Evidence Based Practice - Essay Example

EVIDENCE BASED PRACTICE INTRODUCTION Changes occurring in Health care delivery and Medicine are the result of social, economical, technological, scientific forces that have evolved in the 21st century. Among the most significant changes are shift in disease patterns, advanced technology, increased consumer expectations and high costs of health care. These factors have redefined medical practices to fit into the changing health delivery system. Thus, Nursing Profession is 'accountable' to the society. i.e. obliged to the laws regulating the professional activity. This 'accountability' is usually spelt out in "Patient Care Documents" established by hospital associations and medical associations or councils of every country (Suzanne, 2004). In addition, nursing profession has defined its standards of accountability through a formal code of ethics. Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996). The practice of evidence-based practice is the integration of individual clinical expertise with the best available external clinical evidence from systemic research. Individual clinical expertise is the proficiency and judgment that nurses acquire through clinical experience and practice. External clinical evidence is the relevant patient centered clinical research from the science of medicine. This includes the accuracy and precision of diagnostic tests, prognostic markers, therapeutic, rehabilitative and preventive regimens. External evidence sometimes replaces previously accepted treatments by virtue of accuracy and safety. Evidence based practice takes patient's perspective also into account. Hence, evidence based practice involves a big process of question building and this process of question building takes into account clinical findings, aeotiology, diagnosis, prognosis, therapy and prevention of diseases. This question building process gives the idea on the most important question, the question which is encountered very often in practice and the question's relevance very often in practice and the question's relevance to the patient situation. Evidence based practice is probably best understood as a decision - making framework that facilitates complex decisions across different and sometimes conflicting groups. It involves considering research and other forms of evidence on a routine basis when making health care decisions. Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). At a broader level, evidence based practice works by providing a safe framework in which different groups can make tough decisions by safe guarding their concerns by a fair and scientifically sound process. There are essential differences between traditional and evidence based practice. Traditional medical practice has always drawn upon the personal experience, case studies and research of the physician. In evidence based medical practice, health care decisions are based on a structured organized process to help physicians, nurses and patients alike to choose the best health care options and their consequences. Thus, the basic idea of evidence-based medical practice is to create a process of life long, self directed, problem based learning for nurses in which caring for their own patients is the prime motive. This caring creates a need for clinically important information about diagnosis; prognosis, therapy and other health care issues. In this process of evidence based medical practice, the nurses convert this information into answerable questions, tracking down with maximum efficiency, the best evidences which can answer these questions, critically analyze them for clinical applications, apply them, integrate them with their clinical expertise and evaluate their own performance. Of course, the best evidences are based on the conviction that a systematic documenting of a large number of high quality RCTs (Randomized with Concealment, Double blended, complete follow-up, intention to treat analysis) gives the least biased estimate. Thus, this becomes level 1 evidence and recommendations based on level 1 evidence are Grade A. Various terminologies aid evidence based medical practice such as 'Clinical practice guideline' which assists practitioner and patient make decisions about appropriate health care and 'Randomized controlled clinical trial' where a group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables and outcomes of interest. Nurses are under increasing pressure to keep up to date and to base their decisions more firmly on evidences as opposed to anecdotal information of the past. Patients are much more informed than they were 10 years ago. No nurse can tell a patient what to do without being questioned. The most important aspect of evidence-based practice is that it has provided a fair, scientifically rigorous method for making best-practice decisions. This has ensured professional transparency and accountability. Evidence based medicine does have limits. Absence of support structures for sustained evidence, lack of commitment to the process, insufficient evidence for too many problems do pose some challenges. But, evidence based medicine provides a medical practice with a stronger application of the scientific method (Baum, 2003). This also provides all groups involved in providing health care with a rigorous and acceptable frame work for making complex decisions, at a time when effective decision is badly needed. In this context, the ultimate goal of medical profession is to care and cure keeping in view the trust issues in dealing with the patient. The nurse's primary commitment is to the patient and profession. Recent studies identify 16 interventions with proven efficiency under ideal conditions for neonatal survival. These can be used to scale health systems by three approaches, namely outreach delivery mode, family community mode and facility based clinical care. All the modes have been found to be cost effective. Universal application of these is estimated to avert an estimated 72% of neonatal deaths all over the world. Neonatal mortality of less than 50% can be achieved with high-coverage outreach and family-community care. Averting neonatal deaths is possible even in high mortality weak health systems through outreach and family-community care, including health education to improve homecare practices. Clinical care of babies and mothers is an essential aspect of reduction in neonatal deaths (Bhutta, 2005). JudithGreen et.al (1998) have used the asthma treatment to illustrate how qualitative methods can broaden the scope of evidence-based medicine. According to the authors, Qualitative methods can help bridge the gap between scientific evidence and clinical practice, provide rigorous accounts of treatment regimens in everyday contexts, help us understand the barriers to using evidence based medicine, and its limitations in informing decisions about treatment. Recognizing the limits of evidence-based medicine does not imply a rejection of research evidence but awareness that different research questions require different kinds of research (JudithGreen et.al, 1998). The authors classify qualitative research into various components as Naturalism which is the understanding treatment regimens in an everyday context ;Interpretation which explains what meaning do symptoms and treatment regimens have for patients and practitioners; Process which explains how might these meanings change over time ;Interaction which explains how communication between patients and practitioners impact on the meaning of medication and Relativism which explains how scientific reality look different from different perspectives. Qualitative findings as discussed, are often the first type of evidence available relating to innovations and contextual constraints relating to existing practice (David R. Thomas, 2000). According to this published article, the value of good qualitative data is that it can provide crucial information about context and processes related to health practices and interventions and can be useful in areas for which there is little or no previous research, the use of RCTs or other types "experiments" is impossible and to complement quantitative data gathering providing data about unanticipated impacts of interventions.Qualitative procedures can form information not obtainable using quantitative methods. Qualitative evidence is often the "best available" evidence until quantitative research is carried out. (David R. Thomas, 2000). Lincoln and Guba (1985) suggest that various techniques are necessary for improving and documenting the credibility of data. Having the participants together encourages sharing of thoughts / views and test for misinformation and understanding amongst the participants, builds trust and good rapport with each other. Cohen and Manion (1994) suggest that Multiple methods measure and investigate factors such as academic achievements and cultural interest. For example in case of maintaining hand hygiene among nurses it is important to access how individual speciality view their academic level in relation with hand hygiene. The cultural differences amongst the specialities also determines how each makes the decision to wash their hands depending on the activity they have been involve in. Patton (1990). Suggests that researchers should report of any personal and professional information that may have affected the data collection / study. Bell (1996) confirms that the presence of a supervisor in a study environment create a positive relationship and can also impede students achievements. TrishaGreenhalgh et.al (2003), view evidence based practice as a sequence of framing a focused question followed by a thorough Search for research derived evidence supported by the appraisal of the evidence for its validity and relevance incorporating the user's values and preferences. Henderson et.al (2004) have developed an instrument, suggested by Cuba's Model of Trustworthiness of Qualitative Research, to evaluate the methodological rigor of qualitative papers expanding Sackett's Rules of Evidence Model for qualitative studies in clinical decision making and have proved that the appraisal instrument and the methodology straightforward, simple to use, and helpful in clinical decision making (Henderson et.al ,2004). The impact of healthcare-associated infections (HCAIs) on the National Health Service. (NHS) has prompted steps to prevent and reduce risk throughout the patient's journey within the NHS. In 2003, Winning Ways recommended that all staff apply "rigorously and consistently the measures known to be effective in reducing the risks of healthcare-associated infection", and specified that there should be high levels of compliance with infection prevention and control procedures. The Trust is committed to reducing Health Care Associated Infections. It has been providing guidance on moving towards compliance, surveillance, research, auditing, evaluation, assessment support and gives evidence-based information. WHY HEALTH CARE PROFESSIONALS NEED TO FOLLOW A RECOGNISED PROTOCOL TO MAINTAIN EFFECTIVE HAND HYGIENE AN EVIDENCE BASED APPROACH Hand washing programmes remains one of the most effective tools available to help reduce infection, promote patient and health care workers safety and create an organizational climate that reinforces primary prevention of infectious diseases. The impact of appropriate hand hygiene on infectious risk is very well recognized. Nevertheless, the importance of this simple procedure is not sufficiently recognized by healthcare professionals and compliance with recommended hand hygiene practices remains unacceptably low (Jarvis, 1994). By using the qualitative method of study, this paper attempts to look into the factors preventing healthcare professionals' uptake and implementation of evidence based hand hygiene recommendations. The target population for this study are; general practitioners, school nurses, health visitors, practice nurses, speech & language therapist, domestics, district nurse, podiatrist and community nurses. All were randomly selected through the work force development's email adverts for teaching programmes. This email was sent purposively to the group selection above. The study hoped for 10% of the population but unfortunately very small number responded. All respondents reported of washing their hands, but 20% reported that hand washing is not always needed, depends on what takes or activities they do. The result revealed that the theory of reasoned action is a good model to explain / understand the attitude of the professionals towards hand washing, use of alcohol hand rub / gel and use of gloves. Despite the constant information on hand washing, use of alcohol hand rub / gel before and after every task or pre & post donning gloves etc, the increase of health care associated infection such as MRSA through inadequate hand handgiene is very well recognized. The strategy by using the sample as stated above, was to ensure that the target population would be represented in the study. By using this sample, the researcher would be able to determine if there was bias in sample group. LITERATURE REVIEW Health Care Associated Infection (HCAI) is described as infection acquired in hospital or other healthcare setting (clinical standard 2001).Healthcare associated infection include infections acquired in health care setting but not apparent until after discharge , infection contracted while receiving care in the community as well as infections contracted by staff in health care facilities. HCAI) is now recognized as a major and increasing problem with no single determinant to explain its growth. Strategies are being developed at local, national and international levels to prevent and control the many factors known to contribute to the current high rates ((NHS QIS 2005). Government initiatives aim to ensure that infection prevention and control is at the center of care management and delivery across all healthcare settings within the National Health Service, with effective infection prevention and control at management level and in clinical practice now becoming a major goal for all healthcare personnel. While infections can be prevented and despite the fact that most can be successfully treated with good infection control practices including appropriate antibiotic use; the burden of HCAIs cannot be underestimated (Damani 2003). The impact of HCAI in terms of human and financial costs is substantial. Financially, the annual cost is estimated to be around 1 billion in England and Wales and in human terms, HCAIs are potentially life threatening (Walker 2001, Plowman et al 1999).The spread of infection via hands s well established (Larson, 1981; Ayliffe et al 1990). Hand washing is one of the most important procedures for preventing the spread of infection and disease. Hand hygiene is an infection control practice with a clearly demonstrated efficacy and remains the cornerstone of efforts to reduce the spread of infections. Hands play a significant role in breaking the chain of Infection, the transmission of infection between patients. (Reybrouck, 1983). Factors that influence hand hygiene compliance include workload and staff shortage, poor facilities and lack of understanding (Wilson 2001). EVIDENCE BASED RECOMMENDATIONS Hand Hygiene Technique Hands should be decontaminated by systematically rubbing all parts of the hands and wrists with soap and water and/or an alcohol hand gel and/or antiseptic solution etc; being particularly careful to include areas of the hand which are most frequently missed (Taylor, 1978). This aim to remove transient micro-organisms from hands. See Appendices 1 and2 for the parts of the hand most frequently missed and the six step technique used to ensure coverage of all areas of the hands. Antiseptic Hand Hygiene Semmelweis 1847 confirms that hand hygiene with soap and water alone is not always sufficient to prevent the spread of infection and recommended hand disinfections / antiseptic for certain procedures, it is therefore essential to perform hand hygiene with both soap and water and alcohol hand gel /rub after they may have become contaminated with micro-organisms and before contact with a susceptible site on a patient. The aim of antiseptic hand hygiene is to kill pathogenic organisms present in transient flora and to have a residual effect after washing that will reduce the ability of pathogenic organisms becoming transient flora. Surgical Hand Hygiene The aim of surgical hand hygiene is to remove and destroy transient micro-organism. It should also substantially reduce detachable resident micro-organisms; this is achieved by using an antiseptic hand wash solution. Surgical hand washing is essential for all surgical and some invasive procedures. Therefore every individual involved in surgical procedures must have received appropriate training in surgical hand hygiene. This involve the use of antiseptic solution (e.g. Hibiscrub or Betadine) applied to the hands, wrist and forearms. The recommended duration for surgical hand washing process should be two minutes. A sterile brush may be used for the first application (however care must be taken to avoid skin damage), but continual use is inadvisable as damage to the skin may occur. This may increase the level of microbial colonisation. Hand Drying Effective hand drying is important because wet surfaces transfer micro-organisms more effectively than dry ones. Cloth towels and hot air dryers are not recommended in health care settings. The recommended method of drying is using good quality paper towels as the action of drying with these can also assist in rubbing away transient organisms. Paper towels should be conveniently placed in wall -mounted dispensers with foot operated bins for disposal close by. The Gloved hand Occupational safety require that health care workers to wear gloves when they are likely to have to contact with blood or other potentially infectious material, mucous membrane and non-intact skin; when performing vascular access procedures and when handle or touch contaminated surfaces or items. It must be emphasised that the use of gloves in addition to the process of hand hygiene is an added protection, not an alternative to hand hygiene. Gloves easily break and can facilitate the growth of bacteria, which may lead to infection Pittet et al (2000). Gloves are an important protective measure providing the same gloves are not worn when moving from one patient to another. The same gloves should not be worn between clean and dirty procedures. Hands hygiene should always be performed after removing gloves and before sterile gloves are worn. Gloved hands should not be washed or cleaned with alcohol hand rubs, gels or wipes. Gloves comes in various types, each with different properties and appropriate for use in a range of activities. Assessment of risk is required to ensure correct selection (Wilson 2001).Wet hands should be dry completely before hand rub application ; further hand should also be dry completely before donning gloves or resuming any activity. Skin Care Health care workers perform frequent hand hygiene and are susceptible to long-term changes in the skin. These can result in chronic damage, irritant contact dermatitis and eczema as well as changes in the bacterial flora of the flora. Failure to remove jewellery may predispose to skin problems, and eczema can begin under a ring and spread over the hand. Lack of education and knowledge on this is a key barrier to compliance. Larson et al (1997) suggests that during the winter months, the skin on the hands of personnel may become dry and cracked that can re result in bleeding. When this occurs people avoid washing their hands because of the involved. Prevention of Skin Damage Skin damage is generally associated with the detergent base of the preparation and/or poor hand washing technique. To reduce the risk of skin damage, hands should be wet under running warm water before applying the hand- washing product. After washing the hand should be rinsed thoroughly to remove residual soap and then dried carefully, paying particular attention to between the fingers. When hands are not visibly soiled alcohol gel is preferable as it is associated with less skin damage. Larson et al (1997) again confirm that alcohol hand rub contain emollient irrespective of the type of alcohol that have significant improvement on hand conditions. Hand Creams Hand creams should be applied regularly to protect the skin from drying effects of regular hand hygiene. Commercial pots of hand cream should not be used as they can become contaminated and a source of cross-infection. Wall mounted dispensers of hand cream should be available in clinical areas. If reaction occurs hand hygiene products advice should be sought from Occupation health. Orientation & Overview Of The Study The link between hand hygiene compliance in relation to Healthcare associated infection is very well known and as an infection control nurse, it is my part of my job to carry out hand hygiene training programme for all trust staff. It is therefore important to conduct this study to enable me to understand the staff's thinking, knowledge, practice or behaviour of the subject. This will give me the kind of information needed for the training and how to capture the staff's co-operation / full participation to improve compliance. Sampling: Focused exploration The group chosen to take part in the study consist of General practitioners, School Nurses, District Nurses, Health Visitors, Community Nurses, Health Care Assistants, Practice Nurse, Domestic , Podiatrist and speech and language therapist. The group was chosen because they represent the professionals' population within the PCT (Primary Care Trust) who has direct patient contact. These individuals were invited via the trust's training and development advert process for teaching to the above departments. After the confirmation slips had been received from them, then the letter of the study with a consent form and the questionnaire were sent to invite them to study via the email system. Explanation of the study was given in the letter and it was made clear that they are to complete and bring the questionnaire with them to the teaching session. This was to ensure that only the control group received the questionnaires and attended the teaching. Sampling: Although the sampling selected was voluntarily and self-nomination by the participants, the sample selected was purposive as explained above. A purposive sample was needed because a representative sample is required to ensure that the measurement accurately reflected and could be generalized to the population within the PCT. This brings about meaningful realities within the specialities of the population (Nardi 1998). Confirmation Of Sample The PCT has over eight hundred staff and the sample obtain for the study was 22 in total. The study was done in two separate teaching sessions on the same day. With over 800 staff, the study sought to obtain a sample of 10% participants. But it was felt that the 10% was a large sample for such a small study. Also, there was limited resources and restriction with time. For such a large number of sample, a room with capacity of at least 20 people was required for the teaching sessions, on at least four separate occasions and was not possible. Although the size of 22 participants was manageable, it was believed that perhaps the size might not represent the true thoughts of the population. On the other hand, the group selected are believed to be the sample that can best supply or give information according to the conceptual requirement of the study. Given the circumstance where by the sample was selected, it was felt that not everyone within the population was given the opportunity to take part in the study. This is because the invitation was sent only to those who confirmed their attendance for the teaching session. The reason was to cut cost and also for assurance that those individuals will return the questionnaires. Thosendividuals who were unable to bring their questionnaires with them for various reasons were given a copy to be completed before the teaching started. This was to prevent their answers to the questions being influenced by the information and knowledge obtained through the teaching session; which may not have given the actual information the study was intended for. If the researcher had not given these individuals another copy of the questionnaires at the teaching site to be completed, it would mean that another group of the same speciality would have needed to be selected to replace them, which would have taken time and also cost implications in relation to postal. Bringing the questionnaires to the teaching was to ensure that participant response effectively and also to prevent non-respondent as possible. Justification: Carrying out the teaching programme after collection of the questionnaires, gives the participants the opportunity to ask any questions that they feel should have been part of the questionnaire. It also provides answers to some of the questions they did not understand or had different interpretations. The teaching session with practical observation by using the UV light box (glo- germ machine), encourage participants to identify areas in their own hand hygiene compliance where improvement is required. Having the questions electronically and asking the individuals to bring their copies to the teaching session also prevent those who were not computer literate or those who had no access to printer from taking part; which means their knowledge on the subject was not presented. The use of the Internet and email for data collection pose challenges in collecting a) anonymous data, b) obtaining informed consent and c) ensuring that participants are of the appropriate age to give informed consent. In this study, this was the quickest way of doing it, considering the restrictions such as time and cost. Again, by checking with the work force department and ethic committee, it was made known that all employees within the trust were to be over the age of 18 years. Having questionnaire mean respondents can answer without feeling intimidated as tend to happen in an interview. Respondent can answer as they feel knowing that their anonymous is maintained. Having the teaching for all the representative of the various specialities together in one place provide the assurance that hand hygiene is everyone's responsibility a stated by the chief nursing officer. It also create discussion that brings understanding of why the different specialities practice hand hygiene in the way that they do. Credibility of data collection Using both questionnaire and glo-germ observational method is to evaluate the credibility of the data. Lincoln and Guba (1985) suggest that various techniques are necessary for improving and documenting the credibility of data. Having the participants together encourages sharing of thoughts / views and test for misinformation and understanding amongst the participants, builds trust and good rapport with each other.Cohen and Manion (1994) suggests that Multiple methods measure and investigate factors such as academic achievements, cultural interest, etc. This is to show the thoughts of the participants in relation to hand hygiene. In this case it was important to access how individual speciality view their academic level in relation with hand hygiene. For example, doctors might hand-washing as a simple practice below their academic standard therefore will not comply as they suppose to. The cultural differences amongst the specialities also determines how each makes the decision to wash their hands depending on the activity they have been involve in. Age was added to the questionnaires to identify if certain age group takes hand hygiene more seriously than others. Researcher credibility Patton (1990). Suggests that researchers should report of any personal and professional information that may have affected the data collection / study. Being an infection control nurse for the Trust, I believe being with the teaching, observing both hand-washing technique with use of the glo-germ machine amongst the participant mat have created some form of uneasiness; however, this could also create a positive atmosphere for them to ask any questions bothering them knowing that I know and also have understanding in the topic and the related infection control issues. Bell (1996) confirms that the presence of a supervisor in a study environment create a positive relationship and can also impede students achievements. On the other hand, this could either prevent them from asking any question they may think is unnecessary or make them try and wash their hands by using the six hand wash technique to pretend that they comply at all times. To ensure the validity of the questionnaire, a sample was first given to a group of clinical staff in the same office to find out or to measure whether the questions are likely to provide the answers expected and corrections were made accordingly Conclusion And Recommendation In conclusion adherence with the recommendation for hand hygiene practices remains low in most health care settings. Among the issues associated with non-compliance, time constraint is the leading factor for non -compliance with hand hygiene, but it is also the easiest to modify. Pittet et al (2001), suggest that these findings relate to hand washing only but not to the use of hand rub. Therefore system change is required all areas where waterless hand hygiene disinfections has not become a standard of care. Education and Audit Health care workers education and motivation are equally important and must be part of multimodal strategies to enhance compliance in all health care settings. All clinical staff when joining the Trust and then on an annual basis (at least) should attend an infection control session run by the Infection Control Team. These sessions should cover an update on hand hygiene practices. This will include importance of and when to perform hand hygiene, technique (with practical session using UV light box (glo- germ machine), appropriate product to be used for skin care.Non-attendance should be followed up by the education department responsible for planning and running the induction and mandatory training programmes. The Infection Control team should run promotional and awareness programmes aimed at improving adherence to hand hygiene practices. The Infection Control Link Nurses in each area is required to carry out performance and Observational audits of hand hygiene rates every 6 months with feedback given to staff. POSTER .. SURVEY CONSENT.. REFERENCE Ann J. Zwemer, 1995. 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