Evidence-Based Practice in Decision Making

Evidence based practice (EBP) is a global experience that involves research evidence appraisal, patient choices, context of care delivery to enhance best practice knowledge and delivery of quality care by making informed decisions (Barker, 2010). The aim of this essay is to comparatively analyse and appraise one research element of two research papers by Mattheus-Kraemer et al. (2016) and Milano et al (2018) using contemporary literature. Moule (2018) critical appraisal tool will be used to discuss the chosen element for data collection. Research literature will be used to discuss and critique the validity, reliability and the credibility of the research papers. Also, the research papers position within the hierarchy of evidence, its benefits and the relevance of research and evidence-based practice in nursing will be explored.

Although there are many definitions for EBP, the widely accepted is Sackett et al, (1996) which defines EBP as the “ conscientious, explicit and judicious use of  current based available evidence in decision making of care of individuals”. Nursing research is described as the methodological analysis devised for problem solving and establishment of reliable evidence related to issues arising from nursing discipline, practice, information and education (Polit and Beck, 2012).

The past knowledge of nurses on decision making has been based on experiences, trial and error, intuition, logical reasoning and traditional practices (Polit and Beck, 2010). Although Brooker and Waugh(2013) recognises this means of knowledge transfer as essential however, they challenged it by stating the risks for  the nurse and patient  due to invalid information been transmitted and can lead to bias. Nurses have formed a part of an initiative that has changed over the past decades with regular changes made to national and local regulations and policies, bearing in mind that patients are becoming experts in their own diagnosis which has impacts on care delivered (Stevens,2013; Ellis ,2016). According to Emanuel et al. (2011), it has become more imperative that evidence which is synthesized into guidelines is required in nursing due to its evolvement from dictated duties to an individualised approach to care. Ellis, (2016) argues that not only should nurses act in the best interest of patients but should also be able to justify the decisions made in relation to patients care. Moreover, nurses have a duty to understand research and ensure the application of best evidence available to their everyday practice in other to give reliable advice and help patients make informed decisions due to accountability in providing the best quality of care (NMC,2018). Additionally, this focuses on efficient provision of care and enhances outcome on patient’s quality of life. However, healthcare practitioners require awareness of the research related to their own clinical expertise and implement it accordingly (Moule, 2018). Furthermore, EBP and research has proven to reduce cost as a result of the effectiveness of streamlined services provided (Barker et al., 2016). Therefore, it is of great importance for nurses to be updated with the knowledge of policies, perform research and understand evidence through variety of research methods to ensure safe delivery of care using evidence-based practice and research (Ellis, 2016). Quantitative and qualitative methods are widely used for research (Gerrish and Lathlean, 2015), (Polit and Beck, 2012). Qualitative research is a subjective systemic approach conducted to gather information using individual experiences. However, data is collected in words rather than statistics. Quantitative research is described as a recognised systemic, unbiased process used in testing hypothesis and shows its result (LoBiondo-Wood and Harber, 2018).    However, Polit and Beck (2012) argues that quantitative research methods is considered more efficient and reliable compared to qualitative.

Although, the benefits of EBP is widely recognised and used in nursing practice, there are limitations and barriers affecting the implementation of evidence-based care. Dicenso et al. (2008) argued that the processes of clinical decision making, and expertise are centralised to EBP. However, all these processes are needed in collaboration with all other forms of evidence for the usage of guidelines generally. Evidence-based practice is suggested to have replaced the use of professional and judgement in the delivering of care (O’Halloran et al, 2010) . Furthermore, Moule (2018) argues that implementation of only evidence-based practice can restrict decision making and constrain autonomy and the proof that evidence-based practice works is non-existence. It also argues the simplicity of the EBP methods which has led to resources been limited.  Also, lack of organizational support for staff, lack of communication between healthcare professionals, nurse’s unawareness of research, language barrier, inadequate time to research paper, lack of training, inadequate staffing and level of knowledge of EBP has posed a barrier to the application of evidence-based practice to care delivery (Shayan et al., 2019).

The research article by Matthaeus-Kraemer et al, (2016) intended at recognizing the obstacles that affect time management and early diagnosis of severe sepsis in the hospital wards, whilst the research by Milano et al (2018). aims at identifying the correlation among sepsis bundle adherence with mortality of patients including the relevance of the infection source and site of declaration to the increased mortality. Focus group discussions data collection was used by Matthaeus-Kraemer et al. (2016) to conduct a qualitative research whilst Milano et al. (2018) used clinical record data collection to conduct a quantitative retrospective observational study. It is important to note that both articles have homogenous research theme and topic, however the data collection methods are different. Qualitative focus group research is a comprehensive and open discussion which aims at collecting experiences, feelings, views, thoughts of a group of individuals and increase understanding on specific topic or issue (Goodman and Evans, 2015). In contrast, retrospective observational studies research a current issue and collects data from the previous to examine medical incidents and consequences (Song and Chung, 2011; Hasson et al., 2015). According to Barker (2010), data collection  is described as the process and tools used in gathering information and measurement of variables to test hypothesis, evaluate outcomes and  answer questions. Moreover, its role is important in the evaluation, implementation and design of public health programs (World health Organization, 2017).

Rees et al. (2015) describes hierarchy of evidence as the ranking of research evidences into different categories according to there strength and extent to which bias is prevented from findings. Healthcare professionals need to have an understanding and be able to place available research evidence in a hierarchy because it enables clear communication in everyday practice when teaching colleagues, advising patients and more importantly when developing guidelines for practise (Petrisor and Bhandari,2007). Furthermore Inghram-Bloomfield (2016) recommends that the knowledge of the hierarchy of evidence will improve nurse’s competence in assessing the weakness and strength of research evidence and application to practice.

The application of the hierarchy of evidence has been criticised due to exclusion of some evidence and underrating of qualitative research and other participatory evidence (Rees et al., 2015). It is imperative to note that hierarchy of evidence was established to help decide the validity of evidence by assessing the treatment and clinical intervention outcome (Moule, 2018) however, Gerrish and Lathlean (2015) argue that it is not appropriate for providing information in developing understanding in relation to patients and other practitioners in which case qualitative evidence is more appropriate. Murad et al (2016) hierarchy of evidence design ranks Milano et al (2018) retrospective observational study on level 4 of 5 as ‘case control study’ only above reports, which shows lack of validity however the limitation to this evidence pyramid is that it does not consider qualitative research and experiences. Polit and Beck (2012) hierarchy of evidence design suggests that the qualitative study by Matthaeus-Kraemer et al. (2016) lacks reliability as it is placed on level six out of seven however Milano et al. (2018) retrospective study is placed in level four out of seven as ‘single observational study’ in this same pyramid of evidence. Equally Moule (2018) describes the effectiveness of research evidence by placing Milano et al (2018) study as ‘case control or observational study’ on level 3 above Matthaeus-Kraemer et al. (2016) qualitative study which is ranked at level 4.This suggest that although Milano et al (2018) is low on the hierarchy it is classed more reliable when compared to Matthaeus-Kraemer et al. (2016) qualitative study (Polit and Beck, 2012). Although retrospective observational study is partially reliable due to its ranking the  risk of bias which affects information quality when information is recalled is noted(Jirowong and Pepper,2013). In contrast Noyes (2010) hierarchy of evidence for experience and views in delivering service suggests that qualitative research is more important when compared to quantitative research by placing the qualitative study by Matthaeus-Kraemer et al.  (2016) higher in the third level whilst Milano et al (2018) quantitative study is ranked sixth. Therefore, when providing care, researching and using best evidence all levels of evidence should be considered and understood to be able to determine the validity, reliability and the credibility  of evidences because one hierarchy of evidence cannot be used in relation to all research (Burns et al.,2012).

Research should be systematically evaluated for value, reliability and relevance before conclusion is made, this method is known as critical appraisal (Barker and Kane, 2016). The use of critical appraisal tools enables nurses to make crucial decision in practice by considering the study’s validity, the results and its usefulness.  (Al-jundi and Sakka, 2017). The critical appraisal framework by Moule (2018) will be used to evaluate the data collection method in relation to the articles by Matthaeus-Kraemer et al. (2016) and Milano et al. (2018). Questions from the framework considered are the following.

If the appropriate method of data collection was used

If the data was gathered by appropriate people

If the participants were protected from physical and psychological harm

If researcher’s role and relationship was considered

Matthaeus-Kraemer et al. (2016) used focus group discussion which is frequently used in qualitative healthcare research (Tausch and Menold, 2016). The completion of the research design was based on semi-structured interviews which involves open ended discussions however, the approach cannot be justified. Semi structured process enables in-depth narrative of participants experience, thoughts and belief by covering key topics ( Polit and Beck, 2010). Limitations of this methods includes difficulty of engaging participants in conversations arising from sensitive topics been mentioned which can affect data collected (DeJonckheree and Vaughn,2019). The focus group discussion was carried out using a topic guide which was formed using a concept mapping approach which facilitated discussion using main themes identified in the article thereby allowing a structured discussion and result of data collected (Matthaeus-Kraemer et al., 2016;Burgress-Allen and Smith, 2010). Concept mapping is a tool used in mixed method research that involves structuring and induction of group data collection which enables collation of several participant ideas by applying quantitative tools to develop hypothesis and new concepts (Wheeldon,2010;Dejonchkheree and Vaughn,2019). Furthermore, this allows comparison of focus groups and consistence among groups however, this can lead to restriction to questions asked, discussions and contribution made (Goodman and Evan, 2015). The transparency of the research was shown by including the location, method and length of the discussion in the appendix and body of the literature (Whiting,2008). Also, transcribed audio recordings of discussions in conjunction with semi structured interviews can enhance validity of findings however it can result in  anxiety and self-consciousness leading to participants giving bias response (Williamson et al., 2015). The data collection method by Matthaeus-Kraemer et al. (2016) proved appropriate because it aided diverse perspective to be expressed on issues meaningful to the participant (Cridland et al,2015).

In contrast, Milano et al. (2018) used retrospective observational approach which involved collection of data from patient’s medical records review. Medical records review is used frequently in retrospective clinical data collection and are documents deemed by healthcare professionals to be accurate and reliable (Engel et al., 2009). However, there can be misinterpretation in data collected as a result of incomplete records, loss of patients’ records, non-documentation of reports etc (Sarkar and Seshadri, 2014). The strength of this study includes the use of statistics  to measure data collected allowing for statistical  description and analysis which is the objective of the (Moule, 2018). Furthermore, the bundle adherence variable of interest was operationally defined in the study and  adapted from previous studies which enhances the quality of the research suggesting previous validity(Reber and Gersch, 2015). Hence when critically appraised,  the data collection method used by Matthaeus-Kraemer et al.(2016) and Milano et al.(2018) proved to be appropriate though limitations to the method were present.

The quantitative study by Milano et al. (2018) engaged trained utilization- review nurses as abstractors in the collection of data from medical records. According to Gregory and Radovinsky (2012), data abstractors should have experience of collecting data from medical records, professional healthcare knowledge, qualifications and experience relevant to the study undertaken. The trained review nurses used in gathering information in this research are trained and have prior understanding of the study and can recognise the needed variables in the clinical record (Gregory and Radovinsky, 2012). This enables consistency and optimization of collated data which increases reliability and validity of the research (Reisch et al. 2001). Furthermore, the data abstractors were blinded to study outcomes which is appropriate in clinical record review and helps to reduce bias (Patanwala, 2017). However, there may be  bias arising from pressure exerted from administrative workload (Milano et al.2018). Although there is risk of bias,  Milano et al (2018) highlighted in the study that measures such as usage of timestamps and recalculation of bundle compliance and intervals were put in place   to reduce the risk of bias affecting findings and results.

Mattheus-Kraemer et al. (2016) on the other hand used moderators consisting of 2 trained employees which includes physicians and Social Scientist of the MEDUSA study in each focus group. According to Nyumba et al.(2018), research facilitators are important when collecting data in qualitative research. Also, Morrison-Beedy (2001) suggest that qualification, expertise, knowledge of research topic and familiarity of the research topic should be considered when selecting a moderator. Equally, Ellis (2016) argue that a researcher expertise and background must be relevant to the research topic as this improves the credibility of the research. It is important to note that moderators utilized in collecting data in the study by Mattheus-Kraemer et al. (2016)  are trained physicians and social scientist who have been involved in similar study which suggest reliability and have the knowledge of the subject and can guide the discussion and supporting participants. In context, the moderators in this study aided the guidance of the open-ended discussion and ensured the inclusion of every participant using the topic guide which will enhance data collected, improve credibility and reliability of data collected( Cranley et al., 2017 ; Nyumba et al., 2018). However,  there is risk of personal bias as moderators can intimidate the answer or discussions given by the participants by the way in which the questions for discussions and formulated (Seale, 2012). Therefore, the utilization review nurses used by Milano et al.(2018) and Mattheus- Kraemer et al(2016) to gather information are appropriate as they had a background relevant to the research and had knowledge of the research topic.

According to  Gerrish and Lathlean(2015), the protection of participants from harm should be considered when undertaken a research because the duty lies with the researcher. Moule(2018) also argues that before conducting any research, consent must be gained, anonymity between participants and researchers and confidentiality should be  maintained. Matthaeus-Kraemer et al. (2016) gained prior consent from participants ,maintained confidentiality before and after  collection of  data that were audio recorded and maintained anonymity between participants and moderators while Milano et al.(2018) gained consent from ethical committee before conducting the research. Equally, the UK policy framework for health and social care researchers includes consent, confidentiality, participants safety and choice of participants as standards that must be met when conducting a research(NHS Health Research Authority, 2017). Furthermore, the dignity and rights of a patient must be safeguarded in addition to gaining informed consent from participants, maintaining confidentiality and explaining the right of participants to withdraw at any time in healthcare research (GMC,2013). Although Milano et al.(2018) got approval from the Dhs institutional review board there was no documentation of consent from patients for there medical record. This has been an ethical issue when collecting using clinical record review as there is no prior consent for use of data for research when keeping medical records (Sarkar and Seshadri, 2014).Furthermore, data collected can be misused and sensitive information of patients can get to people not involved directly in patients care thereby breaking confidentiality (McCarthy, 2008). The studies by Matthaeus-Kraemer et al.(2016) and Milano et al.(2018) both gained ethical approval which suggest the ethical soundness of the research and shows actions was taken to protect participants from harm. However, there might be limitations when considering ethical validity.

The role of the researcher and relationship with participant was not discussed in either Milano et al.(2018) or Matthaeus-Kraemer et al.(2018) study. Moreover, the researchers in both studies didn’t have contact nor interacted directly with the participant instead they engaged  data abstractors and moderators in collecting data.  According to the NHS Health Research Authority(2017), the researcher’s role and details of how research would be conducted must be discussed with participant. However, it is noted that the researcher’s role in data collection in quantitative study  is practically non-existent(Simon, 2011).Furthermore, there was no researcher- participant interaction in Milano et al.(2018) study hence the need for the relationship to be considered is not needed. On the  contrary, the role  of the researcher and relationship  with participant needed to be considered in Matthaeus-Kraemer et al.(2016) because interactions between researcher and participants allows comfortability and engagement  of participants in conversations (Ellis,2016). Also, Sutton and Austin(2015) argued that researchers have a role which involves accessing the thought and feelings of participants which can give them more insight and understanding of the data collected when present. However, the presence and relationship between participants and researchers can lead to professional bias arising due to hierarchy of the researcher which results in participants responding in a  manner that will please the researcher (Raheim et al., 2016) .It is imperative to note that although Matthaeus-Kraemer et al. (2016) were not present in the focus group discussions, the moderators used were anonymized from the participants which enhance the strength of the research and reduce the risk of bias (Fink, 2000 ;Sutton and Austin, 2015).

An overview of Milano et al.(2018) study showed an association between sepsis bundle adherence, timely care, location and improved mortality. It also establishes limited relationship with anatomic source of infections and improved mortality. The study supports the practice of timely sepsis bundle adherence to reduce mortality in patients over time. On the other hand, Matthaeus-Kraemer et al.(2016) focused on the causes of delay in early detection and treatment of sepsis and septic shock using the focus group. Participants identified errors in communication and handover challenges between inter and intra units as barriers that could impact detection and treatment.

The findings of both studies are relevant to practice as they have similar views on staff  training on awareness of sepsis, early identification and communication between multidisciplinary team especially during handover. Nurses are required to work in cooperation with colleagues, communicate effectively, identify deterioration of a person health, treat and make referral in a timely manner(NMC,2018).

In conclusion, nurses have a duty to apply best evidence based on research and evidence to everyday practice and decision making on  patient care in other to preserve patient safety. The research conducted made use of different methods of data collection however when critically appraised both proved reliable, credible and valid. Understanding the hierarchy of evidence and where research is placed aids decision making and helps relate the relevance of research findings to practice .

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