Evidence Based Practice In Nursing

This essay focuses on critically appraising a journal article regarding nurse-led services and decides if they offer something unique to the patient.

The article being appraised is “Self Harm in Adults: A randomised controlled trial of nurse-led services case management versus routine care only” (Clarke et al 2002).

Critical appraisal is assessment of the research quality and a deeper look into the method used. Appraising an article also involves applying the research to clinical praxis and experience (Gerrish and Lacey 2006).

To appraise this article the Critical Appraisal Skills Program (CASP) tool (Public Health Resource Unit 2006) was used. The CASP tool was used because the questions it asked of the article were relevant to the topic discussed. It also focuses on randomised controlled trials and quantitative results. An appraisal tool should cover three key concepts: validity, reliability and applicability (Gerrish and Lacey 2006), which the CASP tool does successfully. The CASP tool is very easy to understand and use. It also has a clear structure. One of the most helpful features were the first two questions which if the answer had been “No” to then the CASP tool asks “Is it worth continuing?” (Public Health Resource Unit 2006).

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There are other frameworks for critical appraisal of research. Some of these were considered for appraising this article. Two of the frameworks looked at were the Salford tool (2001) and the British Sociological Association Medical Sociology Group (1996). A comparison was made between mainly the Salford (2001) tool and the CASP tool to determine which would be most suitable for appraising the article “Self Harm in Adults” (Clarke et al 2002).

The Salford tool (2001) did not offer as much guidance as the CASP tool. It did not ask questions but instead used a list of sub headings showing the information that the article should contain. It was also harder to understand what information the sub heading wanted. Whereas the CASP tool had prompting questions to reinforce the areas that should be thought about in order to sufficiently answer the question. When compared to the CASP (Public Health Resource Unit 2006) tool the Salford (2001) framework was more suited to experienced analysers who understood the terminology used within the framework and were familiar with the critical appraisal process.

The study asks a clearly focused question. Research needs to be focused because if the area chosen is to big then the right depth of information will be hard to achieve (Samuels 2004). The abstract contains the aim of the research, details of the population included in the research, involvement given and the conclusion. The research was conducted using a randomised controlled trial (RCT) design. However, the article does not actually say why the research was conducted as a RCT.

RCT’s are considered one of the highest rating methods of collecting nursing data. They are defined by three characteristics: an intervention group, a control group and participants being randomly allocated (Melnyk & Fineout-Overholt 2005). The “Self Harm in Adults” article does all of these things and is therefore very suitable to have been done via this method.

By choosing RCT’s the researchers came up with quantitative results, if they had obtained the research through open ended methods such as grounded theory research the results would have been qualitative. Quantitative research is based far more in a scientific approach than in person centred. It looks for a cause and effect result. It is possibly not the best research method to influence nursing behaviours, but more suited for nursing knowledge. Personal feelings, experiences and ethics are not allowed to influence quantitative results. However, the core of nursing is the patient and therefore this methodology conflicts with the research topic. When the research is looking for a clinical, scientific and measurable result, for example a placebo drug versus the real drug then quantitative is most effective (Burns and Grove 2003).

A qualitative method would have been harder to do for this study. Qualitative research would have meant greater involvement with the participants to access if they felt the intervention had worked increasing the risk for possible bias.

The allocation of participants into the intervention and control groups was not entirely random. The article describes the method they decided to use for collection of possible participants; everything was unbiased except the first part of the process. Researchers informed an outside administrator about possible participants via the phone therefore choosing the eligible participants. The ideal situation would have been the participants being chosen by the independent administrator in the first place. The results, treatment and interactions with participants can all be affected by the decision the researchers made to choose the participants themselves, this is known as researcher bias (Gerrish and Lacey 2006).

The research had an efficient method of allocation, which despite the removal of some participants remained nearly equal. The random allocation was also stratified by sex and admitting hospital. Stratification ensures that there is a fair distribution of certain factors within the sampling group. It is done to provide a fairer and more realistic result because it looks at a realistic selection of participants than just randomised sampling would (Bowling and Ebrahim 2005).

After randomisation 59 participants were excluded from the groups, the article explains why these cases were excluded from the research. The article explains that there may have been differences in the results caused by the research exclusion. The researchers excluded participants >16 years old from the study, 16-19 years old (and in full time education) and those with problematic alcohol usage. This would have majorly affected the results because there are many studies that show the correlation between problematic alcohol use and self-harm (Welch and Fairburn 1996; Pattison and Kahan 1983).

Blinding was an issue in this research because of the ethics involved. Blinding is always an issue when doing research because of people’s rights. In an ideal world, all participants should know exactly what is going on and how it affects them, which is called informed consent. However changing a participant’s treatment to something new may make them feel psychologically better because they receive more attention. It may produce a false positive result but blinding prevents this (Cormack 2000).

The participants signed consent forms before commencing in their allocated treatment. The research topic would mean having to be sensitive about the information participants were given, because the research was expecting participants to be readmitted with self-harm within 12 months. In addition, the participants were being asked for consent due to their index episode of self-harm that would have been recent, therefore making them very vulnerable (Oliver 2010).

Ethically this research topic is very tricky and although the researchers did the right thing by gaining consent from the participants it must be questioned scientifically. For example was it a suitable time to approach participants after their index episode, did it affect the results knowing that researchers were expecting a certain number of readmissions and how did it change the trust between the nurse who made the referral and the participant. Getting the patients to sign consent forms had made them aware that the research was going on; it has to be considered that this may have caused bias in the results. Observer bias is when the participant’s behaviour changes because they are being watched (Parahoo 2006).

The research article shows a table stating that all participants completed the trial however; not all the participants were accounted for at the completion of the study. A study can also be deemed good or bad research by its loss-to-follow-up percentage, 80% is the recommended amount of the participants that should be followed up. Anything lower than that is cause for concern because of the ethical problem raised when participants are not debriefed properly (Fewtrell et al 2008). It would have been better if the research had followed up all participants for a further 6 months after the trial had ended.

All the participants were given 12 months for readmission. The precision of this would have varied between participants because the 12 months started from when the last participant had been admitted (with an index episode). This would have meant that the first participant admitted (with an index episode) would have the time it took between then and the last participants index episode added onto their 12 months, resulting in an extended inclusion time within the study. The results of research studies are dependant of the time scale used because participants reactions will be different at different times, so those that waited a longer period than 12 months will have a higher chance of being readmitted (Cormack 2000).

Other variables of the study include things like time spent with participants in the intervention group and if the participant actually accessed their case manager. The research does not give enough detail to find the answers to these questions; all these variables will have an effect on the results. The research has completed a power calculation with type I error at 5%. They used previous hospital records and a pilot study to determine that the lowest number of participants needed for this study was 438. However, because the participation number was so low the risk of a false positive result was higher. This means that an improvement within the intervention group could have been shown where there was not one (Kieser and Friede 2000).

The results of the research are well presented using fractions and percentages. They are described for each group and then compared. The findings and any other results are also discussed. The result is not meaningful when relating to the aim of the research because the findings are too close to define an answer. This may be because of the sample size, bias or because the research had nothing to prove. They may have been looking for a difference that does not exist. The research does not mention a confidence limit; however, it does use p values. The p values are used for most of the differences that the participants had between them.

The “bottom-line” (CASP 2006) of this research is that nurse-led services had no measureable effect on participants. Throughout this research appraisal, problems had been found that question the validity, reliability and applicability of the study. The validity regards some of the areas that need improvement such as the method chosen (Quantitative), the exclusion criteria (>16…) and the approach to gathering data (RCT’s). The reliability is dubious because the method used to achieve its results had many flaws as well. In addition, the study had such rigorous criteria for eligibility it would be hard to apply the method strictly enough to another study for comparison (Graneheim and Lundman 2004).

Applicability is always going to be an issue when researching people because as everyone is different there is only so much similarity to be achieved (Graneheim and Lundman 2004). The participants included in this trail will always therefore be different to any other trial carried out. The setting of the research is also unique because there are many factors above the researchers control such as history of services available, staff levels and previous use of services. The same treatment could be carried out in most hospitals although the effectives of the treatment would depend on the hospital and would affect the reliability of the research. The United Kingdom is behind some other countries with the introduction of nurse-led services, places such as Japan have been using a similar method called “nursing leadership” before us (Faithfull and Hunt 2005). It is always good for research to be carried out because it increases knowledge of participants, researchers and public, even in the case where it shows something does not work. The ethics and values of nursing should always mean that the research would never outweigh any harm (Oliver 2010).

This article found nurse-led services had no positive measureable impact on the readmission rate following self-harm, however due to the issues found surrounding the validity and reliability of this study wider research is needed to find if nurse-led services do offer something unique.

Nurse-led services are being seen as the way forward and the nursing role is changing quickly. Nurses are no longer just there to care for patients, now they are being given more responsibilities such as nurse prescriber and nurse-led case manager (Latter and Courtenay 2004). It is felt that nurse-led services can offer something special to the patients being cared for. One of the main reasons is because of values that nurses believe. Some of the key values influencing nurse-led services include helping others when they are in need, supporting people during difficult stages of the lives and improving the lives of others (DOH 1999).

The research article “Self Harm” (Clarke et al 2002) looked for quantitative results; however, the biggest indicator for positive nurse-led services is becoming patient satisfaction (Sitzia et al 1996). What and how a patient feels about their treatment in nurse-led services cannot be measured in quantitative results because quantitative research disregards feelings and experiences (Burns and Groves 2003). Research has shown that the special values nurse-led services bring to patients are therapeutic alliance, ability to deal with the unknown, time management, higher autonomy, flexibility within their role, communication and trust (Faithfull and Hunt 2005).

The relationship between nurses and patients is known as therapeutic alliance. This relationship underpins the whole concept of nurse-led services. It was only about 10 years ago that the relationship became a measureable and valued nurse/patient interaction, before that the focus was on the physical needs of the patient. From most of the research done regarding nurse-led services it is the support of the nurses increased involvement that makes any difference seen (Green 2009; Armstrong 2002; Faithfull and Hunt 2005; Wright 2010). A big part of the therapeutic alliance is active listening, just allowing a patient to have a voice empowers them to own their problems (Barker and Buchanan-Barker 2008).

The therapeutic alliance also helps to build trust between patients and nurses, promote individualised care and ensures a holistic approach. The research article (“Self Harm”) used nurse-led individualised care management to reduce admission into A&E departments and the results showed not significant change. Another study looked at nearly the same area although they included participants that the “Self Harm” article excluded. Newton et al (2010) found that using individualised care plans did significantly reduce the readmissions into A&E. although Newtown’s et al (2010) study took a far more holistic approach to the research. They looked at the social demographics of participants, any alcohol/substance misuse and geographical location in relation to the hospital. It shows that if Clarke et al (2002) had been more holistic in their approach then the results might have been more valid, reliable and applicable.

Although to make the most of nurse-led services the nurses need to be properly trained in the area. The nurses in the research article (“Self Harm”) were mental health nurses, however the intervention they were trying to start is very dependent on the skills of the nurse case managers. Applying the intervention to other A&E departments might not have worked because not every department has access to specialised mental health nurses. The general nurses would not have the specialised skills to deal with mental health unless training had been given.

An example of this is the minor illnesses clinics being set up at GP (General Practitioner) surgeries. The use of nurse-led specialist clinics helps improve the allocation of the GP’s caseload. It has been found to reduce the need for an emergency on call GP, help the surgery treat more patients, and develop the role of the nurses. To make sure that the nurse-led team could provide the service that was needed the nurses had to do extra training and were asked about how they felt regarding the change. Overall this nurse-led service did offer something different and effective. Although the benefits for patients were not obvious they were seen quicker and the clinic became so effective that it influenced other surgeries, out-of hour’s services and departments of health to begin using more nurse-led services (NHS 2010).

Although to ensure the smooth workings of services such as nurse-led clinics communication between nurses and other health workers needs to be improved. Communication with other health workers is strongly influenced by nurses and the values they display. It has been seen that support workers will have better standards of care if they work alongside nurses who embody good values (DOH 2001a). Nurses often become role models for other professionals. Communication to patients is strongly influenced by the nursing role. In some cases where patients have accessed nurse-led services they have thought that the nurses were more qualified than usual, and in one case even redesigned their view of the role turning the nurse into a doctor. Not every nurse is ready for this amount of responsibility (Chapple et al 2001).

However by empowering the patients to take back the control of their care nurses do not only aid the recovery of patients but they can lighten their workload. There are several things the research article (“Self Harm”) could have done to empower the participants. They could have set up drop in centres, then measured the frequency they were being used and the impact it had on readmissions. In addition, since the reason they excluded self-harm involving alcohol/substance misuse was due to the success of existing services like drop in centres they might have got clearer results.

Encouraging patient autonomy plays a big part in the recovery process. A patient being able to take control of their own lives is another improvement that some nurse-led services have shown. Some of the aspects that autonomy covers are patient choice, privacy, dignity, liberty, respect and independence (Moser et al 2006). The research article “Self Harm” prompted independence by providing the participants a number that they could contact their case manager on when they chose, also the study allowed participants that were not on wards to have their initial psychosocial assessment where they chose for example mental health centre or at home.

Some of the more basic values that nurses hold are compassion, respect and dignity. The research article on “Self Harm” does not necessarily promote all of these. The article gave no reason to question the respect and dignity that the participants received, however there may have been a lack of compassion. If the participants were asked for consent to observe their possible readmission within 12 months (following self-harm) during their index episode then little compassion was shown. However, respect should be automatic although as the DOH (Department of Health) document “Principles, Standards and Indicators” (2001b) shows this is not always true. Things such as making sure nurses ask what name a patient would like to be known by, maintaining confidentiality, remembering privacy of personal details and trying to maintain individuality is all forgotten.

Considering all values that nurses bring to their roles, future research needs to look at those values that make nurse-led services effective. A more holistic and person friendly approach would receive better results. Nursing research needs to move away from the scientific views to more philosophical ones (Munhall 2001).

The evidence presented above supports the view that nurse-led services are still in their infancy, however with time and regular reviewing nurse-led services will be the way forward.

The role of nurses is changing and they are being seen in a far more professional light. This will be reinforced by all the nursing courses converting to degree. Nurses will no longer be nurses but degree graduates standing shoulder to shoulder against medical practitioners. With appropriate training they should be able to provide just as effective health care as doctors. The hope will be that nurse-led services can remove some of the pressure from doctors, however the likelihood is that nurse-led services will cover an unmet need and not touch the doctor’s workload (Laurent et al 2009).

There are many reasons why much of the quantitative research into nurse-led services is not showing any strong correlations between their results and patient views. It might be because nurses are already doing that something special that the researchers are looking for. Therefore it will never show up as a change or improvement because it is already effective. There is a lack of solid research into nurse-led services this is partly because of the ethics and the newness of the concept (Gray 2004).

In the future the DOH (2006) want to push for more nurse-led services. They want nurses to continue to develop the values that make them so effective at their jobs. They need to focus on being person-centred and taking a holistic approach to care. The approach needs to cover all aspects of patient’s lives to make it truly holistic such as health promotion, spiritual, cultural, social, physical and deal with poor health. In addition, the therapeutic alliance will become more important due to the importance of it regarding the future of nurse-led services.

The prime minister calls it “Nurses and Midwives leading services: our call to action” (The Prime Minister’s Commission on the Future of Nursing and Midwifery in England, 2010). The government is pushing nurses to take a more active role in decisions and policies. They want nurses to seek recognition through leadership roles in the hope that it will encourage better practice and improve care for patients.

Nurses should lead and participate at all levels to teach and help the next generation grow (The Prime Minister’s Commission on the Future of Nursing and Midwifery in England, 2010).