I have studied Nursing for 4 years in the Philippines and I have not encounter the term Evidence Based Practice. It took me by surprise that such subject exist. On my first day of class at Thames Valley University I have learned that EBP is about exploring a medical intervention through research of published research articles based on clinical trial conducted by various researchers and clinicians. The process starts by proposing a research question, and I chose to focus on Pain Management but I have notice that pharmacological management is too common. For such reason, I have decided to aim the attention of my research to Non-pharmacological Management such as Diversional Therapy. This kind of therapy is seldom used in the clinical setting because a lot of medicines are being discovered and used as often. As the process continues, I have learned how to properly critically appraise an article and notice its importance no matter how old it was and enhance my problem solving skills. Furthermore, adjusting and somehow changing the learning method is a big alteration I have encounter as I need to spend a lot of time reading and making the paper. After all the amplitude I put into making this Folder of Evidence, I consider the entire course a success. I have learned so much of new things that somehow I ignored before.
Module Learning Outcomes
Identify and critically examine priorities for improving practice.
Asses the ability to identify evidence and critically appraise its value.
Critically analyze the change description and understanding about the nature of evidence in health care practice.
Page 18- 21
Para 2, 3, 4, 5, 6
Evaluate the possibility and effectiveness of evidence for change in practice.
Page 24- 25
Para 2, 5
Study Day 1: 11th October 2010
Understanding the Nature of Evidence
Evidence Based Practice
Information Skills Development
Exploration of the Concept of Evidence Based Practice.
Sources of Evidence
Developing Search Skills Library Session (1)
Evidence based practice is providing the best evidence of treatment to facilitate effective treatment/intervention. A discussion of what to be expected from folder of evidence as it highlights how the folder will be collated and how to set aims and objectives for FOE.
Study Day 2: 25th October 2010
Questioning Practice/Research Questions: Finding Evidence
The relationship between questions and types of evidence;
Questioning own practice – explore types of research questions.
Developing simple and structure search strategies
Information Skills Development
Group Presentation: Evidence Based Practice
Group Poster Presentation
Concepts Definitions and Understandings Session
Relationship Between Questions and Types of Evidence
Descriptive and Relational Questions
Writing Searchable Questions for Evidence Based Practice
PICO – Identifying Preliminary Search Terms
Developing Search Skills Library Session (2)
We discussed how to proposed a searchable question and how important it is. I formulated a topic based on my own interest and experience beforehand. Revision of question also was supervised and breakdown using PICO framework.
Study Day 3: 8th November 2010
Differentiating Between Research Paradigms.
Evidence Based Practice
Information Skills Development
Quiz – Review Research Designs
Discussion of Types of Questions (researchable and unsearchable questions).
Group Work to Refine Final Practice Issue and Search Question
Refine PICO Framework for Search
Inclusion and Exclusion Criteria
Appraisal Tools, CASP, SIGN, AGREE
Group Work Assessment and Discussion of Two Papers Retrieved Last Week. (Question, Design, Methods and Results).
I have learn the different types of research designs that supports my research scheme for the 5 primary articles together with supporting documents that will be used in making EBP. This session also emphasizes the importance of PICO as this will help how to refine searches. Different appraisal tool was also discussed and its importance as this provide effective filter for the reliability and validity of published literature.
Study Day 4: 29th November 2010
Systematic Reviews/Meta-analysis: An Introduction Appraising Evidence – Part 1.
Developing Critical Appraisal Skills
Group Presentation – Features of Systematic Review
Group Discussion – How Does an SR Differ From a Traditional Review?
Appraising a Systematic Review – Individual Exercise and Group Discussion.
Using Appraisal Tools
Appraising of an RCT and a Qualitative Study Using CASP or an Alternative Appraisal Tool.
Group Discussion Analysing the Appraisal Process and Effectiveness of the Appraisal Tool.
A systematic review is a study that identifies, appraise, select ans synthesize a collection of research articles with relevance to each piece of work.
Critically appraising a systematic review article excludes lesser quality studies to minimize error and bias in the findings. It Assess the validity of
research by means of determining whether the
methods used during the study can be trusted to
provide a genuine, accurate account of the treatment being studied.
Study Day 5: 6th December 2010
Establishing the Quality of Evidence
Making Judgements About the Quality of Evidence
GRADE – How to Move from Evidence to Recommendations.
Workshop- Grading Evidence
Independent Work or Further Electronic Searches.
As I appraise each primary articles collected, a summary of critical appraisal of the 5 primary articles was made. This strategy helped me to make an apprehension toward the affirmation of each articles towards making the summative 3.
Study Day 6 – 13th December 2010
Translating Evidence Into Practice
Guiding Principles for Implementing EBP
Barriers to Implementing EBP
Identify Barriers to Implementing Evidence Base in Practice
Identify Strategies to Implementation that Avoid/Overcome these Barriers.
Students to work in pairs to devise a search strategy for use in one electronic database to identify an article that describes and evaluates the introduction of evidence based change in practice.
Implementation has its various barriers to consider such as time, support, lack of knowledge, lack of motivation of the workers and too much research evidence. As a group activity we critique an implementation article as to determine the process of implementation of the studied intervention.
Study Day 7 – 10th January 2011
Evaluating Changes in Practice
Application of a Framework for Evaluating Change.
Final Module Evaluation
Measurement for Improvement/Change
Sustainability of Change
Examine Effectiveness of Evaluation Strategies.
Module Evaluation and Individual Tutorials
It discussed about the evaluation process of a study and the use of guidelines in each step. Evaluation meant by achieving a research aims and objectives and most importantly if the study conducted able to answer the hypothesis, as this entails whether the study is effective or not.
Summative 1: Concept of Evidence-based Practice
The challenge for best quality of care, combined with the need for recommended usage of resources has heightened the pressure on health care professionals to ensure that clinical procedures is based on sound evidence. Frequent change and advancement in treatments, an increasingly numbers of research information, and the increase of expectations from clients to provide the best care possible, place high demands on healthcare providers to maintain a service that is based on current best evidence. (Bennett and Bennett, 2000). Evidence-based practice (EBP) is a clear path to healthcare wherein health professionals use the best evidence possible, such as the most suitable information available, clinical decisions for individual patients. EBP values, enhances, and builds on clinical expertise, knowledge of disease process, and patho-physiology (McKibbon,1997). Evidence-based practice presume knowledge of and skills in literature searching, research methodologies apprehension , appraisal and apprehension of research. It also requires healthcare professionals to have access, critique and coordinate literature study with clinical experience and clients’ aspect. In order to gain a greater interpretation about the nature of evidence in the context of health care, consideration needs to be given to the history of the evidence-based health care movement while the concept was originated in medicine, it has influenced a wide range of health professions (Trinder & Reynolds, 2000).
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In addition, it is an approach to decision-making that has permeated all aspects of healthcare. It’s characterize can be seen in many of the leading health systems and government health policies across the world. EBP model highlights the value of research as a source of information which is potentially less biased than other sources for informing practice, it also clearly acknowledges the importance of integrating this research with clinical expertise and clients’ perspectives (Sackett et al., 2000). Moreover, it involves complex and reliable decision-making based not on available evidence alone but also on patient characteristics, situations, and preferences. Changing practice is not easy to do therefore careful selection of the topic is very significant. For the benefit of the patient is of first importance when selecting a topic, however it can not be the main basis as to literary evidence is inadequate to figure what are the benefits. Researchers must also consider the time, level of consumption and other resources for the study. Research evidence is most frequently found in peer-reviewed journals as this is where results are first published and where enough detail on methodology exists to make informed judgements on the validity and clinical relevance of the findings (Bury & Jerosch-Herold, 1998). Research using the strongest and most appropriate study design for the question being studied, will provide the best evidence.
Summarizing the evidence is a vast intellectual endeavor according to Fitzpatrick (2007). Healthcare workers must be capable combining ideas and recommendations from an extent of references to make appropriate advices. Implementing a plan is consider challenging because standards and regulation of an organization can either help or ruin an EBP approach to care. Evaluation process involves short term and long term coverage to provide essential data.
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Bennett S & Bennett J (2000) The process of evidence-based practice in occupational therapy: Informing clinical decisions. Australian Occupational Therapy Journal. 47 p171-180.
McKibbon K (1997) Evidence-based practice. Bulletin of Medical Library Association. 86(3)p396-401
Trinder, L., & Reynolds, S. (Eds). (2000). Evidence-Based Practice – A critical appraisal. Oxford: Blackwell Science.
Sackett D, Richardson W, Rosenberg W, Haynes R (2000).Evidence based medicine: How to practice and teach EBM (2nd edn). Edinburgh: Churchill Livingstone.
Bury T & Jerosch-Herold C. (1998). Reading and critical appraisal of the literature. Evidencebased healthcare. A practical guide for therapists Oxford: Butterworth Heinemann. p136-161
Fitzpatrick J (2007. Finding the research for evidence-based practice,part one: The development of EBP 103 (17) p.32-33
Summative 2: Critical discussion on formulating question using PICO
There are many times that new information is required when contemplating clients in order to analyze clinical problems and make treatment resolutions, and these questions pertains to a specific client or groups of people. Questions usually arise concerning the effectiveness and choices of an intervention, how treatments are best implemented and whether there are any associated difficulties included (Bennett and Bennett, 2000).The question for this study is about the effectiveness of Diversional Activities as a form of pain management to paediatric clients. Pain management is the alleviation of agony and suffering of a patient with the use of Pharmacological and Non-pharmacological treatment or nursing intervention. Diversional therapy is a non-pharmacological approach and a client centered practice that recognizes the leisure and recreational experiences of an individual (Diversional Therapy Association of Australia,2008).Through the act of psychological and behavioral factors regarding pain, complimentary medicine are significant in altering pain experiences. These interventions bears to minimize fear, worry, pain and heighten a client’s bodily process.
According to Bennett and Bennett (2000), when there is uncertainty, the need for information can be interchange into a clinical question. Clearly framing a question not only clarifies what to aim, but it can also facilitate the search for answers. Sackett et al. (1997) point out that the identification of congruent data for answering a particular clinical question may be facilitated by diving the question into components including: A client or a dilemma being considered, an intervention or indicator being considered, outcomes of interest you would like to measure or achieve and a comparison. PICO represents an acronym for Patient, Intervention, Comparison and Outcome. These four components are the essential elements of the research question in EBP and of the construction of the question for the search of evidence (Santos et al. 2007). The PICO strategy can be used to compose several kinds of research analysis, originated from clinical practice, human and material resource management, the search of evidence assessment instruments, among others. The research question allows for the correct definition of which evidence is needed to solve the clinical research question, focuses on the research scope and avoids unnecessary searching (Fleming, 1999). Based on the clinical question formulated and utilization of PICO, a literature search strategy can then be formulated that includes search terms reflecting each component of the question.
The next step in the evidence-based practice process is to search the literature for evidence that may assist in acknowledging the question posed. The literature search will be focused by the clinical question that has been identified with use of PICO, as well as other relevant information (Bennett and Bennett, 2000). While evidence for informing clinical decisions may come from various sources including clinical experience, education, textbooks, discussion amongst colleagues and from clients, evidence from well-performed research may be less prone to bias or to the tendency to believe what we want to believe ( Tickle-Degnen, 1999).The internet and the portals of open-access journals allow for accessibility to knowledge, keywords such as non-pharmacological, complimentary medicine and diversional therapy were used to search for the 5 primary articles to be used for this study. An article must be good and interesting, should be well written, and old articles are also considered. Moreover, comprises a body of knowledge in academic and scientific based from an original research.
Word count= 548
Bennett S and Bennett J (2000) The process of evidence-based practice in occupational therapy:
Informing clinical decisions. Australian Occupational Therapy Journal. 47 p.171-180
Diversional Therapy Association of Australia(2008) what is diversional therapy?[online].
Flemming K.(1999) Critical appraisal 2: Searchable questions.NT Learn Curve 3(2) p. 6-7.
Sackett DL, Straus S, Richardson S, Rosenberg W, Haynes RB (2000) Evidence-based medicine: how to practice and teach EBM.
Churchill Livingstone. 2nd edition.
Santos C, Pimenta C, Nobre M.(2007) The PICO strategy for the research question construction and evidencesearch. Rev Latino-am Enfermagem maio-junho. 15(3) p.508-11.
Tickle-Degnen,L. (1999). Organizing, evaluating and using evidence in occupational therapy practice. American Journal of Occupational Therapy; 53 p.537 539.
Summative 3: Synthesis of research findings.
This part of work is the review of the 5 primary articles chosen for the topic effectiveness of diversional activities for pain management to pediatric clients. The articles will be analyzed by using CASP tool, examining each relevant findings and by compare and contrasting ideas of each authors, thus, resulting to further evaluation of such intervention in hospital and non-hospital setting for its efficacy. This research desires to have a thorough understanding of non-pharmacological intervention in managing pain to children that soon will complement pharmacological management by provide stronger evidence. Pain is a dreadful feeling and emotional experience related to injury or damage to children ‘s body, it is usually caused by trauma, disease, medical procedure or surgery. Pain may affect children ‘s appetite, sleeping patterns and lessen energy level hence disabling child to do things. Pediatric pain is complex and often difficult to assess, that is why effective pain management in children is a challenge to medical practitioners because there are many special considerations when providing treatment. On the other hand, non-pharmacological therapies or diversional activities are treatment that do not use medicines to decrease or control child ‘s pain. They may convey comfort to the patient during a long standing condition or illness. Certain activities may help improve the child ‘s state by making him/her more comfortable and relaxed. It involves methods such as teaching and leading your child through thinking exercises and other techniques. It can also be used before and after a child undergoes painful experience, such as medical procedure or surgery.
Vessey et al. (1994) stated that, Distraction is the single most commonly used diversional activity among children. Fernandez (1986) stated that distraction refers to the direction of attention to a non-noxious event or stimulus in the immediate environment. When a patient worries too much about his/her pain causes more pain than what is really there. Vessey et al (1994) surveyed 100 children, aged 3 years to 12 years, majority are males (62%) to examine the effectiveness of Distraction method during venipuncture or needle prick, the child’ s memory may lead to stressful psychological responses, such as crying, and physical responses such as venous constriction during the procedures. It is important that in conducting a study the respondent’ s age, developmental level and prior hospital experience must be considered during the selection, Broome (1985). Furthermore, Researchers uses the Wong-Baker FACES pain rating scale in evaluating children’ s perception of pain. Wong-baker pains scale is know to be a reliable and valid device for children 3- 18 years of age in evaluating their pain,Wong and Baker (1988). In using distraction, the patients may paint, play with friends, watch TV and play with board games or video games and other novelty toys to help them relax and deflect their attention during the procedure since it provokes curiosity and require children to use their auditory, visual, tactile and /or kinesthetic senses. These activities may keep them from thinking about the pain.
Weekes et al (1988) Distress is known to cancer patients for years during and after the completion of anti cancer treatments. According to National Institute of Clinical Excellence (NICE), (2005) the role of imagination can play in a child’s ability to cope with painful operations. The NICE concluded that there was a strong evidence for the use of hypnosis in alleviating chronic pain associated with cancer. Richardson et al (2006) mentioned that hypnosis is a method where the subject is guided by another to respond to suggestions for changes in subjective experience such as perception, sensation, emotion, thought or behavior. It can be utilized in a variety of ways to cut down stress, acquire coping strategies and halt the experience of pain. Self-hypnosis tends to ease self management of symptoms, hence providing a sense of self-efficacy and control over pain and distress, however, it creates less therapeutic benefit compared to therapist- directed hypnosis. It is evident that patients who underwent hypnosis reported less anxiousness and pain while using direct and indirect forms of hypnosis, demonstrating leveled effectiveness. Though, there is some evidence that under hypnosis, girls exhibited more distress behavior compared to boys, Katz et al (1987). Richardson et al (2006) concluded that hypnosis has potential as a clinically valued intervention that could impart to the establishment of procedure- related pain and distress in pediatric cancer patients.
Oshikoya et al ( 2008) reported that complementary and alternative medicine has been advantageous for children by some parents, such benefits includes prevention of illness, maintenance of good health, relief of musculoskeletal pain, control of asthma symptoms, treatment of mild respiratory problems, relief of sickle cell anemia and enhancement of the immune system in cancer. 80% of the parents used alternative medicine to cure their children during the study, however, 7% discontinue the use of such practice because the symptoms of the illness come about in their children with exacerbation after their regular medications had been discontinued. Moreover, Kemper et al (2010) expressed that pediatric patients benefit from stress reduction by means of using complimentary medicines and techniques such as biofeedback which teaches the child to control and calm body’ s reactions when there is pain, it is one of the treatments researched most extensively for migraine, Allen (2004). Guided imagery is used by letting the patient imagine that he/she is his/her favorite place, the patient will feel safe and relaxed and pain may be decrease. Relaxation and self-hypnosis methods that re mostly used for migraines and headache by asking the child to breathe slowly and deeply and let the patient imagine that his/her muscles are relaxing.. Holroyd and Drew (2006) stated that cognitive behavioral therapy has been utilized successfully to help manage headaches, depression, and anxiety, Lawler and Cameron (2006). This practice has proven effective in reducing migraine headaches, improves mood and cognitive function through an experiment. Also, Acupuncture and Massage can help both adults and pediatric patients who have chronic headache and can be provided by family members, which allows for more regular, inexpensive and favorable treatments.
Salantera et al (1999) investigates 265 nurses about the knowledge and abilities of nurses towards pain management of pediatric clients. Health care practitioners such as nurses, are well placed to provide such supportive interventions in both pharmacological and non-pharmacological treatments. According to Ross et al (1991) Healthcare providers lack of knowledge and negative attitudes may lead to under medication and under treatment of pain. Nurses are close to the children the whole day and have more chance to use non-pharmacological pain management methods in their work. Clarke et al (1996) that education about pain was most inadequate in areas of non-pharmacological interventions to relieve pain, the difference between acute and chronic pain, and the anatomy and physiology of pain. Nurse’s knowledge differed according to their age, education, and place of work, and uses a fairly wide range of non-pharmacological pain alleviation methods, most of the time the nurse was in the active role and the child was passive, restricting the child to take an active part in their own pain comfort. Studies shows that children like to have some responsibility for their own care. Furthermore, Pederson and Harbaugh (1995) explicit that there are obstacles in terms of using non-pharmacological pain management in hospital setting and found to be that excess workload, lack of proper materials, lack of knowledge and skills, and not knowing the child were the most common problems nurses confronts. Some of them felt that they receive very brief education on non-pharmacological pain management, and 90% had no documented evidence of the use of any non-pharmacological modalities to relieve pain that will serve as nurse’ s guidelines. The nurses who thought they had good knowledge about non-pharmacological management got a lower score from the survey, nurses consider themselves knowledgeable in stress reduction but not in play therapy and hypnosis method. Effective pain management in children requires cognition of both pharmacological and non-pharmacological methods. There are evidence found that nurse’ s characteristics, such as age, knowledge, experience, intuition, attitudes and beliefs, as well as nurse’s personal experience with pain, determines their implementation of pain interventions and knowledge about it. Nurses should be encouraged to actively seek new information and extend their training. More comparative, dismantling, constructive, and process oriented research strategy is required in the area of non-pharmacological pain management and different practice of pain alleviation should be generalized.
Non- pharmacological approach has been found to be an effective adjunct method for the control of pain. A wide range of complementary and alternative medicine therapies are being used by children, including herbs and dietary supplements. Given the influence of psychological and behavioral factors on pain, non-pharmacological interventions are important in altering pain perception/behaviors. Diversional activities are intervention used for managing pain in both children and adult to reduce fear and, minimize distress and pain and increase a child’s sense of control. For these techniques to be effective, it must be appropriate to patient’ s age and developmental abilities and must also be appealing to the recipient. There is still continues need to educate the medical community regarding the long term outcomes of pain control.
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Allen KD (2004) Using biofeedback to make childhood headaches less of a pain. Pediatric Annual. 33: 241-245
Broome M (1985). The child in pain: A model for assessment and intervention. Critical care quarterly, 8: 47-55
Fernandez E (1986). A classification system of cognitive coping strategies for pain. Pain. 26: 141- 151.
Holroyd KA, Drew JB (2006) Behavioral approaches to the treatment of migraine. Seminar Neurology. 26: 199- 207
Katz E, Kellerman J, Ellenberg L (1987) Hypnosis in the reduction of acute pain and distress in children with cancer. Journal of Pediatric Psychology; 12: 379- 394
Kemper K, Breuner C, (2010) Complimentary, Holistic, and Integrative Medicine; Headaches. American academy of pediatrics, 31(2) p.17- 23
Lawler SP, Cameron LD (2006) A randomized, controlled trial of massage therapy as a treatment for migraine. Annual Behavioral Medicine. 32: p50-59
National Center for complimentary and alternative medicine, NIH (2007) Non-pharmacological pain management therapies for children. Available at http://nccma.nih.gov
National Institute for clinical excellence (NICE) (2005) Service guidelines for improving outcomes in children and young people with cancer-second consultation. Available at http://www.nice.org.uk/pdf/cacancer_2ndcons_manual.pdf
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