Evidence-based practice (EBP) is widely recognised within the role of nursing. Its implementation and purpose in the delivery of care is seen as an important driver for nursing practice and clinical outcomes (Cullen & Adams 2010). It has been defined as the:
“…conscientious integration of best research evidence with clinical expertise and patients values and needs in the delivery of high-quality, cost effective health care” (Burns & Grove. 2007, p.4).
EBP provides opportunity for nurses to ensure that clinical interventions and decisions making processes are safe and suitable for every patient group and enabling effectiveness in patient advocacy (Parahoo, 2006). An important part of practice and nursing culture, EBP should not be seen as an extra aspect to daily workload. Knowledge-base gained from pre-registration educational programmes and clinical experience should be the basis for the development of EBP (Cleary-Holdforth & Leufer 2008). Nurses critically reflect daily in clinical practice with the implementation and evaluation of care and it is important to understand that this forms the foundation in research for evidence. Quick reference for guidance does not necessarily need to be a lengthy process with accessibility to intranet and local policies, protocols and best practice statements. However, the self-recognition of base knowledge and skill should be continually developed (Parahoo, 2006). Nurses require time to strive for answers to clinical questions, expanding clinical expertise in locating research evidence. Using critique frameworks as suggested in Burns & Grove (2007), articles should be critically appraised with time spent deciding how they might apply to clinical practice. By taking a rigorous approach to appraisal, making an informed decision about the reliability and validity of sources of evidence, nurses can really look the effects in clinical practice and how the evidence can be delivered (Cleary-Holdforth & Leufer 2008). Nurses working in clinical settings should really think about dilemmas or problems that come up frequently in their clinical practice that they would like to know further research and evidence for.
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It is expected that registered nurses should be comfortable and competent with the components of EBP such as forming clinical questions, literature searching skills, including accessing appropriate literature and showing enthusiasm in its development. Nurses need to have good resources and support from employers through providing access to library facilities containing major on-line databases such as EBSCO; Cochrane library database; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the British Nursing Index (BNI). Through the use of databases, a comprehensive literature review should be conducted to generate understanding of what is known and not known about the particular clinical problem (Cleary-Holdforth & Leufer 2008). The review can allow the nurse to decide whether adequate knowledge exists allowing for change in clinical practice or whether further research is required.
From this initial thought may follow development of clinical question creating ethical consideration and understanding of beliefs and values of patients and colleagues. Nurses should being with searching ‘highest level’ of evidence such as systematic reviews involving the compilation and ranking of evidence according to its methodological origin (Whiting. 2009). Systematic reviews summarise the results of high quality studies, often reviews of randomised controlled trials (RCTs). Described and the ‘gold standard’ to research, they identify which interventions work, those which are not as effective and where further research should be carried out. In this way, bias is reduced and the effects of treatments studied are not overestimated. By using such evidence, time will be reduced in the need for critical appraisal (Whiting. 2009). It is important to note that as nurses move forward having more autonomy in decision making and its emphasis of patient centred care there still remains lack of appreciation in ‘best evidence’ for patient response in emotional, psychological and holistic understanding and focus lies within scientific interventionism. Cleary-Holdforth & Leufer (2008) criticise that the described ‘highest level’ of evidence fails to acknowledge research based on patient experience and perception and aspect fundamental to nursing practice. This can be viewed in clinical guidelines developed by Scottish Intercollegiate Guidelines Network (SIGN), derived from systematic reviews of scientific literature all guidelines have levels of evidence statements with the ‘highest level’ of evidence being meta-analyses, systematic reviews or RCTs (SIGN 2010).
To apply evidence into practice it is vital for nurses to have role models that respect EBP, rather than relying on clinical expertise alone (Cleary-Holdforth & Leufer 2008). They must value ideas and effectively support the process if clinical questions arise. Role models need to be enthusiastic about EBP and having positive vision about the opportunities EBP can provide when integrated into day-to-day practice. Nurses need be able to view the benefits of applying best current evidence to their practice and therefore creating a positive motivation for EBP. At all levels, nurses need to be interested in using the EBP and adopt certain practices and attitudes. These include devotion, professional pride, positiveness, courage and willingness to carry out change and commitment to continuous learning (Cleary-Holdforth & Leufer 2008). The nurse will not only see maturity in professional self but also development of personal achievement and identity.
Decision makers and new found knowledge needs to not only be distributed but fully utilised and the nurse must ensure that colleagues receive, read, understand and appreciate the value of and actually utilise it in their own decision-making processes and, where appropriate, alter their behaviour.
As with any clinical intervention, evaluation of its effectiveness is essential and nurses must discuss with colleagues and participants
Further to this assignment will be appraisal and evaluation of two papers providing critique and discussion. Each will be assessed for the appropriateness for evidence-based practice.
Gethin, G. & Cowman, S. (2008) Manuka honey vs. hydrogel – a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. Journal of Clinical Nursing. 18 (3) p.466-474.
Gethin and Cowman (2008) clearly seek to measure the effective comparison of two healing agents on venous ulcers and use a quantitative paradigm with two views to methods of debridement, and indicate that an RCT was undertaken. In a quantitative research study there is focus measurement of the relationship between variables (Burns & Grove, 2007). Being the area of interest in the study, the variables that change over time are subject to statistical analysis. A prospective design has been decided on and to the reader indicates a collection of variable data with one or more points in the future. Macnee (2008) adds that time is a defining factor in the design of a quantitative study. In this case the time points were at week 4 and week 12 from initial baseline. A reasonable amount of information has been provided in the design title and allows the reader to be aware of the approach used. It seems that the research hypothesis is best addressed by quantifiable approach being the appropriate design methodology for investigation.
Gethin and Cowman (2008), aimed to select adults presenting with venous leg ulcers having over 50 percent of the wound area covered in slough. Further to this, they followed substantial inclusion and exclusion criteria which was clearly stated and indicated in the research including tables that could be easily understood by the reader. There could however be potential problem with this as a more tightly controlled or restricted sample could lead to limitations to clinical meaningfulness (Parahoo, 2006). The researchers goal is to avoid bias which could potentially distort findings and making it difficult or impossible to interpret results (). There is inconsistency in the description of the members in the study that could indicate bias. The researchers use both the term ‘subject’, ‘participant’ and ‘patient’ and to the reader, this could be questioned as to how removed the researchers were from those in the sample (Macnee, 2008). Had ‘sample’ been used consistently then the reader could interpret this as being a distance and impersonal approach. Reassuringly the researchers state that they removed themselves from selection process and used blinded randomisation by two persons independent of the study to eliminate personal bias. Blinding refers to the group allocation and the concealment from one or more individuals involved in the research process (Karanicolas, Farrokhyar & Bhandari 2010).
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The larger the sample size in a quantitative study, the more likely the study will apply to clinical situations and aiming to make generalisations about the larger population based on findings (Parahoo, 2006). The study uses a sample size of 108 which seems small and perhaps is unlikely to produce results of statistical significance failing to disclose the actual effectiveness of the agent used. It may have been that Gethin and Cowman (2008) failed to get enough funding to support their study or an increase in sample size would have been too time consuming. Non-probability sampling was used with recruitment of subjects attending a clinic. This type of sampling limits the extent of generalisation of the results to the population outside the research (Burns & Grove, 2007).
Failure to enrol the predetermined number of subjects creates limitation and restricting what a reader may learn about the study. Further to this, Gethin and Cowman (2008) did not discuss
During the data collection stage of the process, there are two important considerations: the potential impact on the reliability and validity of the study. Reliability refers to how reliable the data collection methods are, this is the extent to which the selected methods will collect the same data on repeated occasions. The more consistent this is, the more reliable the methods are (Macnee, 2008). Gethin and Cowman (2008) used local clinical investigators who took part in a pretrial inter-rater reliability (IRR) study determining the level of agreement between the three raters when assessing slough as a percentage within wound bed. As the assessment was split between three data collectors, the reader could query potential differences in subjective opinion in deciding the percentage of slough within the wound bed. Thus influencing the accuracy and consistency in measurement making the measure less reliable.
Validity refers to the extent to which the methods used to collect and analyse the data accurately measures what the researchers intended it would measure (Macnee, 2008). They selected to use Visitrak Digital Planimetry a tool for wound measurement. Sugama et al. (2007) explores and concludes that this type for wound measurement device was a efficient reliable system applicable for use in clinical practice improving validity of the research. It must be noted however, that this is only valid if the users are fully competent in its use.
An important methodology feature of RCTs is to minimise bias and maximise the validity of the results (Whiting 2009). Gethin and Cowman (2008) failed to blind participants and data collectors due to the obvious orange staining from the Manuka honey. For a reader this is a immense flaw in the research introducing bias.
The data collected in quantitative research must either be numerical or converted to numerical data and entered into a database (Macnee, 2008). Gethin and Cowman (2008) selected to use a Statistical Package for the Social Sciences (SPSS) and further a statistician who was completely disconnected from the research in terms of collection and interaction with the subjects. This is a very positive aspect of the research and
Gethin and Cowman (2008) failed to elaborate why participants pulled out from the study and a reader should be highly concerned as to what exactly happened to these subjects and question averse reactions to the chosen product. A nurse having found this during a literature review would suggest there are too many weaknesses in the research to apply this to clinical practice and decision making. A main concern is the safety of patients and I would decline to use this product until further research was carried out considering all the available evidence potentially utilising a systematic review approach. Until then, it would not influence decision making in relation to methods of debridement. This intervention applied in everyday clinical practice could potentially have adverse consequences that outweigh the potential benefits. The cost was not reported and it may be that the Manuka honey treatment is very expensive providing only small health benefits and failing to make good use of resources. It may have been beneficial for the researchers to provide a rough idea of the cost of producing one unit of benefit.
An aspect fundamental to nursing practice is to incorporate understanding of the participants perspective about their experiences (Leufer & Cleary-Holdforth 2009). This is not something that was not explored, had funding been available qualitative research, which will be explored in the next paper could have been incorporating using two design methods.
Hancock, H. C. & Easen, P. R. (2006) The decision-making processes of nurses when extubating patients following cardiac surgery: An ethnographic study. International Journal of Nursing Studies. [Online] 43 (6) p.693-705.
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