The author will discuss in this essay the standards of evidence based practice. It will also be discussed the different levels of evidence. The author will also discuss the different processes of research including qualitative, quantitative, meta-analysis and randomised controlled trials. The author has looked at a wide range of evidence to back up this essay. The author has also looked at dissemination and barriers that prevent this. The author will also critique two articles to identify the different types of research used and the evidence provided.
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First of all the author will primarily briefly discuss the principles of research evidence based practice and will then inform the reader of the types of research available. Sackett et al (1996) as cited by Gerish (2006, pg 492) defined research evidence based practice as ‘the conscientious, explicit and judicious use of current based evidence in making decisions about the care of individual clients. The practice of evidence based medicine means integrating individual clinical experience with the best available external clinical evidence from the systematic research’ (Sackett et all 1996). Parahoo (2006) states that research evidence based practice is important in clinical practice to inform up to date interventions and effective decisions. Dissemination of the best available evidence is useful to improve clinical guidelines and service user autonomy as information technology has increased providing the public with greater access to knowledge which can encourage informed choices for service user’s in health care. Types of research are widely known as quantitative, qualitative or mixed methods of both. According to Burns and Grove (2007) quantitative research is defined as a ‘formal, objective, systematic process used to describe variables, test relationships between them and examine cause and effect interactions among variables’ (Burns and Grove 2007 p 551). This type of research primarily deals with statistics and aims to measure relationships between variables; this approach is researched by data collection using questionnaires and structured interviews. Structured questionnaires are usually used incorporating mainly closed questions such as questions with set responses. Qualitative research according to Burns and Grove (2007) is defined as ‘a systematic, subjective methodological approach used to describe life experiences and give them meaning’ (Burns and Grove 2007 p 551). Qualitative research findings are presented in numbers or statistics to answer the research question. Randomised control trials aim to evaluate the effectiveness of interventions in nursing (Centre for Reviews and Dissemination, 2001). This type of research is considered gold standard for nursing implementation of research that is quantitative in evaluation. Both quantitative and qualitative have pros and cons but would work well together. Qualitative research aims to understand human experience that promotes understanding of social phenomena. The qualitative researcher is interactive within the study in order to get close to personal experience. The researcher uses interviews, observations and scales to gain evidence for the research findings. Mixed methods combine quantitative and qualitative research. There has been many debates about this although within nursing mixed methods provide valid, reliable evidence and reflect service users experiences. This is important to consider for implementation of interventions.
Health care research and the need for evidence based practice have become evident and more advanced for professionals in practice. Different codes of practice have now highlighted the identification and application in health care and why it is important. Opinions of experts including traditions can no longer be legally or clinically justifiable in evidence based practice (Rice 2008 p 181). It is important to all professionals including service users and carers that the efficient and effective up to date treatments be used in their care. It is important that evidence is there to prove this is the case by basing decisions on clinical decision making guided by research, science and evidence. This is a move away from past practice being based on opinions and the way it has always been done. It has now moved towards clinical decision making (Appleby 1996). Sackett et al (1996) states that ‘without clinical expertise, practice risks becoming, tyrannized by evidence but without best available evidence, practice risks becoming rapidly out of date’ (page 312).
In the research process there are different types and levels of evidence used. There are also different ways to correlate the findings from different studies to produce evidence. These are mostly systematic reviews, literature reviews and meta-analysis. A literature review is an objective, thorough summary with critical analysis of the relevant available research and non research literature on the topic being studied (Hart 1998). This reviews the methods and theories around particular studies (Burns and Grove 2007 p 509). A systematic review summarise available literature on a precise topic both systematic and literature reviews summarise available literature on specific topics. Systematic reviews provide a full list which is carried out of published and unpublished studies available on a particular subject (Cronin et al 2008). The aim of this is to summarise the evidence of a particular problem or topic. This is beneficial for professionals as it demonstrates the effects of treatment methods, interventions or a variety of different measures (www.sos.se/socialtj/cus/cuse/Definite/defkunse.htm).
For results to be compared in a methodical manner, meta-analysis has been known to be used. Egger et al (1997) had described this as statistical procedure integrated in the results of several studies completed independently which is considered to be ‘combinable’. To come to the conclusion, gathering the data from numerous studies is essential for the outcome. In order to come to conclusions and identify patterns and relationships between findings methods of research and analysis are used (Polit and Beck, 2006). This has often produced a balanced result. Melnyk (2004) disputes that systematic reviews and meta-analysis of randomised controlled trials and evidence based practice are considered to be very strong levels of evidence in which to guide practice based decisions.
Dissemination of research is very important to inform the public of new evidence which may have an impact on the effectiveness in the care and treatment of clients. A study was conducted at Edinburgh University, Crosswaite and Curtice (1994) said that ‘dissemination is about the communication of innovation, this being either a planned and systematic process or a passive, unplanned diffusion process’ (page 289). Although there is an extensive awareness of how important dissemination of research is, active implementation of research into practice remains limited. Difficulties arising are because of disseminating research findings to different users. A major problem seems to be that practitioners do not have the access or have not been told how to access recent findings of research. Training has been an issue and has been a barrier for most. Researchers received specific training language used is specialised and technical it makes it difficult for untrained individuals to understand the findings of the research (Last, 1989). It has been found that the cost of research findings to be disseminated is almost as costly as the research itself to other professionals and disciplines in health care. This has been known to cause problems. In addition there can be factors that can hinder the research findings to be made available for all professionals and disciplines. These factors may include professional’s attitudes towards change, lack of education and support and fear of the unknown including the risk involved. The research has been known to be a problem in itself. An example of this is research that has been recommended can be difficult to implement into practice or university based research that may not have been implemented into practice and leave a large gap between these two.
Nevertheless these obstacles and barriers can be overcome to allow implementation of practical implication of procedures. Various organisations have a responsibility to set the high quality of standards for research and have the responsibility to disseminate the finalised research materials that has been finalised. In Scotland the guidelines are collated by The Scottish Intercollegiate Guidelines (SIGN). The aim of SIGN is to ‘improve the quality of healthcare for patients in Scotland by reducing variation in practice and outcome, through the development and dissemination of national clinical guidelines containing recommendations for effective practice based on current evidence’. In addition to the SIGN guidelines there is also the National Institute for Health and Clinical Excellence (NICE). NICE is an organisation associated with the NHS. NICE provides professionals and practitioners with guidance on treatment, promotes good health and prevent ill health. It would be helpful if such organisations looked at developing guidelines on evidence based practice. As this relates to clinical practice therefore the organisation may also facilitate the change (Stonestreet & Lamb-Harvard, 1994). Information systems could also be put in place to make information more accessible to other professionals and practitioners. ‘NHS Evidence’ has been available since April 2009. This ‘will help find, access and use high quality clinical and non clinical evidence and best practice’.
The author has informed the reader the importance of evidence based practice in a health care setting. A lot of training is required as it can also be rigorous. It is also a complex process. In order for professionals and practitioners to develop the best quality of care it is essential that they keep themselves up to date with the latest research findings.
‘Why are my friends changing?’ Explaining dementia to people with learning disabilities
This article was carried out on a group of people co-habiting who have learning disabilities. The article shows this is an example of qualitative research and the aim was to educate them about dementia as two of the residents had a diagnosis of this. Burns and Grove (2007, pp 551) describe qualitative research as ‘as systematic, subjective methodological approach used to describe life experiences and give them meaning’. Parahoo (2006) illustrates the key aspect of the qualitative research as being investigative in the approach in order to appreciate the actions and sensitivity of participants within the group.
As the participants had little of no knowledge regarding what dementia was or the effects this had on an individual and instead became frustrated and annoyed with their peers not realising how this affected their friends, the authors used different tools including visual aids, use of equipment, role play and props that the group could interact with. The group the writers were working with demonstrated that it helped educate the targeted group they were working with.
Although the group was small as it only had four group members aged between 37 and 54 (mean 45 years) and included two females and two males, the chosen group was successful in teaching all involved. The writers involved in this study admitted that there was not a independent assessment nor a control group carried out prior to the study that could have showed the evaluation of results and prove success or validity of the study carried out. Although the tools used in this group were effective it may not have been effective in another group as the mean age may be different. The group had also lived together for ten years which is a long time and they may have felt more at ease with each other and felt more comfortable in each others company to engage in the activities asked of them. As the group members all got on very well it may be that the group participants felt more sympathetic towards the people who have dementia. If a group had been set up using the same educating methods the results may not have been the same due to the relationships not being as close.
At the beginning of the sessions it was not explained why the methods used to educate the residents were changed other than them saying it was too complex although this may have been a positive step as this meant the facilitators working with the individuals in the group could work at a level they were comfortable with. The methods used to teach the group involved or the tools used were not advised if they had been effective with another group. The data collection used did work well with a qualitative research study. The interviews and questionnaires used with staff were to gain feedback. The group participants used a semi structured interview to gain feedback. The interviews were carried out one week before then one month after and then six months after. The study was completed after the six months to allow the writers to gain knowledge on the group participants involved regarding their level of education on dementia and then after the study was carried out to gain an insight of how much they learned regarding dementia therefore assessing the success of their teaching. Although they did admit that their methods of evaluation were weak to response effects (i.e. questionnaires and interviews). Although it was found that the use of the proven Psychosocial Interventions framework along with several tools and methods used could educate people with learning disabilities about dementia successfully.
Caring for older people with dementia in residential care: nursing students’ experience
This article aimed to determine student’s attitudes toward working with people with dementia and improve their experiences of working with these people. The students involved in this study were 2nd year Bachelor of Nursing Students. Two projects were completed over a four year period and the students participated in three week placements in eight residential care facilities. The group used consisted of 87 people which is a large number for a group although is a reasonable size for a qualitative study. The study was carried out in Tasmania between 2001 and 2005. There was not a guarantee that the study being carried out at this university would produce the same results if done with another group due to student training with another university. Also students did not have any previous experience working with dementia and also only had three week placement in the facility. As three weeks is not a long time this could have an impact on their feelings and opinions regarding the work in this area. Throughout the students practice placements including their mentors they both engaged in focus groups and this was facilitated by the research team member. According to Welman and Kruger (1999, p189) ‘the phenomenologist are concerned with understanding social and psychological phenomena from the perspectives of people involved’. The focus group involved is illustrating that experiences and opinions on a personal level can be valuable and effective. Morgan (1997p 12) said about focus groups that ‘interactions within the group based on topics that are supplied by the researcher’. Kitzinger (1995) states that working within a group can help build up trust and find solutions to problems being experienced by individuals and can be helped by working with the group to resolve the problems. It has been known within group work for people who are shy or quiet can at times be overpowered by others in the group. Questionnaires are beneficial in this case to allow the more quiet members of the group to get their point across without being interrupted or not being heard. The writers of this article recorded the sessions on audio tapes. This will be used for further analysis and the facilitator also took minutes and these were given to the group members to reflect on and allow them to address issues. The group members were then able to validate the discussion previously. Throughout this study the writer used thematic analysis so that they could identify repeated points raised by the group members. This helped the researchers to set up suggestions for those involved. The recommendations put forward to be considered for further education where caring for people with dementia and more support for students and mentors. To help the reader relate more to the article the author has used direct quotes. This allowed the reader to communicate the fears and some concerns that the students where involved in.
Frewin, D. (2005) ‘Editorial: Evidence Based Healthcare’, International Journal of Evidence-Based Healthcare Vol 3 (Issue 1), pp 1
Burns, N. And Grove, S. (2007) Understanding Nursing Research: Building an Evidence Based Practice, Philadephia, Saunders
Rice, M.J. (2008) ‘Evidence-Based Practice in Psychiatric Care: Defining Levels of Evidence’ J Am Psychiatric Association Vol 14, (Issue 3), pp 181-187
Appleby, J., Walshe, K., and Ham, C. (1995) Acting on the Evidence. Research paper 17. NAHAT, Birmingham
Hart, C. (1998) Doing a Literature Review. Sage Publications. London
Sackett D L., Rosenberg WMC., Muir Gray JA., Haynes RB and Richardson WS (1996) Evidence Based Medicine: What is it and what it isn’t British Medical Journal 312, 71-72. Cited by Gerish K, Chapter 31: Evidence based practice, Research process in nursing 491-505, Blackwell Publishers Ltd
Parahoo K. (2006) Nursing research: principles, process and issue (2nded) Basington: Palgrave Macmillan
Cronin P., Coughlan M., Ryan F (2008) ‘Undertaking a literature review: a step by step approach’ British Journal of Nursing. 17(1) 38-43
Egger M., Smith GD., Philips A.N., (1997)’Meta-analsis: Principles and Procedures’ BMJ 315:1533-1537
Polit D., Beck C (2006) Essentials of Nursing research: methods, appraisals and utilization. 6th Edition, Lippincott Williams and Wilkins, Philadelphia.
Melnyk, B.M. (2004). Integrating levels of evidence into clinical decision making. Pediatric Nursing, 30 (4), 323-325
Crosswaite C., Curtice C., (1994) ‘Disseminating research results-the challenge of bridging the gap between health research and health action’ Health Promotion International 9(4) 289-296
Last J.M. (1989) ‘Making the most of research’ World Health Forum 10, 32-36
Stonestreet J.S., Lamb-Harvard J. (1994) ‘Organizational strategies to promote research-based practice’ AACN Clinical Issues 5:133-146.
Welman, J.C., Kruger, S.J. (1999) Research methodology for the business and administrative sciences. International Thompson. Johannesburg, South Africa.
Morgan D.L. (1997) 2nd Edition. Focus groups as qualitiative research. London: Sage
Kitzinger J (1995) ‘Qualitative Research: Introducing Focus Groups’ BMJ 311:299-302
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