Evidence Based Practice In Nursing

I am a staff nurse of six years of working experience, attached to a well established private hospital with 200 beds and I am attached to a pediatric ward and currently there are 30 beds available in my unit. Although it is a specialized unit, not all the staffs are specialized in this area. However, all of them need to go through a training period of 6 month and they are required to answer the competency tests from the senior nurses and nurse manager, to be competent in their skills and knowledge.

In this paper, I will analyze different forms of evidence and analyze how different philosophical might affect the methods used to obtain and use the evidence in practice. I have chosen a piece of research paper and using the selected piece of research, I will analyze the evidence selected and include the philosophical standpoints underpinning the evidence; as well as discuss the implications of the evidence for my practice. For the critique of the research paper, I will use the critiquing guidelines for qualitative research by Streubert and Carpenter (1995) as analysis tool. I have chosen this particular piece of research paper as I find it is very significant and related to my practice arena. Apart from that, I will discuss how the implications and recommendations of the research can be applied to my practice arena.

The word evidence is commonly used in health care systems and there are various permutations of evidence including evidence-based practice, evidence-based nursing, evidence-based guidelines, evidence-based decision making and evidence-based policy making. In a study, Upshur (2001) stated that the word ‘evidence’ is rooted in the concept of experience, relating to what it is manifested. In another study, Davies et al., (2000) suggested that evidence need to be construed and verified to ensure that the evidence used to inform practice are related to healthcare concept. Therefore, it is essential that health care professionals, especially nurses realize the importance of evidence and consider how different sources of evidence may contribute to patients’ care.

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In order for the health care professionals to understand the nature of evidence in the context of health care; it is important that they consider the history of evidence-based health care movement. The term evidence-based medicine started in 1980s’ when it was used to integrate individual clinical medical experience with external clinical evidence by using a systematic research approach. In a well known study, Sackett et al., (1996) defined evidence-based medicine as conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. In another study, Rosenberg and Donald (1995) described evidence-based medicine as the process of systematically finding; appraising and using contemporaneous research findings as the basis for clinical decisions. Therefore, as a practicing nurse, evidence-based practice is using the current evidence from research to support and making decision in patients’ care.

However, majority of nurses are not aware that there are latest research findings available to optimize patients’ care. In my practice arena, research is seldom used as a source of evidence. Instead of depending on research findings, most of the nurses rely on intuition, experience and the authority of policies and procedures in their work routine. Besides that, majority of them do not have the exposure and proper training in doing research. Although it is proven that research is one of the best evidence that available, it also has disadvantage as there is a need to translate these evidence in order to make sense of it in the context of caring for individual patients. Thompson et al., (2001) stated that research evidence is crucial to improve patients’ care; but it may not be on their own and it influence practitioner’s decision making. Therefore, it is essential that health care professional especially nurses, realize the importance of research and they know how to apply research evidence in their work routine. As a result, this will not only help them to improve patients’ care but it is also useful to develop the skills in doing research.

Besides using research alone as evidence, clinical experience is also play a important role and can be used as a source of evidence. In a study, Eraut (2000) stated that knowledge accrued through professional practice and life experience served as an important part in the delivery of evidence-based and patient-centred care. In another study, Titchen (2000) described clinical experience as a source of knowledge which expressed and embedded in practice and is often tacit and intuitive. Although knowledge and clinical experience can be used as sources of evidence, it is crucial that health care professional especially nurses, have the sufficient knowledge to analyze and transform the knowledge into practice. In my practice arena, clinical experience is developed into evidence-based practice by providing clinical practice guidelines. These clinical practice guidelines are similar with policies and procedure guidelines; and it is used as a source of evidence as well as protocols for all staffs in my practice arena. However, there is no professional organization or other expert panels convened specifically to construct the evidence-based guidelines as the policies and procedure guidelines are set by the authority of management in my practice arena. Therefore, there is an underlying assumption in the field and practice of evidence-based health care that such sources of knowledge are idiosyncratic, subjected to bias and, as a result, lack of credibility.

Apart from research and clinical experience, audit and performance data are other sources of evidence. In a study, Stetler (2003) described that these evidence sources are systematically obtained; and it has the potential to be valued as a source of evidence that inform the development of evidence-based patient care. In another study, Overtveit et al., (2002) suggested that these locally-collected evaluation data can be used to inform changes of practice as well as improve the existing practice. In my practice arena, audit and performance data collection are used as a source of evidence. The data was collected systematically including obtaining information from the local context, planning and evaluation. For example, the nurses in my practice arena at pediatric ward are required to collect data on asthma cases; and these data were then integrated into the framework for changing and improving current practice. As these process of data collection have an important role in the development of evidence-based practice, it is also crucial that the nurses understand the importance of collecting data in a systematically order, how these data are integrated with other kinds of evidence and how such data inform and influence individual clinical in decision making.

As there are many sources of evidence available, health care professionals are required to understand and identify the best method that they can used to provide the best outcome for patients’ care. In addition to implement research evidence and clinical experience in evidence-based practice, nurses need to reflect on their practice. In a study, Edwards (2002) proposed that besides traditional research methods, nurses use reflection as well as techniques such as written dialogue and narratives to generate knowledge. In another study, Rolfe (1996) stated that the reflection process can be used to identify areas where research is necessary; and these are linked to research design with the goal of developing evidence for practice. However, there is a debate that these form of knowledge such as intuition, ethical and experience does not fit the current view of evidence-based practice. Carper (1978) described that there are four ways of knowing including empirics, aesthetics, personal knowledge and ethics; and these concepts are widely accepted and being used as fundamental patterns of knowing that underpinning nursing profession. Therefore, nurses need evidence to be related to theory in these forms of knowing to provide holistic care for the patients.

In the effort of implementing evidence-based practice, health care professionals are required to have adequate skills and knowledge. Deficits in current knowledge related to evidence-based practice triggers problems as they are unable to provide the basis of solving problems and posing an answerable question to the choice of their clinical actions. In a study, Melnyk and Fineout-Overholt (2005) suggested the ‘PICO’ method which includes patient, intervention, comparison and outcome in constructing an answerable clinical question. However, health care professional especially nurses, must find a special interest somewhere in their practice, which can spark an investigation of recent research findings. The area of interest may include population, different gender group, illness conditions or level of prevention. Besides that, it is essential that nurses are well prepared before attempting to change current practice. Therefore, it is important that they have the knowledge and skills in determine the scientific value of various research, appraise the relevance of the evidence, determine if the potential benefit would actually benefit the practitioner’s patient of family; and ultimately are the preferences chosen met by the practice regimen in the systematic review (Melnyk and Fineout-Overholt, 2005).

Although evidence-based practice is important, there are many barriers and challenges in implementing these changes, including in my practice arena. The most common factor will be resistant when planning and implementing changes of current practice. A study shows, individuals and organizations require congruent goals and objectives to implement changes. In order to implement changes and adapt evidence-based practice, it is important for the organization to promote, develop and sustain research as the basis for clinical practice. Besides that, health care professional especially nurses must open to new practice and changes. Other factors that influence evidence-based practice include lack of access to technology, excessive time demands for clinical work, and most importantly lack of peer or administrative support. Therefore, organizations should provide sufficient computer access, facilitators, dedicated time for evidence-based practice activities and commitment to dissemination of research.

As research play an important part in evidence-based practice, all the health care professionals must understand the research process; and have sufficient skills and knowledge in critical appraisal of research evidence. It requires nurses to develop a critical and questioning approach to their work and identify problems or questions that can be answered through research. Therefore, nurses who are research-aware will demonstrate the ability to find out about the latest research in their area together with an openness to change their practice when new knowledge becomes available. However, not all research studies provide conclusive findings that can be used to guide practice. Thus, before findings can be applied, a research study needs to be evaluated critically in order to judge the quality of the research. There are many tools that can be used in critical appraisal of research, but I have chosen the method by Streubert and Carpenter (1995) as analysis tool.

In a study by Graziano and Raulin (2004) stated that research is a systematic search for information or inquiry, and it can be carried out anywhere including libraries, laboratories, schoolrooms, hospitals or even factories. In another study, Robson (2002) described that for any research in a social context, the process is complicated by practical and ethical constraints of working in the ‘real world’. There are different kinds of research designs including quantitative and qualitative research. In quantitative research, the researchers collect numerical data and are amenable to statistical analysis. Such research designs often have a hypothesis or statement that can be tested. Quantitative designs are observational, such as survey using a questionnaire and the data is translated into numerical form. In contrast, qualitative research designs use narrative, words, documents or graphical material as their data source. These research designs analyze material to identify themes, relationships, concepts and in some cases, to develop theory. In qualitative research, the research often explores an experience, culture or situation in depth, taking account of the context and the complexity of the context. It is also used where comparatively little is known about a subject, so there is no hypothesis formulated. The purpose of qualitative research is often exploratory, although it may certainly contribute much to the understanding of phenomena.

It is essential that health care professional, especially nurses realize the importance of systematic review and how it contributes to evidence-based practice. Systematic review as a review in evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research, and to extract and analyze data from the studies that are included review. Over the years, there has been a rapid evolution of techniques for identifying and synthesizing qualitative research although there is little consensus as to which methods should be used for appraising the quality of studies. However, systematic review is still an important part in both quantitative and qualitative research.

For the piece of research paper that I have chosen, it is a qualitative research. Qualitative research is a systematic, subjective approach used to describe life experiences and give them meaning. The research studied about the quality of life of children with asthma at children’s hospital of Philadelphia and it is consider a qualitative research. In qualitative research, there are various methodologies that can be used including ethnography, grounded theory, phenomenology, and case study. For this research, it is phenomenological research as the phenomenon of interest was clearly identified and stated by the researchers in the title of the research. Besides that, qualitative studies often focus on the whole of human experience and the meaning described by individuals living the experience, and these methods extend understanding of certain topics (in this instance) health, beyond traditionally measured units of evidence. In fact, Evidence must extend beyond the current emphasis on quantitative research and randomized clinical trials to the kinds of evidence that generated by ethical theories, personal theories and aesthetic theories. Thus, the evidence provided by qualitative studies that consider the unique perspectives, concerns, preferences and in-depth understanding of experience is important for theory development of nursing practice.

Phenomenological researches have become an important approach in nursing. The strength of a phenomenological approach is that it provides both philosophical and methodological support in attempting to capture and express the meaning of significant human experiences in a rigorous manner. Such forms of knowledge is important as one of the basis for ethical practice and these studies seek to express insights in a way that it may evoke a sense of recognition; as well as understanding in readers. However, there are also limitations in phenomenological approach. One of the limitations is that it is difficult to get an external perspective as phenomenological research focus on the inner perspectives of the people (subject) in the research. Besides that, when the research involve children, the researchers may face difficulty in getting information from them.

In this study, research purpose is a clear, concise statement of the specific aim or goal of the research. It is also important that the research purpose is clearly stated as it can capture the essence of a study; and it is essential for directing the remaining steps of the research process. Further more, the purpose of the study is supported by literature review, in which the researchers have given the evidence that asthma is a growing health problem among children, and has a significant impact on the quality of life as well as daily routines for children. The researchers did not directly describe the projected significance of the work to nursing; but it was emphasized in the nursing implications and recommendation of the research paper.

In the methods, the researchers have explained in detail on how they obtained the data for the research. For the sampling of this research paper, children were selected. In this research paper, the researchers have clearly described the selection of participants as the target groups of participants were children. There is no purposive sampling in this research as the participants are selected. Sample selection is also an important part in conducting a research.

As ethical approval is important in a research, the confidentially of the participants is equally important as protection to their rights; and to avoid any violation. Besides that, the procedure for collecting data was clearly described in this research paper as they researchers stated in detail the process of retrieving data, but the attrition rate was not stated in the research. Therefore, the attrition rate for this research is unknown for the reader. In qualitative research, there are some other tools or instrument that can be used for data collection such as interviews and observations. However, these tools are prone to the influence and bias of the observer. Thus, it may affect the reliability of the research.

In a study by Guba and Lincoln (1981) stated that credibility, audit ability and fittingness were scientific criteria proposed for qualitative research. In this research paper, the credibility was not stated by the researchers. However, the participants in this research have recognized the experience as their own. For the audit ability, the reader can follow the thinking of the researchers and the research process was stated clearly in this research paper. As for the fittingness, the findings of the research could help to raise nurses’ awareness towards methods to find out the causes of impairments of quality of life; and the factors which contribute to improve the quality of life of these children with asthma.

The findings are presented within a context and the reader is able to comprehend the essence of the experience from the report of the findings. The researcher conceptualizations are true to the data but, the researchers did not place the report in the context of what is already known about the phenomenon. Therefore, this section should be included in the research paper. Besides that, the researchers have given recommendations that there should be a further research done in the future. As a nurse, I find that the implications and recommendations of the research are useful and can be applied in my practice arena. As the asthma cases are increasing each day including in my practice arena, there is also a need to increase the number of well-qualified and trained nurses to improve patient education in my practice arena. Apart from that, there is lack of nursing research in my practice arena as well. Therefore, it is crucial that the nurses in my practice arena realize the importance of research to generate new knowledge that can be used as evidence-based practice; and this will also indirectly improve the quality of patients’ care.

In conclusion, there is a need that evidence-based practice is adopted by the health care professionals, especially nurses. Although evidence-based practice is currently limited because of its emphasis on particular types of empirical evidence and the scarcity of this type of evidence for nursing practice, this must not remain as limitations as evidence-based practice is useful in generating more knowledge in medical treatment and other aspects of health care. Therefore, nurses especially must realize the significance and importance of evidence-based practice to improve patients’ care.

In order to achieve this, it is essential that all health care professional, especially nurses equip themselves with knowledge and skills in accessing and appraising research that relevant to their practice. Besides that, it is also crucial that the organizations should provide the facilities and support in implementing evidence-based practice. However, as nursing is considered an art that cannot be evidenced in a purely scientific way; it is important that nurses valued and select the best evidence based on what it is relevant to their practice to enhance and optimize patients’ care.

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