C-T-E Structure and EBP Theory - Essay Example

C-T-E Structure and EBP Theory C-T-E Structure and EBP Theory Introduction The C-T-E structure that will be used in the currentstudy is Clinical Judgment (C), Interpersonal Relationship Nursing Theory (T) and Lasater Clinical Judgment Rubric (E). This structure is important to a doctorally prepared nurse because they have to understand the relationship between nursing knowledge and actual interventions. The understanding is helpful to a doctorally prepared nurse in that it helps them develop and test the said interventions. As researchers, doctorally prepared nurses need to explain to their readers how they conduct their studies in order to court reader’s trust in the outcomes of those research activities. The failure to identify, expressly, the conceptual model that a researcher used in his or her study leaves readers guessing within a study’s conceptual context. It is not guaranteed that readers will guess the right conceptual model and they might end up not benefitting from such studies. Conceptual model: Clinical Judgment Clinical judgment entails the use of information observed and recorded from a patient to make conclusions. This process helps in advising patients on how to improve their health. When promoting evidence-based research, clinical judgment involves patients in deciding the best practice to be adopted in intervention while taking into account their values. The situation is another thing that is considered in clinical judgment because different situations will come with unique sets of conditions. Clinical judgment is needed in different aspects in the clinical setting including communication, decision-making, therapy, and diagnosis (Kienle & Kiene, 2011). Continuous critical analysis, knowledge, experience, and practice are needed in the development of clinical judgment. These elements accounts for the differences noted between junior and senior medical practitioners in terms of their level of clinical judgment. Senior medical practitioners emphasize theoretical knowledge less than their junior counterparts do. Previous experience of cases and course of events is central to the level of clinical judgment exuded by senior clinicians whereas it is less important to the juniors. Senior clinicians are more likely to emphasize ethical and moral considerations when making clinical judgment more than junior clinicians do (Nilsson & Pilhammar, 2009). This made Kienle and Kiene (2011) to conclude that clinical judgment can be optimized and professionalized. This explains why new interns need intense supervision while on residency. Some interns have problems during clinical rotations and supervisors have to guide them on what to do. Information gathered from supervisors can be used in the development of early interventions and instruction goals to raise an intern’s clinical performance. Many interns do not perform as highly in clinical judgment as their faculty expect. The performance is attributed to the lack of confidence and familiarity with the clinical set up. Even so, tests show that interns internalize aspects of clinical judgment with time as they meet more patients and handle different issues and needs (Wendling & Baty, 2009). Theory: Interpersonal Relations Nursing Theory Hildegard Peplau is the founder of the Interpersonal Relations nursing theory. The theory was founded in 1952 and was influenced by the works of Fromm-Reichman and George Herbert Mead. The theory perceives nursing as an interactive process between the patient and the nurse seeking to accomplish a common goal. The interaction makes both parties learn and grow. According to Peplau, human beings constantly seek to minimize tension brought about by felt needs. Health denotes the progress of human process including personality towards productivity, creativity and constructive living both personally and communally. The theory assumes that nurses and patients can interact. It also assumes that interpersonal skills are crucial to any nursing process. The last assumption with this theory is that nurses have to understand themselves in order to be in a position to promote a patient’s growth and not limit them (patients) to the choices they (nurses) like (Courey et. al., 2008). The last assumption is one of the things that justify the suitability of this middle range theory to the current study. Clinical judgment and evidence-based practice implicitly emphasizes the need for nurses to forge a relationship with the client in order to settle on what works best for the patient. Self-awareness would be needed for any nurse not to impose their idiosyncrasies on the patient and ignore the input of a patient in addressing his or her own problem. Knowledge of the self would remove the hindrances that cripple interpersonal relationships between persons due to poor skills such as lack of effective communication skills (Courey et. al., 2008). Whether the use of JNC guidelines in the treatment of hypertension helps avoid future risks of cardiovascular disease is the PICO of the current study. Peplau’s theory strongly supports this PICO because it requires a nurse to refer to knowledge that is beyond their personal frame of reference during practice. The guidelines are a collection of evidence collected from the studies conducted by other people and evidence-based practice will require nurses to factor in all available knowledge in deciding the most appropriate intervention (Melnyk & Fine-Overholt, 2011). If nurses were to follow the tenets of Peplau’s theory, they will put the interests of the patient before everything else. On another level, like in the treatment of any other disease, the treatment of hypertension and prevention of cardiovascular touches on the economic, social, and psychological wellbeing of the patient. Although implicit, Interpersonal Relations theory encourages the nurse to pay attention to a patient’s background during the nursing process. It would hurt the process if the suggestion that the nurse would make to the patient would significantly disrupt the different aspects of life of the individual. The nurse would have to consider whether the patient could afford the cost of the intervention. Cost is both in monetary terms and the things that the things that the patient would have to part with socially and psychologically. One of the four phases of the therapeutic nurse-patient relationship that Peplau conceived in developing her theory is resolution phase (Finch, 2008). According to this phase, the nurse treating a patient for hypertension using JNC guidelines needs to get a patient to a level where he or she does not need professional services and can live independently. Empirical indicator: Lasater Clinical Judgment Rubric (LCJR) Lasater Clinical Judgment Rubric (LCJR) is a tool used in the measurement of the performance of health professionals in clinical judgment. The tool will be used in a pre and post examination related to the JNC guidelines. The tabular rubric uses a clinician’s observation, interpretation, response, and interpretation skills to measure their level of performance in clinical judgment. The reliability of the tool is evidenced in the consistency showed by the scores that clinicians get on the rubric and the actual performance during clinical sessions with patients (Sideras, 2007; Ashcraft et. al., 2013). This consistency is established through the comparison of the scores that different raters come up with and if it were high, the tool would qualify as reliable (Adamson et. al., 2012). Consistency in the results of many other reliability analyses can also help in proving the dependability of LCJR. The validity of the tool is underpinned by the use of concepts that define clinical judgment holistically. Observation helps nurses to focus their observation on certain aspects on the patient, recognize deviations and patterns, and seek for details. Interpretation entails prioritizing data and making sense of the gathered data. In response, the nurse needs to be confident, clear, organized, and skillful. Reflection involves the nurse evaluating the nursing process in which they are engaged and committing him or herself to improving the elements that are ineffective (Lasater, 2007). Additionally, the validity of the LCJR is seen in the way it remains in tandem with the theoretical constructs of clinical judgment. In fact, the tool was developed based on Tanner’s Clinical Judgment Model that acted as its theoretical underpinning. The tool has been used and evaluated in many studies (Ashcraft & Opton, 2009; Strickland, 2009; Shin, Park and Shim, 2014; and Jensen, 2010) with data related to the augmentation of clinical judgment skills supported by Tanner’s Model of clinical judgment. Evidence-Based Practice Change Theory Rempher’s evidence-based practice change model consists of six steps that can work well for the current study. The first step in the model is conducting a focus group that brings nurses together in choosing an evidence-based model that is line with the mission and vision of the organization. The model to be selected should also have support from the patient care delivery model used in the organization. A good model should establish an answerable question that is based on a given catalyst in the organization. It must help critically review and synthesis evidence from available literature. There should be clear guideline on how to translate evidence into practice, and it should allow for the evaluation of the practice to ensure it is appropriate and sustainable (Rempher, 2006). The second step in Rempher’s evidence-based practice change model is the actual selection of a model. The selection should consider whether a model is intuitive and easy to understand. After a model is selected, the third step should be garnering support for the selected model. The organizational leadership is one of the parties from whom the most important support is sought. This is because once the leadership has approved the model it will influence its adoption by the organization’s personnel. As such, there is a need to furnish the leadership with all information that will help in its decision to adopt the model. Nurses also need to be provided with the information on the selected model because they are the implementers and their input is invaluable. The organizational nurse leaders and clinical practice council can act as resource contact in the activity (Rempher, 2006). Education is the other step in the model and this involves conducting intense, brief, and direct sessions that equip direct-care nurses with the basic understanding of the selected model. The knowledge emanating from this education reinforces the existing knowledge about evidence-based practice. Central to this step is informing nurses about point-of-care information resources to which they can turn to in times of difficulty. Nurses also need information on the person they can turn to for further guidance on the execution of the model. Implementation is the next step in the model. Councils and committees tasked with policy development and research in an organization are key stakeholders in implementation. This is because they would help in spearheading the exercise. Implementation should seek to integrate the model seamlessly with the organization’s standards (Rempher, 2006). Evaluation is last step in Rempher’s model, it involves coming up with mechanisms, and processes that help uphold the effectiveness of the model. The evaluation can take the form of an online survey that seeks to capture the attitudes of nurses towards the model. It is to be expected that nurses’ attitudes will change with time as nurses’ struggle with the difficulties making the model work. The evaluation can also review the results of the model when used to revise protocols, procedures, and policies in the organization. It can also take the form of a focus-group discussion that would bring together different committees tasked with the formulation of policies and practice guidelines (Rempher, 2006). Overall, the adoption of an evidence-based change model should start with an assessment for the need for change. The assessment entails the collection of internal data and comparing it with external data. The results are linked with standardized outcomes and interventions. The selected interventions should be synthesized and be synchronized with clinical judgment in addition to contextual data. In addition, there is need to conduct a pilot implementation of the selected interventions in order to evaluate their feasibility. Pilot implementation can help in modifying the selected intervention to avoid impediments noted and to enhance observed strengths (Rosswurm & Larrabee, 1999). Rempher’s model is workable in the current study because it bears close semblance with the nursing process. In conclusion, C-T-E structure of the current study is Clinical Judgment-Interpersonal Relations Theory-Lasater Clinical Judgment Rubric. Clinical judgment will be an important conceptual framework for the consideration of whether the use of JNC guidelines helps avoid the future risk of cardiovascular disease because of the nature of this clinical problem. Interpersonal Relations Theory is the middle range theory that will underpin this research endeavor. Lasater Clinical Judgment Rubric will be the instrument that will be used as the empirical indicator in the study. The tool is suitable for this study because of its reliability and validity. Rempher’s model will be the evidence-based change model that will be employed in this study. It is easy to adopt and can work for many organizations. References Adamson, K., Gubrud, P., Sideras, S. & Lasater, K. (2012). Assessing the reliability, validity, and use of the Lasater Clinical Judgment Rubric: three approaches. J Nurs Educ., 51(2): 66 – 73. Ashcraft, A., Opton, L., Bridges, R., Caballero, S., Veesart, A. & Weaver, C. (2013). Simulation Evaluation Using a Modified Lasater Clinical Judgment Rubric. Nursing Education Perspectives, 34(2): 122-126. Courey, T., Martsolf, D., Draucker, C. & Strickland, K. (2008). Hildegard Peplau’s Theory and the Healthcare Encounters of Survivors of Sexual Violence. J Am Psychiatr Nurses Assoc., 14(2): 136 – 143. Finch, L. (2008). Development of a Substantive Theory of Nurse Caring. International Journal for Human Caring, 12(1): 25 – 32. Houser, J. & Oman, K. S. (2011). Evidence-based practice: An implementation guide for healthcare organizations. Sudbury, MA: Jones and Bartlett Learning. Kienle, G. & Kiene, H. (2011). Clinical judgement and the medical profession. J Eval Clin Pract. 17(4): 621 – 627. Lasater, K. (2007). Clinical Judgment Development: Using Simulation to create Assessment Rubric. Journal of Nursing Education, 46(11): 469-503.  Melnyk,  B.M. & Fine-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadephia: Wolters Kluwer/Lippincott Williams & Wilkins. Nilsson, M. & Pilhammar, E. (2009). Professional approaches in clinical judgments among senior and junior doctors: implications for medical education. BMC Medical Education, 9(25): 1 – 9. Rosswurm, M. & Larrabee, J. (1999). A model for change to evidence-based practice. Journal of Nursing Scholarship, 31(4): 317 – 322. Sideras, S. (2007). An Examination of the construct validity of a clinical judgment evaluation tool in the setting of high-fidelity simulation. Student Scholar Archive, Paper 450: 1 – 172. Wendling, A. & Baty, P. (2009). A step ahead – evaluating the clinical judgment skills of incoming interns. Fam Med, 41(2): 111 – 115. Read More