Health Care System, the Integration of the Best Available Evidence into the Practice - Assignment Example

Health Care System Introduction A number of national initiatives have been launched to help healthcare professionals integrate the best available evidence into their practice. These include the National Institute for Clinical Excellence (NICE), the Centre for Evidence-based Nursing at the University of York and the NHS Centre for Reviews and Dissemination, also at the University of York, the Clinical Effectiveness Support Unit (Wales) and, in Scotland, the Scottish Intercollegiate Guidelines Network (SIGN). All of these developments signify an impetus within the health services to ground clinical and managerial decision-making more firmly in the evidence generated by well-conducted research. The purpose of this study is to understand the importance of evidence based practice in a proper healthcare system. Over the past decade a number of authors have attempted to define the term 'evidence-based practice', in order to better understand its meanings and its implications for healthcare practice. It is when we begin to consider the definitions of the different terms, such as EBP, EBM and EBN (evidence-based nursing), that subtle differences in meaning are highlighted. These differences may have implications for the way in which evidence is understood, generated and utilized. Evidence-based practice has become part of the normal national and international language of healthcare practitioners over the last ten to 15 years. The number of journal articles citing the term has increased dramatically and there are now journals devoted entirely to this topic. The evidence-based practice movement originated with Archie Cochrane, a British epidemiologist, who recognized that while much individual research had been undertaken on particular areas of medicine, the findings of these studies had not been collectively reviewed and had only been considered individually. When studies are examined in isolation there is limited capacity to implement findings confidently and effect change in policy and practice, thereby hindering decision making and progress in health care. Professor Cochrane’s work inspired the creation of the Cochrane Collaboration, which sets the standard for systematic reviews and provides a repository of up-to-date, reliable information on the effectiveness of healthcare interventions (Pearson et al. 2007). The Cochrane Database of Systematic Reviews, part of the Cochrane Library, is a collection of reviews that is freely available to all members of the multidisciplinary team. The evidence-based practice movement today continues to promote the values that were espoused by Professor Cochrane and advocates the critical appraisal of best available evidence to underpin practice decisions. Benefits of Proper Healthcare System Appropriate healthcare system is essential and its proper implementation and evaluation make the system more better. Proper system enhance the patient confidence and helps in improving the process, patient feel more comfortable if the process of treatment share with the patient and adopt the procedure that is acceptable for the patient and the family. Evidence-based practice is the tireless pursuit of the best evidence, clinical expertise and patients’ preferences to inform and enhance patient care. Central to this is the inclusion of patient preferences to support decision making (Sackett et al. 2000). This approach not only espouses use of good quality evidence to underpin practice, but also values the individual as a recipient of care and a partner in the planning of care. PICO The execution of evidence-based practice relies on a sound knowledge of what it is and the skills to apply it in practice. Skills of question framing, database searching, critical appraisal, implementation, evaluation and dissemination are essential to ensure an evidence-based profession. The process of evidence-based practice should be as simple as possible. To this end, the steps involved in evidence-based practice are outlined. The process of evidence-based practice is underpinned by five steps (Melnyk and Fineout-Overholt, 2005): Asking the important clinical question. Collecting the most relevant and best evidence. Critically appraising the evidence. Integrating the evidence with one’s own clinical expertise and patient preferences to make a practice decision. Evaluating the outcomes of that decision. Asking the Important Clinical Question Clinical questions emerge from various sources and for a variety of reasons. All are driven by practitioners’ intellectual curiosity and need for answers to these questions. The manner in which these questions are articulated is key to the success, or otherwise, of the overall outcome. The importance of this cannot be over- emphasized. While this step can appear arduous and time-consuming as a novice, it will pay dividends and is something that becomes less arduous and less time-consuming with practice. Refining the question so that it is focused and specific will ensure that searching relevant databases and literature yields the evidence needed. It will also reduce the likelihood of an unrefined search producing either no related material or an abundance of irrelevant information. In such circumstances the quest for information becomes an unmanageable task that could quickly be abandoned, leaving important questions unanswered. An example of a poorly structured clinical question could include: ‘How often should patients who are confined to bed rest be turned?’ This type of question is likely to yield excessive amounts of information on the broad topic of patient repositioning but little in the way of specific guidance on current best practice relating to the frequency recommended. The use of a question-framing format is recommended to encourage effective searching and yield the best and most relevant evidence available. Many authors advocate using a question-framing format known as PICO. This is an acronym representing the four elements that should be included when asking a clinical question (Dawes, 2005, Melnyk and Fineout-Overholt, 2005, Gerrish and Lacey 2006, Craig and Smyth, 2007). They are: P - population of interest. I - intervention. C - comparison. O - outcome. The following are examples of potential clinical questions structured using the PICO format and include a revised version of the question about turning patients who are confined to bed rest. For example: in patients who are confined to bed (P), what is the effect of two-hourly turns (I) on skin integrity (O) compared with four-hourly turns (C)? Or the following example: in an acute medical ward (P) does single-nurse drug administration (I) increase the risk of drug errors (O) compared with dual-nurse administration (C)? In some cases it might not be necessary, feasible or appropriate to have a comparison component in the question. For example: how do adolescents (P) who have been diagnosed with epilepsy (I) perceive the impact of this condition on their social functioning (O)? Once the clinical question has been framed, it is then possible to progress onto the second step of the evidence-based practice process. Collecting the Most Relevant and Best Evidence This step requires knowledge of what evidence is and what constitutes quality evidence. Dale (2005) suggests that relevant and best evidence are intimately linked. Traditionally the best evidence was deemed to be that derived from rigorous scientific research methods, such as randomized controlled trials. The nature of the question determines the nature of evidence that should be sought. Therefore, if the information being sought concerns the effectiveness of a clinical intervention, for example the effectiveness of patient-controlled analgesia post-operatively, one would seek the answer in quantitative evidence. An example of how this question might be phrased for searching purposes using PICO format is: ‘In post-operative patients (P) what is the effect of using patient controlled analgesia (I) on post-operative pain levels (O) compared with intramuscular analgesia as and when required (C)?’ If the question concerns patients’ experiences or perceptions, for example of pain management or quality of life aspects, one would seek the answer in qualitative evidence. An example of this type of question phrased using PICO format is: ‘How does oncology patients (P) diagnosed with terminal cancer (I) perceive (O) others’ perceptions of their physical limitations (C)?’ Some forms of quantitative and qualitative evidence are more robust than others. For example, in qualitative evidence a meta-analysis of qualitative studies is a stronger form of evidence than a single qualitative study or evidence from an expert committee or authority. It might not always be possible to use the most robust form of evidence because it may not exist. In such cases, the practitioner must rely on the ‘best available’ evidence as opposed to the ‘best possible’ evidence to make evidence-based decisions in practice (McKenna, 2004). The key point is the untiring pursuit of the best available evidence. To guide the pursuit of the most relevant and best evidence, hierarchies of evidence have been recommended by various authors in the field (Guyatt and Rennie 2002, Melnyk and Fineout-Overholt 2005, Gerrish and Lacey 2006). Many of these hierarchies have been adapted from the work of Gray (1997). One of the criticisms of such a hierarchy of evidence is that it neglects evidence from sources other than medical science (Dale, 2005). For example, qualitative research is excluded. While such a hierarchy might be appropriate to answer questions that arise in medicine, it falls short of meeting the information needs of nurses and patients. Qualitative studies, such as those underpinned by phenomenological or grounded theory methodologies for example, are equally as valuable and necessary as systematic reviews or randomized controlled trials in answering the questions that arise in nursing. This is essential to inform holistic and patient-centered care. Knowing where and how to search for the evidence are key elements of this part of the evidence-based practice process. A literature search that is tailored and comprehensive will underpin the entire process and enable prompt identification of relevant evidence and appropriate answers to the questions posed (Craig and Smyth, 2007). Specific skills are required to undertake these elements. Critically Appraising the Evidence The purpose of critical appraisal is to determine the relevance of the material collected in relation to the clinical question raised. In other words, does the evidence provide the answer to the question raised and how confidently can the evidence be applied to practice? The development of critical appraisal skills enables a nurse to make a judgment about whether the evidence is applicable and appropriate to practice or whether it should be discarded (Booth, 2006). Having the skills to discern what renders the evidence useful is one of the cornerstones of evidence-based practice. Fineout-Overholt (2005) suggests some broad questions to guide critical appraisal of the material collected: What are the results of the study? Are the results of the study valid and reliable? Was robust methodology used to obtain the results or findings? Are the results clinically relevant to the patient? Answering these questions enables nurses to ascertain the value of a given study in their day-to-day practice, thereby enabling them to make informed decisions about patient care in the clinical setting. Other questions that can be used by nurses in practice to determine the appropriateness and applicability of the evidence amassed to inform their decision making include those proposed by Glasziou, (1998). They suggest that the following questions should be asked: Is my patient or this problem so different from those in this study that the results cannot be applied? Is the care or treatment feasible in my setting? What are the likely benefits and harms from the treatment? How will my patient’s values influence the decision? Questions such as those proposed by Fineout-Overholt et. al. (2005) and Glasziou et al (1998) provide nurses with the initial information to enable them to rise to the challenge of applying the evidence to patient care. Integrating the Evidence Integrating the research evidence to make a practice decision is a significant challenge. It relies on several factors not least of which are the practitioner’s clinical expertise and the patient’s preferences. This approach is in keeping with the values of nursing which espouse holism and patient-centeredness. The challenges for clinicians in integrating evidence and practice are numerous. They include: poor critical appraisal skills; poor access to quality information; lack of leadership; tradition; fear of interprofessional role erosion; power imbalance; lack of motivation, vision, strategy or direction among managers; and the influence of funding sources and key stakeholders such as pharmaceutical companies (Balas and Boren 2000, Ciliska, 2005, DiCenso et al. 2005, Pravikoff et al 2005, Craig and Smyth 2007). Evaluating the Outcomes Evaluation of the impact of an intervention is a crucial aspect in the process of evidence-based practice. It is imperative that this step is not overlooked because it will serve to inform clinical practice in the future and it should be decided at the outset of the process. Methods of evaluation will vary depending on the intervention or change in practice that was implemented. They can include: physiological and psychological measures; functional improvement; decreased cost or length of stay; nursing retention or job satisfaction; and patient satisfaction surveys. In this way it can be determined if the ultimate goals of improved patient care and improved practice have been realized. PICO question: PICO question for this research study is: What is the importance of evidence based practice and how it impacts in life? Literature Review Melnyk and Fineout-Overholt (2005) define evidence-based practice as a problem-solving loom to clinical practice that incorporate a systematic explore for, and decisive appraisal of, the mainly related evidence to answer a fiery clinical question, one’s possess clinical skill, patient inclinations and standards. Patient preferences are key to this approach. It is therefore important that the uniqueness of each patient is not lost amid the quest for robust evidence (Franks 2004). This definition of evidence-based practice places significant value on the experience and expertise of the practitioner coupled with his or her clinical judgment and decision-making skills. Teaching the fundamentals of evidence-based practice to nurses is imperative to enable them to recognize and deliver high quality care that is evidence based. Fostering in nurses the culture, knowledge and capabilities to execute evidence-based practice will produce a nursing profession that will influence policy and practice for future generations. Guidelines for evidence-based practice in psychology (EBPP) require that clinicians attend to the cultural context of the individual client while integrating best research practices and clinical expertise (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). Typically, “cultural context” is conceptualized as synonymous with ethnic culture, and numerous authors have proposed strategies for tailoring interventions to ethnic minority populations (e.g., Bernal, Jiménez-Chafey, & Rodríguez, 2009; Hwang, 2009; Sue, 2004). While acknowledging the importance of ethnicity, we take a broader view of culture in which the concept of cultural context is not limited to ethnicity and can be extended to incorporate other kinds of cultural considerations in clinical practice. Specifically, in this paper we focus on “adolescent culture” as a frequently encountered, but often overlooked, culture that should be considered within the context of evidence-based practice. We argue that adolescence is more than a stage of development; it represents a unique culture with common values, challenges, and characteristics. Accordingly, evidence-based practice with adolescents requires an understanding of and attention to this culture. Design for Change Unfortunately, evidence-based practice is an often misused and misunderstood term. EBPP is not simply the use of evidence-based or empirically supported treatments (EBTs; ESTs), but rather a broader framework for practice encompassing the integration of best available research evidence, clinical expertise and client context (APA Presidential Task Force on Evidence-Based Practice, 2006). Best available research can include evidence from a diverse set of study designs (ranging from randomized clinical trials to systematic case studies) and provides the scientific foundation for clinical practice. Although not without controversy, the application of EBPP principles in working with adolescents has been highlighted as an important consideration for the future of the field (e.g., James & Roberts, 2009). Sackett et al (1996) suggest that different forms of evidence are required in order to build a strong evidence base. However, despite the fact that they indicate evidence-based medicine should not just be limited to evidence generated by randomized controlled trials, there are many clinical and academic nurses who express concerns about the implications of adopting a medically-orientated concept of evidence into the nursing profession. Different Types of Evidence We have so far examined some of the different meanings attached to the concept of evidence-based practice and the different types of evidence that can contribute to a profession's evidence base. In medicine, the evidence base has been largely generated by research conducted most frequently using randomized controlled trials. This research approach is frequently regarded as the only way to generate 'best' evidence. However, writers such as French (1999) and Closs and Cheater (1999) argue that evidence generated from other sources can also help to construct a more comprehensive body of evidence. This article now explores this argument in more detail, beginning by outlining the different types of knowledge that can constitute a body of evidence for healthcare practitioners in general and gerontological nurses in particular. Research Evidence Knowledge generated by healthcare research is an important form of evidence. However, the quality of this research varies and it is important that the strengths and weaknesses of different research approaches are understood so that nurses can make decisions about the relative merits of different kinds of evidence (Closs and Cheater 1999). It is important to remember here that different research questions require different research designs and approaches. It is not that one research design is superior to all the others; it is more about whether the researcher has chosen the most appropriate approach with which to answer the question. In other words, has the researcher chosen the right tool for the job? Quantitative research evidence When a research question is attempting to explain or predict relationships between variables, quantitative approaches are the methods of choice. Quantitative research approaches include survey and experimental research designs and are the dominant research approaches in medical research. When information is required about the effects of an intervention, randomized controlled trials are considered to be the most appropriate approach to use. As a result of the ability to reduce bias, 'the randomized controlled trial is commonly considered the "gold standard" by which other research designs are judged' (Evans and Pearson 2001). However, not all research questions are open to enquiry using this method, particularly in nursing. Although RCTs are appropriate to answer some research questions, they do have their limitations (see, for example, Closs and Cheater 1999). Qualitative research evidence When a researcher is interested in developing descriptive knowledge about a phenomenon, then qualitative research approaches are most appropriate. Within nursing, qualitative research is very popular, as the research methods are well suited to describing a patient's experiences of his or her health or illness. The three main approaches — phenomenology, ethnography and grounded theory — collect data using a variety of methods including interviews, focus groups, observation, diaries, unstructured questionnaires and historical records. A strength of qualitative research is that it enables 'thick description' of the topic under consideration, taking account of the context and setting in which the research is conducted. However, qualitative research has been criticized because it is seen to be subjective, non-generalizable (that is, not necessarily applicable to other settings/populations) and lacking in rigor (Closs and Cheater 1999). In response to these perceived limitations, there has been a developing literature over the last ten years concerning the use of qualitative research in nursing (see, for example, Sandelowski, 1993). It would appear, therefore, that qualitative research methods are well suited to exploring some of the concepts central to nursing. However, it is also important to acknowledge that not all research questions in nursing can be answered using these approaches. Rather than perpetuating the quantitative versus qualitative debate, it is perhaps more helpful for nursing to recognize the strengths of each and promote the complementary nature of these two approaches. Practitioner Evidence In the definitions of evidence-based medicine and evidence-based practice considered, clinical expertise is a key component of this evidence base. So while the availability of high-quality research evidence concerning an aspect of health care is important so, too, is the 'tacit knowledge of the expert practitioner' (French 1999). In making decisions about nursing care, therefore, gerontological nurses must not only draw upon the best available 'external' evidence, but apply this evidence to their individual setting and their individual patients. Summary Evidence-based practice has been demonstrated to yield improved patient outcomes (Killeen and Barnfather 2005, Craig and Smyth 2007). The evidence-based practice movement continues to promote the values that were espoused by Archie Cochrane and advocates the critical appraisal of best available evidence to underpin practice decisions. Fostering the culture, knowledge and capabilities to execute evidence-based practice will ensure the progression of a nursing profession that will influence policy and practice for future generations. The execution of evidence-based practice relies on a sound knowledge of what it is and the skills that are needed to apply it in practice (Profetto-McGrath 2005). The process of evidence-based practice is underpinned by five steps - question framing, database searching, critical appraisal, implementation and evaluation - which are essential to ensure an evidence-based profession. These skills are the cornerstones of evidence-based practice and, if used effectively, will enhance patient care and outcomes. Striking a balance to ensure that the best available evidence is used to improve patient care delivery is essential. The judgment and decision-making capabilities that are inherent in clinical expertise enable the practitioner to discern the quality of the evidence appraised and its applicability to the individual patient. What difference will the evidence make to the patient’s progress, condition or outcomes? 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