidence
Level
(Ferrer, et al., 2009) Type of Study:
Observational
Design Type:
Prospective,

multicenter
Framework/Theory:
Setting:
2,796 adult
septic
patients in 77
intensive
care units
were studied
to determine
the
Concepts:
Early administration of
broad-spectrum
antibiotics
Dependent Variable:
mortality
Findings of this study show that
41.6% of the patients analyzed
died before hospital discharge.
The study suggests that there is
a decreased risk of mortality with
the use of the early
administration of broad-spectrum
antibiotics.
Level IV

None listed effectiveness
of treatments
recommende
d by sepsis
guidelines.
Patients diagnosed
with severe sepsis or
septic shock
(Gaieski, et al., 2010) Type of Study:
Observational
Design Type:
Single-center cohort
study
Framework/Theory:
None listed
261 patients
diagnosed
with severe
sepsis or
septic shock
in one
emergency
department

from 2005-
2006
Concepts:
Effects of the timing of
antibiotics on
mortality.
EGDT, timing of
antibiotics
Dependent Variable:
Mortality
Patient with severe
sepsis or septic shock
There were significant findings to
suggest that the early
administration of appropriate
antibiotics reduces the incidence
of mortality. Patients receiving
appropriate antibiotics under I
hour had a mortality rate of 25%
vs. 38.5% mortality rate for septic
patients that did not receive an
appropriate antibiotic within 1
hour.
Level IV

(Harbarth, et al., 2003) Type of Study:
Observational
Design Type:
Cohort
Framework/Theory:
None listed
Setting:
904 patients
diagnosed
with sepsis
were
evaluated for
the effect of
inappropriate
versus
appropriate
antibiotic
administratio
n related to
mortality.
Concepts:
Evaluate the
effectiveness of the
administration of
inappropriate
antibiotics related to

the prognosis of septic
patients.
Adequate antibiotics,
inadequate antibiotics
Dependent Variable:
Mortality
Patients diagnosed
Findings of this study suggest
that septic patients who received
inadequate antibiotics had
increased rates of mortality. The
mortality rate of septic patients
who received adequate
antibiotics was 24% versus 39%
mortality for patients who did not
receive adequate antibiotics.
Level IV
with sepsis
(MacArthur, et al., 2004) Type of Study:
Observational
Design Type:

Prospective
Framework/Theory:
None listed
Setting:
2634 patients
were enrolled
to determine
mortality rate
of patients
receiving
adequate
antibiotics
versus
inadequate
antibiotics
Concepts: Evaluation
of the effectiveness of
the administration of
appropriate antibiotics
in patients with severe
sepsis or septic shock
on the mortality rate
within twenty-eight
days
adequate antibiotics,
inadequate antibiotics
Dependent Variable:
Mortality at twenty-

eight days
Patients diagnosed
with sepsis
Septic patients who received
appropriate antibiotic treatment
was 33% and a 43% mortality
rate in septic patients who
received inadequate antibiotics
The significant findings of this
trial conclude that the use of
appropriate antibiotic therapy
decreases the mortality rate in
patients with suspected sepsis.
Level IV
(Paul, et al., 2010) Type of Study:
Systematic Review
Design Type:
Prospective, cohort
Framework/Theory:
None listed
Setting:
Meta-
analysis of
seventy
prospective

studies
Concepts:
Analysis of the effects
of appropriate timing
of empirical antibiotics
on the mortality in
septic patients.
Appropriate empirical
antibiotics,
inappropriate
antibiotics
Dependent Variable:
Mortality
The findings of this study
suggest that the use of
appropriate empirical antibiotics
can significantly reduce mortality
among patients with severe
sepsis or septic shock. Mortality
rate was found to be 34% in
septic patients that did not
receive adequate antibiotics.
Level III

Patients
diagnosed with severe
sepsis or septic
shock.
(Siddiqui & Razzak,
2012)
Type of Study:
Systematic Review
Design Type:
Review of RCTs
Framework/Theory:
None listed
Review of
RCTs for
patients with
severe sepsis
of septic
shock, timing
of broad-
spectrum
antibiotics
Concepts:
The outcome
assessment of
patients receiving
early versus late
antibiotic

administration.
Timing of antibiotic
administration
Dependent Variable:
Mortality
Patient diagnosed
with severe sepsis or
septic shock
There were no studies that fit the
criteria to satisfy this study. The
authors of this study do,
however, feel that randomizing
critically ill patients can be
unethical and that observational
cohort studies would be more
appropriate.
Level I
Comment [T5]: This sentence is unclear
Discussion Rubric

Levels of Achievement
Criteria
Outstanding Performance
Excellent Performance
Competent Performance
Room for Improvement
Poor Performance
Content-Main Posting
30 to 30 points
-Main posting addresses all criteria with 75% of post
exceptional depth and breadth supported by credible references
27 to 29 points
-Main posting addresses all criteria with 75% of post
exceptional depth and breadth supported by credible references
24 to 26 points
Main posting meets expectations. All criteria are addressed with
50% containing good breadth and depth.
21 to 23 points
Main posting addresses most of the criteria. One to two
criterion are not addressed or superficially addressed.
0 to 20 points
Main posting does not address all of criteria, superficially
addresses criteria. Two or more criteria are not addressed.
Course Requirements and Attendance
20 to 20 points
-Responds to two colleagues’ with posts that are reflective, are
justified with credible sources, and ask questions that extend
the discussion.
18 to 19 points
-Responds to two colleagues’ with posts that are reflective, are
justified with credible sources, and ask questions that extend
the discussion.
16 to 17 points
Responds to a minimum of two colleagues’ posts, are reflective,
and ask questions that extend the discussion. One post is
justified by a credible source.

14 to 15 points
Responds to less than two colleagues’ posts. Posts are on topic,
may have some depth, or questions. May extend the discussion.
No credible sources are cited
0 to 13 points
Responds to less than two colleagues’ posts. Posts may not be
on topic, lack depth, do not pose questions that extend the
discussion
Scholarly Writing Quality
30 to 30 points
-The main posting clearly addresses the discussion criteria and
is written concisely. The main posting is cited with more than
two credible references that adhere to the correct format per the
APA Manual 6th Edition. No spelling or grammatical errors.
***The use of scholarly sources or real life experiences needs
to be included to deepen the discussion and earn points in reply
to fellow students.
27 to 29 points
is written concisely. The main posting is cited with more than
two credible references that adhere to the correct format per the
APA Manual 6th Edition. No spelling or grammatical errors.
24 to 26 points
is written concisely. The main posting is cited with a minimum
of two current credible references that adhere to the correct
format per the APA Manual 6th Edition. Contains one to two
spelling or grammatical errors.
21 to 23 points
-The main posting is not clearly addressing the discussion
criteria and is not written concisely. The main posting is cited
with less than two credible references that may lack credibility
and/or do not adhere to the correct format per the APA Manual
6th Edition. Contains more than two spelling or grammatical
errors.

0 to 20 points
-The main posting is disorganized and has one reference that
may lack credibility and does not adhere to the correct format
per the APA Manual 6th Edition or has zero credible references.
Contains more than two spelling or grammatical errors.
Professional
Communication
Effectiveness
20 to 20 points
-Communication is professional and respectful to colleagues
and response to faculty questions are answered if posed.
Provides clear, concise opinions and ideas effectively written in
Standard Edited English -Responses posted in the discussion
demonstrate effective professional communication through deep
reflective discussion which leads to an exchange of ideas and
focus on the weekly discussion topic.
18 to 19 points
-Communication is professional and respectful to colleagues. -
Standard Edited English -Responses posted in the discussion
focus on the weekly discussion topic . -Responses are cited with
at least one credible reference per post and a probing question
that extends the discussion. Adheres to the correct format per
the APA Manual 6th Edition. No spelling or grammatical errors.
16 to 17 points
-Communication is professional and respectful to colleagues.
Standard Edited English. -Responses posted in the discussion
focus on the weekly discussion topic. -Responses are cited with
at least one credible and/or contain probing questions that
extends the discussion. Adheres to the correct format per the

APA Manual 6th Edition. May have one to two spelling or
grammatical errors.
14 to 15 points
-Communication is professional and respectful to colleagues.
Provides opinions that may not be concise or ideas not
effectively written in Standard Edited English. -Responses
posted in the discussion may lack effective professional
communication that does not extend the discussion, leads to an
exchange of ideas and/or not focused on the weekly discussion
topic. -Responses are not cited and/or do not contain a probing
question. May not adhere to the correct format per the APA
Manual 6th Edition. May have more than two spelling or
grammatical errors.
0 to 13 points
-Communication may lack professional tone or be disrespectful
to colleagues. Provides opinions that may not be concise or
ideas not effectively written in Standard Edited English -
Responses posted in the discussion lack effective professional
communication through discussion that does not extend the
discussion, do not lead to an exchange of ideas and/or not
focused on the weekly discussion topic. -Responses are not
cited and do not contain a probing question. May not adhere to
the correct format per the APA Manual 6th Edition. May have
multiple spelling or grammatical errors.
Timely Submission
0 to 0 points
All criteria met: Initial post submitted on time. Response to two
peer initial posts. Response on 3 separate days.
-5 to 0 points
5 points deducted for responding to less than two peers or 5
points deducted for responding less than three days
-10 to -5 points
5 points deducted for responding to less than two peers and 5
points deducted for responding less than three days
-10 to -10 points

10 points deducted for Initial post submitted late
-20 to -15 points
Initial post submitted late and 5 points deducted for responding
to less than two peers and/ or 5 points deducted for responding
less than three days
Course Project: Part 3—Translating Evidence Into Practice
In Part 3 of the Course Project, you consider how the evidence
you gathered during Part 2 can be translated into nursing
practice.
Now that you have located available research on your PICOT
question, you will examine what the research indicates about
nursing practices. Connecting research evidence and findings to
actual decisions and tasks that nurses complete in their daily
practice is essentially what evidence-based practice is all about.
This final component of the Course Project asks you to translate
the evidence and data from your literature review into authentic
practices that can be adopted to improve health care outcomes.
In addition, you will also consider possible methods and
strategies for disseminating evidence-based practices to your
colleagues and to the broader health care field.
To prepare:
· Consider Parts 1 and 2 of your Course Project. How does the
research address your PICOT question?
· With your PICOT question in mind, identify at least one
nursing practice that is supported by the evidence in two or
more of the articles from your literature review. Consider what
the evidence indicates about how this practice contributes to
better outcomes.
· Explore possible consequences of failing to adopt the
evidence-based practice that you identified.
· Consider how you would disseminate information about this
evidence-based practice throughout your organization or
practice setting. How would you communicate the importance of
the practice?

To complete:
In a 3- to 4-page paper:
· Restate your PICOT question and its significance to nursing
practice.
· Summarize the findings from the articles you selected for your
literature review. Describe at least one nursing practice that is
supported by the evidence in the articles. Justify your response
with specific references to at least 2 of the articles.
· Explain how the evidence-based practice that you identified
contributes to better outcomes. In addition, identify potential
negative outcomes that could result from failing to use the
evidence-based practice.
· Outline the strategy for disseminating the evidence-based
practice that you identified throughout your practice setting.
Explain how you would communicate the importance of the
practice to your colleagues. Describe how you would move from
disseminating the information to implementing the evidence-
based practice within your organization. How would you
address concerns and opposition to the change in practice?
Course Project: Part 2—Literature Review
This is a continuation of the Course Project presented in Week
2. Before you begin, review the Course Project
Overview document located in the Week 2 Resources area.
The literature review is a critical piece in the research process
because it helps a researcher determine what is currently known
about a topic and identify gaps or further questions. Conducting
a thorough literature review can be a time-consuming process,
but the effort helps establish the foundation for everything that
will follow. For this part of your Course Project, you will
conduct a brief literature review to find information on the
question you developed in Week 2. This will provide you with
experience in searching databases and identifying applicable
resources.
To prepare:

· Review the information in Chapter 5 of the course text,
focusing on the steps for conducting a literature review and for
compiling your findings.
· Using the question you selected in your Week 2 Project (Part 1
of the Course Project), locate 5 or more full-text research
articles that are relevant to your PICOT question. Include at
least 1 systematic review and 1 integrative review if possible.
Use the search tools and techniques mentioned in your readings
this week to enhance the comprehensiveness and objectivity of
your review. You may gather these articles from any appropriate
source, but make sure at least 3 of these articles are available as
full-text versions through Walden Library’s databases.
· Read through the articles carefully. Eliminate studies that are
not appropriate and add others to your list as needed. Although
you may include more, you are expected to include a minimum
of five articles. Complete a literature review summary table
using the Literature Review Summary Table Template located in
this week’s Learning Resources.
· Prepare to summarize and synthesize the literature using the
information on writing a literature review found in Chapter 5 of
the course text.
To complete:
Write a 3- to 4-page literature review that includes the
following:
· A synthesis of what the studies reveal about the current state
of knowledge on the question that you developed
· Point out inconsistencies and contradictions in the literature
and offer possible explanations for inconsistencies.
· Preliminary conclusions on whether the evidence provides
strong support for a change in practice or whether further
research is needed to adequately address your inquiry
· Your literature review summary table with all references
formatted in correct APA style
1

IDENTIFYING A RESEARCHABLE PROBLEM 5
Identifying a Researchable Problem
Janeika Barnes
Walden University
NURS 6052, Section 2, Essentials of Evidence- Based Practice
June 12,2016
Identifying a Researchable
Problem
Nurses are essential key players within the healthcare delivery
system. Research plays a vital role in nursing in terms of the
current and future directions of healthcare. In order for any
research to be successful a strategy needs to be in place. The
researcher must have specific questions which are answerable as
it pertains to the problem in question. Researchers must rely on
successful studies to acquire accurate literature in order to
provide useful and credible information. This can be
accomplished by formulating a list of keywords and background
questions. The purpose of this paper is to identify and
summarize a problem of interest, develop a PICOT question
with back ground questions and identify keywords that will aid
in researching the proposed problem.Problem of Interest
According to (Martha, Karp, Bauer, Raghavan, Terrin and
Zwicker, 2012) over 30 percent of women in the study of 500,
women ages 25-40 who takes oral contraceptives versus Intra
Uterine Devices (IUD) or no birth control are at a greater risk
of having a venous thromboembolic event. Venous
thromboembolic events can be a life threating medical problem.
The risk of these thromboembolic complications can cause
serious issues and is very important to bring awareness to
women within the ages 25-40. According to (Lidegaard,
Lokkegaard, Jensen, Skovlund and Keiding, 2012) studies have
shown that thromboembolic complications ranges from
myocardial infarction, thrombolytic stroke and even pulmonary
embolism.
Studies suggest that before women consider taking any form of

birth control whether its oral or an implanted device to be well
informed of potential risk factors. Risk factors includes
smoking, obesity, and a family history of thrombosis. These risk
factors will increase a woman chances of developing a
thromboembolic complication when taking oral contraceptive.
PICOT Question1
The acronym PICOT is a tool used to break down clinical
questions into searchable keywords (Davies, 2011, p. 75). The
acronym PICOT stands for (P) Patient/Population, (I)
Intervention, (C) Comparison, (O) Outcome and (T) Time.
Composing a question using PICOT is more methodological and
provides more of an effective search. The proposed research
question for his project is: Are women ages 25-40 (P) who take
oral contraceptives (I) at greater risk for developing blood clots
(O) compared with women ages 25-40 (P) who use IUDs for
contraception (C) over a 5-year time frame (T)?
Researchable Questions.
Background questions are general in nature, they form the
foundation of a clinical question (Polit & Beck,2012, p.33). The
following are background questions that will aid in answering
the proposed PICOT question.
· What are oral contraceptives?
· Types of oral contraceptives?
· What is a Intra Uterine Device (IUD)?
· Risk factors for taking contraceptives?
· Complications associated with contraceptives?
The first three questions are geared towards background
information on the proposed problem. The fourth question will
identify the population with the greatest risk factors for the
proposed problem. Last question forms the main focus of the
final paper.
Supporting Literature and Keywords.

Keywords are important terms used to search on a database to
enhance a research for supporting literature (Polit & Beck
,2012. p.732). The keywords: Blood clots, oral contraceptives,
Intrauterine Device, thrombosis, randomized, nonrandomized,
thromboembolic events, systematic reviews, study and risk were
used in multiple search engines to acquire information for this
paper. Systematic review, critically appraised topics, and
critically appraised individual articles fall under filtered
information. Filtered resources offered more detailed
information, eliminates poorly done studies and asks specific
clinical questions and attempt to make practical
recommendations as it pertained to my PICO
question. Unfiltered resources provide access to randomized
control trials, cohort studies and case report. Unfiltered
resources were limited in terms of the quantity of information
found pertaining to my PICO question.
Summary
Thromboembolic events are serious issues that relates to oral
contraceptives. Nurses plays a very vital role not only as a
patient advocate be nurses. Nurses are the major players in
keeping patients informed about potential risk of any
medication. Nurses provide patients with educational tips and
resources. The formulation of a PICOT question can aid in a
successful high quality research.
References
Davies, K. S. (2011). Formulating the evidence based practice
question: A review of the frameworks. Evidence Based Library
and Information Practice, 6(2), 75-80. Retrieved from
https://ejournals.library.ualberta.ca/index.php/EBLIP/article/vie
wFile/9741/8144
Lidegaard, O.,Lokkegaard, E., Jensen,A., Skovlund,C
&Keidling, M. (2012) Thrombotic Stroke and Myocardial
Infarction with Hormonal Contraception. NEngl J Med
2012;366-2257-2266. DOI:10.1056/NEJMoa1111840.
Mantha, S.,Karp,R., Raghavan,V.,Terrin,N.,Bauer,K

&Zwicker,J.I (2012) Assessing the risk of venous
thromboembolic events in women taking progestin-only
contraception: a meta-analysis. BMJ 2012;345: e4944
DOI:10.1136/bmj. e4944.
Polit, D. F., & Beck, C. T. (2017). Nursing research:
Generating and assessing evidence for nursing practice (10th
ed.). Philadelphia, PA: Wolters Kluwer.

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