Development of Nursing Practice PICO Question, Research Paper Example

PICO Question

In postpartum women, how does utilizing a postpartum depression (PPD) screening tool compared with no screening tool, impact the identification or diagnosis of risk factors for PPD during hospital stay post-delivery?

Population of Interest

Postpartum women between ages 18 to 50 with no previously diagnosed psychological disorders. All women will be recruited for study from a maternity ward in the same hospital.

Intervention of Interest

Postpartum screening tests that are approved for use by most health insurance companies, including the Edinburgh Postnatal Depression Scale (EPDS), the Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire (PHQ-9) (Castle, 2008).

Comparison of Interest

No previously utilized screening tools.

Outcome of Interest

Determining whether postpartum screening tests will help identify risk factors for PPD during the hospital stay.

Design

Approximately 120 women will be recruited to the study and randomized to the control group or one of three experimental groups. 30 women will be assigned to the control group that receives no postpartum screening test post-delivery, while 30 women will be assigned to receive assessment under the Edinburgh Postnatal Depression Scale (EPDS), 30 will be assessed using the Postpartum Depression Screening Scale (PDSS), and a final 30 will be assessed using the Patient Health Questionnaire (PHQ-9).Women will not be recruited for study if they are outside the range of 18 to 50 to ensure that all participants are of normal reproductive age and will therefore not be subject to unreasonable mental stress that may confound results. In addition, individuals with a history of other psychological disorders will be excluded from the study to increase certainty that the symptoms being observed are only due to PDD. It is expected that all volunteers will have similar demographics due to their proximity to the hospital. As a consequence, it can be considered that socioeconomic status (SES) is not a relevant confounding factor for the study. The race breakdown of all women is expected to be generally representative of the surrounding population. All volunteers will be approached prior to delivery in the emergency room, where they will be consented. At this point the random number generator will be utilized to assign each participant to an experimental or control group, and a patient identification number will be recorded.

Patients will be consented in a manner that informs them that they are able to withdraw from the study at any time. It will also detail the benefits that patients will receive for agreeing to participate. However, it is essential for all patients to be consented before the birth so that baseline PPD assessments may be performed prior to the event. Furthermore, patients will be asked to complete a quick demographic survey to ensure that they are eligible for the study. Questions will ask the patient to record their birthday and health history as it pertains to mental disorders in addition to basic demographics, such as race and address. Demographics will be used to confirm whether the patient population that was recruited reflects the general population of the area.

On average, postpartum patients remain hospitalized for approximately 2 days (Farhat et al., 2011). Therefore, it is necessary for the patients to be provided the assigned postpartum screening test the day following the birthing, in order to allow for recovery time. Furthermore, since patients are most likely to develop and exhibit PPD symptoms four weeks following the birth, patients will asked to return to the hospital for a follow up examination four weeks following the delivery (Hagen, 1999). Before the birth, one day after the birth, and four weeks following, participants will be screened for PPD symptoms including loss of appetite, insomnia, intense irritability and anger, fatigue, decrease in sexual interest, a general lack of joy in life, feelings of shame, severe mood swings, difficulty bonding with the baby, withdrawal from family and friends, and thoughts of harming oneself or the baby (Thurgood et al., 2009). The researcher will utilize a checklist during the examination to determine whether these descriptions apply to each participant. If a total of five symptoms are checked off, they will be considered to have PPD for the purpose of the study.

For each patient, PPD symptoms prior to the birth and following the birth will be compared in addition to the PPD symptoms following to the birth and during the four week follow up. An analysis will be performed to determine whether the patient developed PPD following the birth, either the day following or four weeks later. Each PPD case will be counted and recorded and the same will be done for the patient population that did not develop the illness. This will be done separately for the control group and three experimental groups to gain a basic understanding of disease development.

Next, the scores retrieved on the PPD screening tests will be compared with the patient disease status using a student’s t-test separately for each tool. This will allow the research to determine which PPD screening tool best helps predict the development of the illness. In addition, analysis will be performed to determine how adequate the disease status of individuals that were not provided the PPD screening tool were predicted. This will determine whether it is necessary to use the PPD screening tool, or whether it is adequate to simply use general symptom recognition.

In addition, line graphs will be generated to depict the evolution of patient symptoms over the three data points, before birth, the day following birth, and the four weeks following birth. This will indicate the general trend of symptom development for the each study group. An average number of symptoms recorded will be determined and represented graphically as well. It is expected that both the control and experimental groups will follow the same trend. If this is not the case, it is likely that the randomization was not effective and that the study should be repeated using a greater sample size.

Feasibility

The average study duration for each participant will be no more than five weeks. Since most patients will be hospitalized for two days, and then asked to return for follow up four weeks later, it is expected that a patient will not be seen after 30 days from the time they give birth. Therefore, to ensure that the project will remain within a 16 week timeline, a maximum of 6 weeks will be spent recruiting patients for study, which will allow the last patient recruited to be seen at the 10 week mark. This will allow six more weeks for the analysis and compilation of results in addition to the production of the written report.

In addition, it will be reasonable to recruit 120 patients in my health care institution. By chance, it is likely that the lowest number of births that will occur in a day is 50. Thus, even if the lower range is met, it would be possible to recruit all patients needed to conduct this study in a three day period. It is likely, however, that all 120 patients would be present in the hospital on the same. To ensure that I am able to approach 120 patients in a manner that will allow them to be consented appropriately, I will aim to spend 5 days a week recruiting patients, meaning that I will need to recruit an average of 4 patients a day to achieve my goal. This study is therefore within the realm of feasibility in terms of the time that I have available to spend for recruitment in addition to the number of patients available for recruitment in the hospital.

It is reasonable to believe that at least 120 patients will agree to taking part in this study due to the free medical benefits that it will provide them with. It is not common practice to utilize a PPD assessment tool until symptoms arise, and the women that participate in the study will therefore have access to early detection. Furthermore, they will be provided with the knowledge that participating in the study will help shape practice and potentially assist many expecting mothers in the future.

An additional concern would be that it is typically unlikely for patients to follow up in studies. However, this should not be an issue for this particular patient population because it will be necessary for them to visit the clinics regularly after giving birth in order to ensure that they are fully recovered. Therefore, their follow up session will be made to coincide with their regular examination so that they will be more likely to attend. In addition, patients will be asked to provide several forms of contact information to ensure that they can be reached. Efforts will be made to reach these individuals for follow ups two weeks prior to their expected visit, and a reminder will be provided one week and one day before the visit. Participants will continue to be contacted if they cannot be reached. Due to the time restriction provided, participants will be considered lost to follow up if they cannot be contacted two weeks after the time that their follow up visit was supposed to occur. Provided that each participant may come in for the follow up at variable times, the amount of days the follow up occurs after the birth will be recorded for records and analysis if necessary.

The results of the study are expected to be relatively straightforward and easy to analyze in the six week period partitioned for these activities due to the efficacy of the study design. Since confounding variables have already been considered during the initial design of the study, there will be no need to conduct multivariate regression analyses to determine whether these confounders or mediators exist. This also provides the researcher with the opportunity to clarify information as needed.

Identification

This study is being performed at the mesoscopic level. While the study is not being conducted on a hospital wide or network scale, the patient population being studied reflects the average individuals who are seen in the maternity ward. Therefore, the results provided by the 120 patients is expected to be internally valid in a manner that will allow practice in the local healthcare organization to shift. Furthermore, this study provides the opportunity for external validation. To do so, it would be necessary to determine whether the results of this study hold true for patient populations in other hospitals, regions and states.

This study functions as a cross-sectional study because the patient population is measured at only a single point in time. In this situation, this is the one month period following the birth. However, data will be incorporated from a second time point in order to draw connections between time and the development of PDD. While it is likely that a longitudinal study would be needed to enact policy change, the cross-sectional format of the study provides evidence in a manner that will allow the generation of preliminary results that can then be used to determine whether a different study design would be necessary to alter practice on a larger scale. However, as is, the study design is useful for changing practice on the hospital level.

References

Castle J. (2008). Early Detection Of Postpartum Depression: Screening In The First Two To Three Days. The Journal of Lancaster General Hospital, 3(4).

Farhat R, Rajab M. (2011). Length of postnatal hospital stay in healthy newborns and re-hospitalization following early discharge. N Am J Med Sci, 3(3): 146–151.

Hagen EH. (1999). The Functions of Postpartum Depression. Evolution and Human Behavior,  20(5): 325–59.

Thurgood S, Avery DM, Williamson L. (2009). Postpartum Depression (PPD). American Journal of Clinical Medicine, 6(2): 17-22.