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Principles of evidence based practice

Introduction

Evidence based practice is a complex experience that requires synthesizing study findings to establish the best research evidence and correlate ideas to form a body of empirical knowledge (Burns & Grove 2007). There are many definitions but the most commonly used is Sackett et al (1996). Sackett et al (1996) as cited in Pearson, Field, & Jordon, (2007).describes evidence based practice

“the conscientious, explicit and judicious use of current best available evidence in making

decisions about the care of individual patients. The practice of evidence based medicine

means integrating individual clinical experience with the best available external evidence

from systematic research”. (Sackett et al 1996 page 5).

The author will discuss the importance of evidence for practice, different types and levels of evidence. The research process, dissemination of evidence, barriers and will conduct a critique of two research articles.

The importance of evidence based practice is to enable nurses to provide high quality care, improve outcomes for patient and families and to run a more efficient health service. Therefore other agencies within the health service will benefit when interventions and care is based on research (Burns & Grove 2007). According to the Nursing and Midwifery Council (NMC) code nurses are accountable to society to provide a high quality of care so therefore it is important that nurses reflect, evaluate the care and keep abreast of new knowledge and evidence that is available (Burns & Grove 2007). Providing a streamlined service, which is cost effective and based on current evidence based practice has shown to reduce cost but also to enhances the quality of care the patient receives (Melnyk et al2010). Working in partnership with the nurse the patient is able to participate in decisions about their care. This is not only beneficial for the patient but also increases the satisfaction of the nurse treating the patient (Craig & Smyth 2007). Furthermore Craig & Smyth (2007) suggests evidence based practice is a problem-solving approach to the delivery of health care. In using a problem solving approach the nurse is able to integrate clinician expertise and patient preferences to provide individualized care suitable for the patient.

To acquire knowledge in the past, nurses have relied on decisions based on trail or error, personal experience, tradition and ritual. Parahoo (2006) suggests learning by tradition and ritual are important means of transferring knowledge, for example learning the ward routine. According to Brooker and Waugh (2007) Students learn from effective colleagues who practice safety and on the basis of best evidence. However, a disadvantage of this method of learning may lead to transmission of invalid information and may put the patient and nurse at risk (Brooker & Waugh 2007). According to Burns and Grove (2007) to generate knowledge a variety of research methods are needed. The two different research methods are quantitative and qualitative. According to Burns and Grove (2007) quantitative research is an objective formal systematic process and demonstrates its findings in numerical data. According Munhall (2001) qualitative research is gathering information to describe life experiences through a systematic and subjective approach and does not use figures or statistics to produce findings. In nursing practice the quantitative approach has been considered to provide stronger evidence than qualitative (Pearson, Field, & Jordon, 2007). Pearson, Field, & Jordon (2007) suggest health professionals and servicer users require a variety of information to facilitate change and to include evidence not only of effectiveness but feasibility, appropriateness and meaningfulness to achieve evidence based health care practice.

Evidence based practice promotes the application of research evidence as a basis on which to make health care decisions so it is important to search for the truth and knowledge logically. Robust research which may draw on expertise and experience represent a higher level of evidence because of the discipline involved (Burns &Grove 2007). There are thirteen steps in the quantitative research process and one step gradually builds on another (Burns & Grove2007). The beginning of the research process starts with a problem which usually highlights a gap in knowledge (Melnyk & Fine-Overholt 2005). The next step is the purpose of the research. This is produced from the problem and identifies the aim of the study (Burns & Grove2007). To build a picture up of what is known or not known about the problem a literature review is conducted. This will provide current theoretical and scientific knowledge about the problem and highlight gaps in the knowledge base (Burns & Grove 2007). This is followed by the study framework and research objectives, questions and hypotheses. This continues to the end till all the steps are covered. The final step is the research outcome.

Hierarchy of evidence is generated from the quality of information from different evidence. Practitioners are able to use the hierarchy of evidence to inform them on which information is most likely to have the maximum impact on clinical decisions (Leach 2006). Leach (2006) suggests hierarchy of evidence may be used to discover research findings that supersede and invalidate earlier accepted treatments and change them with interventions that are safer, efficient and cost-effective. If findings from a controlled trial are inadequate, choices should be guided by the next best available evidence (Leach 2006).

According to Scottish Intercollegiate Guidelines Network (SIGN 2009) the revised grading system is planned to place greater weight on the quality of the evidence supporting each recommendation, and to highlight that the body of evidence should be considered as a whole, and not rely on a single study to support each recommendation. The grading system currently in use with the SIGN guidelines starts with 1++ and ends in 4. For the evidence to be rated at 1++ it must include a high quality meta-analyses, systematic reviews of random controlled trails (RCT) or RCT with a low risk of bias. Level 4 is based on expert opinion (SIGN 2009).

There are many barriers to implementing evidence based practice. One of the common barriers is staff information and skill deficit. Health professionals lack of knowledge in regarding results of clinical research or current recommendations may not have the sufficient technical training skill or expertise to implement change (Pearson, Field, & Jordon 2007). Nurses have also highlighted lack of time as a barrier in applying research to practice. As the number of patients increases nurses face the challenge of providing safe, high-quality care within a short time frame. Nurse educators and researchers have developed a “toolkit” to ease the implementation of evidence based practice into nursing (Smith, Donez & Maghiaro 2007).

According to Gerrish and Lacey (2006) dissemination is a process of informing people about the results of a particular research. There are many ways to present results, video, seminars and the most accepted is through professional journals. However with the internet being more assessable the researcher is able to post details on the website hosted by NHS trust or university. One disadvantage in using the internet is that it provides no guarantee of quality (Gerrish & Lacey 2006). SIGN guidelines are circulated free of charge throughout Nation Health Service (NHS) Scotland. For this to happen they must be made widely available as soon as possible to facilitate implementation. Furthermore guidelines on their own have proved ineffective and more likely if they are disseminated by active educational intervention and implemented by patient-specific reminders relating directly to professional activity (SIGN 2009).

Critique 1

Rydstrom I, Dalheim-Englund A, Holritz-Rasmussen B, Moller C, Sandman P-O (2005). Asthma - quality of life for Swedish children.Journal of Clinical Nursing 14, 739-749. Blackwell Publishing Ltd.

As the title suggests this was a research to find out how Swedish children with asthma experience their quality of life and to look for potential links between their experience of quality of life and some determinants. This study was accomplished by using a quantitative research approach which adhered to the aims and objectives. Quantitative research is formal, objective, systematic inquiry that involves numerical data (Burns & Grove 2007). The two stages used in the quantitative research were correlation and quasi-experimental (Burns & Grove 2007). This is an acceptable method to use as the study was trying to explore the relationship between two variables and the findings were produced in a numerical format.

In previous literature it was noted investigations in children with asthma around the world all had similar experiences (Rydstrom et al2005).It also highlighted that girls and boys perceived asthma in a different way and girls were more likely to include asthma in their social and personal identities where boys would exclude the condition (Williams 2000). The researchers wanted to ask the children how they experience their life living with asthma. Also to look at possible links between children's quality of life and determinants such as age, sex, pets, siblings, location and social status (Rydstrom et.al. 2005).

Some common types of sampling used in quantitative research are random and non-random samples (Burns and Grove 2007). In the article for the purpose of this study all hospitals and clinics were used and fifteen were chosen randomly for the study (Rydstrom et al2005). Both children and parents were asked to participate in the study but children had to meet the inclusion criteria before being selected (Rydstrom et al2005). By using a random sample the general population becomes representative of the larger whole (Parahoo 2006).

Validity was established by cross-matching Paediatric Asthma Quality of life Questionnaire (PAQLQ) with About my Asthma (AMA), by Mishoe et.al.(1998). Warschburger (1998) recommended that PAQLQ was a reliable instrument and Reichenberg & Brogerg (2000) found that there was no difference concerning reliability between the Swedish and the original PAQLQ.

The study was approved by The Ethics Committee at the Medical Faculty of Umea University in Sweden and consent was received from parents and children. Burns and Grove (2007) define sampling as a process of selecting groups of people who are representative of the population.

Data was collected through self administration questionnaires. There advantages and disadvantages in using questionnaires. Advantage firstly, the data is gathered is standardised and therefore easy to analyse. Secondly, respondents can answer anonymously which may produce more honest answers. A disadvantage is the responses may be inaccurate especially through misinterpretation of questions in self completing questionnaires. (Gerrish & Lacey 2006). Children age seven to seventeen were required to fill in Paediatric Asthma Quality of life Questionnaire (PAQLQ) which was used to measure the children's quality of life in different domains. Parents were required to fill in Paediatric Asthma Caregivers Quality of life Questionnaire (PACQLQ) (Rydstrom et al2005). Children and parents filled in questionnaires separately and a nurse was on hand to help children who could not manage on their own.

The researchers clearly identify what statistical tests were undertaken. However the results are presented in a complex manner. The results showed the majority of children estimated their quality of life at the positive end of the scale. Children reported impairment in the domain of activities than emotions and symptoms for example not being able to run around. Living in the south of Sweden and being a boy were reported to have a better quality of life. Furthermore children living with a Mum over forty or with cohabiting parents had a better quality of life (Rydstrom et al2005).

The researchers brought to the attention of the reader the laminations within the study. Children view friends and their social environment being important to them however there were no questions relating to this and also it did not take into consideration the child's stage of development (Rydstrom et al2005). Also the research was done within a week, therefore would the results be different if it was done over a longer period. This was not a controlled research so there is a possibility that some data may be missing as nobody was checking to see if the children had filled in all the questions.

The findings highlight it is important for the nurse to look at all aspects of the child development. Furthermore caring tends to focus on the patients' limitations, another important issue for nurses is to try to discover those aspects in a child's daily life that contribute to a high QoL in order to improve and maintain the child's wellbeing.

Critique 2

Lyte, Milnes, Keating & Finke 2007. Review management for children with asthma in primary care: a qualitative case study.Journal of Nursing and Healthcare of Chronic Illness in association with Journal of Clinical Nursing 16, 7b, pp123-132

As the title suggests this research article will focus on review management for children with asthma within a primary care setting. This study was accomplished by using a qualitative case study design. In using a qualitative case study design it can provide much more comprehensive information than what is available through other methods, such as surveys (Neale, Thapa & Boyce 2006). Neale, Thapa & Boyce (2006) suggest case studies also allow one to present data collected from multiple methods (i.e., surveys, interviews, document review, and observation) to provide the complete story. Qualitative research is systematic, subjective approach (Burns & Grove 2007) which describes life experiences, meanings, practices and views of those involved (Craig & Smyth 2007).

In the UK one in eight children suffers from the effects of asthma and the majority of cases are now being managed in the primary care setting (National Asthma Campaign 2001). With improvement in management of asthma over the years there is still a high level of morbidity and mortality (Lyte et al2005). Out of Sight, Out of Mind (Asthma UK 2005) agrees with Lyte et al(2005) that death rates are high. In Scotland the death rates due to asthma vary each year. Furthermore inquires have shown at least 90% of those deaths could have been avoided. However child admissions to hospital due to asthma have fallen slightly (Out of Sight, Out of Mind Asthma UK 2005). Furthermore it was highlighted through a systematic review of literature published at the time of research that it was unknown whether primary care based asthma clinics were effective. Additionally it concluded that patients' views on asthma clinics were also unknown (Fay et al2003). One cannot ignore the fact that there are evident gaps in generic knowledge of primary care asthma services for children in the UK (Lyte et al2005). Therefore the aim of the study is to investigate current review management of children's asthma in one primary care trust and to consider the views of children, their parents/carers and the role of the practice nurse in asthma care in one primary care trust (Lyte et al2005).

For the purpose of this research Lyte et al(2005) used purposive sampling to gather information. Craig & Smyth (2007) suggests there are various methods can be applied to data collection. Lyte et al(2005) used interviews, observations and reviews of available documentation regarding asthma (Artefactual). In using this type of sampling the researchers can be specific on the groups they wanted to target. However they may be an element of bias as the practice nurse selected the parents and children for this research. To strengthen the research the researchers used triangulated methods for data collection. According to Craig & Smyth (2007) the theory behind triangulation if multiple sources, methods, investigators or theories provide similar findings their creditability is strengthened.

The study was approved by the Local Research Ethics Committee and the University's Senate Ethics Committee. Throughout the research during the data collection consent was treated as an ongoing process. However there was difficulty in communicating with children. To solve this problem, when meeting with the children the researchers would go through the informed consent and voluntary participation again. Confidentially of all participants were protected and guaranteed by the Data Protection Act.

Children expressed a wish to participate and share information in the research (Lyte et al 2005). However some children felt through the research of not being involved. Lyte et al (2005) suggested it is the child's personality that determines how much response the practice nurse receives. It is often said good communication in nursing is crucial and is the foundation of building trust and encourages children to seek advice. It is important to communicate with children appropriately to match the stage of development (The Common Core of Skills & Knowledge 2010). Ultimately effective communication allows for the exchange of information, needs and preferences of the patient between herself and the patient (The Common Core of Skills & Knowledge 2010). However Hobbs (1995) suggests that some practice nurses may not have the training in regarding complexities of caring for children and their families. One cannot deny that it is important for practitioners to have the appropriate training (Alderson 2000) because children have equal rights to contribute to their care as well as adults (Save the Children 1997).

It was noted that children did not have sufficient knowledge about asthma. Furthermore parents and children highlighted that there was insufficient information on asthma in the primary care setting. For children and adults to make informed choices regarding their asthma they require having up to date information to help them in making decisions. Equally in one practice it was identify that the practice nurse lack confidence in caring for children with asthma and Hobbs (1995) confirms this lack of confidence and points out that practice nurses deal with arrange of illnesses.

Parents and children in the study both agreed that one area for improvement was the waiting room (Lyte 2005). Some children may find going to the doctor a very frightening experience. The first expression needs to be reassuring and non-threatening. (Making Your Waiting Room Kid-Friendly 2006). The waiting room should be child friendly and also have books, television/video for older children. With today's technology many children use computers in the classroom. Some computer programs are touch-screen driven, making them friendly to all levels. Providing a computer in the waiting room may be ideal opportunity to encourage children to show off their technical skills by accessing the computer for health-related information (Making Your Waiting Room Kid-Friendly 2006).

It might be concluded from this research the strengths outweigh the weaknesses, despite the research being conducted in one primary care trust. The most satisfactory conclusion that can come from this, to facilitate children and parents a comprehensive package of care needs to be put in place in order to manage their asthma effectively.

References

Burns N, Grove S, (2007). Understand Nursing Research, Building an Evidence-BasedPractice. Fourth Ed

Craig J V, Smyth R L (eds). (2007). The Evidence-Based Practice Manual for Nurses. China: Churchhill Livingstone Elsevier.

Leach M J (2006). Evidence -based practice: A framework for clinical practice and research design. International Journal of Nursing Practice. 12, pp 248-251

Lyte, Milnes, Keating & Finke 2007. Review management for children with asthma in primary care: a qualitative case study.Journal of Nursing and Healthcare of Chronic Illness in association with Journal of Clinical Nursing 16, 7b, pp123-132

Melnyk, Mazurek , Fineout-Overholt, Ellen, Stillwell, Susan, Williamson, (2010). Evidence-Based Practice: Step by Step: The Seven Steps of Evidence-Based Practice. AJN, American Journal of Nursing: January 2010 - Volume 110 - Issue 1 - pp 51-53

Mishoe SC, Baker RR, Poole S, Harrell LM, Arrant CB & Rupp NT (1998). Development of an instrument to assess stress levels and quality of life in children with asthma.Journal of Asthma 35, 553-563.

Munhal (2001) cited in Burns N, Grove S, (2007). Understand Nursing Research, Building an Evidence-BasedPractice. Fourth Ed

Questionnaires - a brief introduction [online]. (2006) [Accessed 15th March]. Available from: <http://www.bolton.ac.uk/Students/StudyResources/Library/HelpGuides/CribSheets/Questionnaires.pdf Questionnaires>.

Reichenberg K & Broberg AG (2000) Quality of life in childhood asthma: use of the paediatric Asthma Quality of Life Questionnaire in a Swedish sample of children 7-9 yearsold. Acta Paediatrica 89, 989-995.

Roberts P et al(2006). Reliability and Validity in research. Nursing Standard. 20,44, 41-45

Rydstrom I, Dalheim-Englund A, Holritz-Rasmussen B, Moller C, Sandman P, (2004). Asthma - quality of life for Swedish children. Journal of Clinical Nursing, 14, pp739-749.

Sackett et al (1996) pp 5 cited in Pearson A, Field J, Jordan Z (eds). (2007). Evidence-Based Clinical Practice in Nursing and Health Care. Singapore: Blackwell Publishing.

Williams (2000) cited in Rydstrom I, Dalheim-Englund A, Holritz-Rasmussen B, Moller C, Sandman P, (2004). Asthma - quality of life for Swedish children. Journal of Clinical Nursing, 14, pp739-749.

Warschburger P (1998) Measuring the quality of life of children and adolescents with asthma - The pediatric asthma quality of life questionnaire.Rehabilitation 37, XVII-XXIII.

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