Medical and Nursing Interventions for Patients - Research Paper Example

Principles of Research & Evidence Based Practice Introduction Evidence-based practice or EBP is one of the emerging trends in healthcare. There arevarious available medical and nursing interventions for patients, but at most times, interventions which are based on specific patient needs are the best and most appropriate interventions which can be applied to the patient. There are various principles and theories related to the implementation of such interventions and a nurse or a medical health professional has the obligation and responsibility to assess which among the available interventions would work best for a particular patient. Student nurses have the responsibility of assessing the relationship of evidence to practice whether it is in the clinical or the community setting. In order to achieve this, the student nurse has to conduct thorough research and evidence-based practice in the different EBP interventions applied by organizations. This paper shall assess such evidence-based practices applied by various institutions and in the process appraise two pieces of evidence relevant to my area of interest. After the development of two in-depth critiques, the usefulness of this evidence in practice shall be evaluated. The principles of evidence based practice shall also be evaluated through a discussion of the different types of evidence, levels of evidence and the importance of evidence for practice. Discussion Evidence-based practice is the act of connecting what the population needs with the most updated and the best evidence possible based on scientific studies; its purpose is to evaluate what would be effective and to utilize studies while considering community resources, values, and preferences in order to improve the health of the general population (Queensland Government, 2006, p. 1). In various fields of practice and even the law, evidence refers to materials which can support or refute a current issue. In healthcare, evidence based practice emphasizes the independent verification and observation of a practice before it can find application. “This does not presuppose the value of a particular evidence source or study design over another, but instead highlights the importance of ensuring that the evidence used to inform practice (and policy) has been subject to scrutiny” (Rycroft-Malone, et.al.,2004, p. 82). There are different sources of evidence which may be applied in evidence-based practice. The two main sources are through the use of the quantitative and the qualitative research methods. Qualitative research basically investigates the essential characteristics of lived experiences by persons (Fischer, 2006, p. xvi). According to the SIGN (2008, p. 37), they are increasingly being used to inform practice in some aspects of medical care. Quantitative research, on the other hand, is a formal and systematic process where numerical data is used to gather information about the world (Grove, p. 18). Other more specific sources of evidence for EBP include the following: systematic reviews and meta-analyses of randomized controlled trials (RCTs); randomized controlled trials; non-randomized experimental strategies; non-experimental studies; descriptive studies; respected opinion and expert discussion (Taylor, 2000). Such sources also follow a hierarchy of evidence which may be considered from the best evidence and downwards to the least favoured evidence. Systematic review is one of the best-evidence for evidence-based practice, for Randomized controlled trials apply the experimental study method which gives the researchers a chance to control the research. In order to implement greater control over the research, studies are compared with each other while considering different interventions and manipulations (McMurray, 2007). The subjects are randomly assigned to either experimental or control groups. In considering interventions covering communities, it is important to recognize people’s preferences and to bear in mind that decisions not based on the reality of application or acceptance will less likely be successful during implementation (McMurray, 2007, p. 356). The second best evidence is the non-randomized controlled trial. Non-randomised controlled trials reveal associations between the intervention and the outcome (Sibbald, 1996). However, these studies cannot discard the possibility that such associations may be caused by another factor related to both the intervention and the outcome. Double-blinding would ensure that the previous views of subjects do not affect the outcomes and what is generally considered to be ‘best’ evidence (Sibbald, 1996). When writing this part of the assignment it is important to try to acknowledge why evidence is important for clinical practice and try to indicate how good quality evidence can be generated. The third best evidence for EBP is the non-experimental study which is considered weak evidence (Taylor, 2000, p. 16). Non-experimental studies are those with single-subject designs and those which utilize pre-test/post-test designs where one cohort of respondents is evaluated before and after intervention (Taylor, 2000, p. 16). They produce unreliable results; hence, their applicability in evidence-based practice is not given much weight. The next evidence in the hierarchy is the descriptive study, which, like non-experimental studies are also not given much credibility and validity in EBP. These types of evidence often produce unrepeatable and unverified results which may be applicable to the general population, but may not be applicable to individual patient needs. Finally, the last in the hierarchy of sources in evidence-based practice are expert opinions and discussions (Taylor, 2000, p. 16). Expert opinions, although they may be offered by a person who is learned or adept in the subject matter, have a semblance of subjectivity. They are not tried and tested results. At most, they may only be suggestions for practice. Research Process The research process is a systematic process. Authors describe the research process as the act of increasing the body of knowledge through the “discovery of new facts and relationships through a process of systematic scientific inquiry” (Macleod & Hockey, as quoted by Sines, 2005, p. 80). The research process is also considered systematic because it follows a step-by-step process which is organized in order to arrive at a scholarly decision or evidence-based result. The research process first begins with the identification of the research problem and the formulation of the research question; second, with the selection of the appropriate research method; third, with designing the study; fourth, with the development of data collection methods; fifth, with the data collection; sixth, with the data management, analysis, and interpretation; and lastly, with the writing, presentation, and dissemination (Sines, 2005). The trends established by evidence-based practice have followed a clear pattern or process. This research process signifies specific tools of practice which gradually create viable results which can therefore be used as tools in evidence-based practice. Dissemination and barriers of implementation of evidence Evidence-based practice is practice which points out that decisions about health care should be based on the best and current evidence (Dawes, et.al., 2005). A paper published in the NICE explains that “evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, as cited by Marks, 2002, p. 5). The dissemination of evidence in medicine and in nursing is done through the various organizations and databases which publish EBP through the NHS Economic Evaluation Database which publishes the details about economic assessments in health care treatments; the Database of Abstracts of Reviews of Effects through the Centre for Reviews and Dissemination which provides data on effects of interventions in healthcare; and the Joanna Briggs Institute which is geared towards providing systematic reviews of materials appropriate for health care interventions (JBI Connect, 2010). The SIGN (Scottish Intercollegiate Guideline Network) is one of the main implementers of EBP. Their guidelines are implemented within NHS Scotland and the implementation is the responsibility of each individual (SIGN, n.d). It is also collaborating well with the NHS QIS Implementation and Improvement Support Directorate in order to put evidence into practice in order to ultimately improve health services (SIGN, n.d). The NICE is made up of health professionals who help support the implementation of evidence-based practice by “engaging stakeholders, patients, and the public in the selection of topics and in the guidance development process” (NICE, 2010). A paper published in the National Institute for Clinical Excellence (NICE) website reveals that the barriers in the implementation of evidence-based practice include complacency, scepticism, ethical concerns, political concerns, inadequate communications, inadequate resources, and organizational barriers. Complacency is seen when practitioners take too long to change their original routines; scepticism is related to doubt in the practitioner’s minds on the epistemological assumptions and the hierarchy of evidence; ethical and political issues are also brought up as concerns by practitioners and this often delays or interferes with the implementation of EBP; inadequate communications used by practitioners can also interfere with the implementation of the EBP measures; there may also be inadequate support and resources to make possible implementation of EBP; and finally, the organizational barriers themselves, including systems and structures in the organization can affect the implementation of change and EBP in the organization (Marks, 2002, pp. 44-45). Evidence-based practice is important and crucial to my practice; however it is sometimes seen as a separate entity. This is because different EBPs are being used on a daily basis in the hospitals, but many nurses do not understand how such practices have come about. Factors emphasized in the Rycroft-Malone, et.al., article truly illustrate how some nurses view research. Many older nurses in practice tend to stick to the concept that the “old practice is the best practice;” and this attitude seems to work well for them. Such methods may have worked before, but patients are now questioning such methods and they have become more inquisitive, especially with access through the Internet. The Nursing and Midwifery Council (2008) points out that the duty of the nurses is to provide the best care possible to patients at all times; this entails a constant update of skills with the best evidence available. It is important for nurses to overcome barriers in implementation of EBP in order to improve clinical judgment, to be more cost-effective and to provide the best care for the clients (LoBiondo-Wood & Harber, 2006). Nurses should be asking for time to conduct research on new tasks which are being implemented in order to further their understanding of such methods. It is up to nurses to ensure that their employers are providing the best education and training for their staff. Rycroft-Malone, et.al., (2004) emphasizes in their article that the multidisciplinary approach and communication is a crucial part of EBP. The model described in Rosswurms & Larrabees (1999) article would serve as a great advantage in implementing EBP. Edwards, H., Courtney, M., Grove, K., Finlayson, K., Lewis, C., Lindsay, E. & Dumble, J. (January 2005) Improved healing rates for chronic venous leg ulcers: Pilot study results from a randomized controlled trial of a community nursing intervention. International Journal of Nursing Practice, volume 11, pp. 169-176 In the article “Improved healing rates for chronic venous leg ulcers,” a quantitative research approach was used. The title states that it is a randomized controlled trial or a community nursing intervention. A randomized controlled trial (RCT) is in essence an experiment which is being conducted in order to determine the efficacy of a new treatment for some condition (Matthews, 2006, p. 1). It is the most appropriate design for the study because the design gave an opportunity for the researchers to compare the application and efficacy of the intervention based on a controlled and on a treated group of respondents. The methodology for data collection was appropriate because the researchers collected the data themselves and they are qualified for such data collection processes. Possibilities for bias in the data gathering process were reduced because of the fact that the researchers did not have a professional or personal relationship with the respondents (Polit & Beck, 2006, p. 315). The data collectors also had adequate data collection training with regard to the information gathered from respondents. The pre and post assessment processes which the researchers employed helped to establish the demographic data on the patient before and after the intervention. The data collection process chosen was appropriate for this paper because it focused on data pertinent to the aims of this research. The data was gathered under a non-threatening environment and no additional personnel were present during the process. There is also no apparent pressure placed on participants during the data gathering process (Polit & Beck, 2006, p. 315). The population under study was described by the researchers. Their eligibility criteria for inclusion into the study were also described and the sample selection procedures specified. The sample was purposively chosen and then randomly assigned to the intervention group or the control group. This type of sampling was appropriate for the paper and no other method of sampling would apply. Parahoo (2006) suggests that randomized controlled trials are used in quantitative studies in order to determine whether interventions have the desired effects. Hence, it is appropriately used for this paper in order to determine the results of the intervention applied. Since the samples were obtained by referral from medical practitioners, community nurses, newspaper adverts and self referrals, this method decreases the possibility of a selection bias (Nelson, et.al., as cited by Lacey & Gerrish, 2006, p. 239). The low turnout of respondents may possibly be due to the low response rates in clients referred from community nurses and medical practitioners. However, it is not entirely sure if such low sample turnout would affect the validity of this paper. Nevertheless, it is important to note that Polit & Beck (2006, p. 267) emphasize that in quantitative research, there is no simple equation which would determine the appropriate sample size; the general recommendation is that the biggest sample size which can be gained should be used for quantitative research. Sample biases were not identified in this paper (Polit & Beck, 2006, p. 277). The main characteristics of the sample size, such as the respondents’ age, gender, and geographical area were specified by the paper. The sample size is not sufficiently large and such small sample size was not justified on the basis of analysis or other rationale therefore, the results of this study cannot be generalized to the population of chronic venous leg ulcer sufferers. The reliability of the research was increased because of the application of recognized measures such as the PUSH scale score which was devised by Stotts, et.al. (Loretz, 2005, p. 396). The authors state that the research data is tabulated and then entered into a SPSS database for analysis. The statistical findings were then presented as numerical data in the body of the report as seen in the series of graphs. This strongly indicates that the researchers went through a thorough application of the quantitative research method (Polit & Beck, 2006, p. 57). The themes, concepts, and categories derived from the data were interpreted by the researchers. The discussion portion discussed the details surrounding the ulcer leg healing process. It also discussed the factors affecting healing in relation to studies cited in the review of related literature and the background of the study. There is a clear distinction made between the data and the interpretation of the study. The results of the study were presented both textually and graphically, and then the discussion portion further explained the correlation of the results with the aims and the questions raised by this paper. Moreover, the discussion portion was able to draw conclusions as to the results of the study, and why things turned out the way they did (Polit & Beck, 2006, p. 74). Older patients’ experience of dressing changes on venous leg ulcers: more than just a docile patient by Britt Ebbeskog and Azita Emami The paper is a qualitative research study and it uses an interpretative phenomenological approach. This method of research was initiated by researcher Heidegger emphasized that the process of interpreting and understanding human experience (Polit & Beck, 2006, p. 220). The interpretative phenomenological method relies on “in-depth interviews with individuals who have experienced the phenomenon of interest, but they sometimes augment their understandings of the phenomenon through an analysis of supplementary texts…” (Polit & Beck, 2006, p. 221). We see in this research how the researchers describe, interpret and understand the experiences of the different respondents in this paper. The paper mentions that it is also a purposive study and this can be seen from the specific objective of the paper. And so in this paper, the purposive nature of the research process is manifested in the deliberate selection of research subjects. Burns and Grove (2007, p. 352) point out that in purposive sampling, the researcher now “consciously selects certain subjects, elements, events or incidents to include in the study”. This would now account for the fact that there were limited respondents which could fit into the criteria for this study. Consequently, the number of respondents for this paper was limited, but still fulfilled the nature of the research being undertaken. This research expressed that it used letters, phone calls, and interviews. These are appropriate data collection methods for this paper because Burns and Grove (2007, p. 669) point out that the main data collection techniques for qualitative research is observation and in-depth interview. The researchers were able to comply with the qualitative research objective by conducting an interview with the respondents after they agreed by phone to be research subjects for this paper. The data was then analyzed through the interpretative phenomenological method. The phenomenological method was applied by first splitting the statement-answers of the respondents and then later splitting further such units into more meaningful ones. The qualitative method is usually implemented with the researchers first organizing their data. The organized data is then grouped into categories relevant for the question and aims of the research (Polit & Beck, 2006, p. 400). This process was detailed by the researchers in this paper and a pattern emerged from the categories and themes formulated by the researchers. With the clear process of categorization detailed by the researchers, the credibility of this study has been increased. As expected in qualitative researches, there are only limited subjects in these studies. As claimed by Polit and Beck (2006, p. 274), respondents in a phenomenological study may be as small as 10 respondents because they must have the relevant experience in the study and must be able to express their experience. This study has 15 respondents and such number is justified by Parahoo (2006) who states that although qualitative studies use small sample sizes, “…the more varied the sample population the larger the sample size should be”. In terms of ethical considerations, the paper went through the approval process with the Ethics Committee at Karolinska Institutet in Sweden. The participants were first contacted by phone as possible respondents; they were then given letters after. The research did not specify if anonymous names of the respondents were used during the data gathering and data collection process. Such anonymous names would have helped in maintaining the respondents’ anonymity which is important in any research process. Boultoun (2009) emphasizes that in order to protect the anonymity of the respondents, such respondents have to be issued vital information about the research to be conducted; they then have to agree to the procedure, and they also have to be informed of the different ways by which their identity would be preserved and protected. Such foregoing process is a part of the process of informed consent which is essential to any research. The researchers in this paper did not mention if an informed consent was obtained from the respondents. Consequently, if no informed consent was obtained, this may be tantamount to a violation of the codes of conduct (Nursing and Midwifery Council 2008). Reference i. Books Boulton, M., (2009) Research ethics In Neale, J., (2009) Research methods for health and social care, London Burns, N. & Grove, S.K. (2007) Understanding Nursing Research, 4th Edn, Philadelphia, Saunders Fischer, C. (2006) Qualitative research methods for psychologists: introduction to empirical research. Oxford, Academic Press Gerrish, K. & Lacey, A. (2006) The research process in nursing. Massachusetts, Blackwell Publishing Grove, S. (2003) Understanding Nursing Research. Philadelphia, Saunders LoBiondo-Wood, G. & Haber, J. (2006) Nursing research: methods and critical appraisal for evidence-based practice. London, Mosby Loretz, L. (2005) Primary care tools for clinicians: a compendium of forms, questionnaires. Pennsylvania, Elsevier Health Sciences. Matthews, J. (2006) Introduction to randomized controlled clinical trials. Florida, Taylor & Francis Publishers McMurray, A. (2007) Community Health and Wellness: A Socio-ecological Approach. London, Elsevier Health Sciences McSherry, R., Simmons, M., & Abbott, P. (2002) Evidence-informed nursing: a guide for clinical nurses. London, Routledge Palgrave McMillan Holloway, I., and Wheeler, S., (2002) Qualitative research in nursing (2nd ed) Oxford, Blackwell publishing Parahoo, K. (2006) Nursing Research Principles, Process and Issues, 2nd Edition, Basingstoke, Palgrave MacMillan Polit, D. & Beck, C. (2008) Nursing research: generating and assessing evidence for nursing practice. Philadelphia, Lippincott Williams & Wilkins Polit, D. & Beck, C. (2006) Essentials of Nursing Research: Methods, Appraisal, and Utilization. Philadelphia, Lippincott Williams & Wilkins Sines, D. (2005) Community Health Care Nursing. London, Blackwell Publishing Taylor, M. (2000) Evidence-based practice for occupational therapists. London, Blackwell Publishing Todres., L., & Holloway, I., (2009) In: Gerrish., K., & Lacey, L. The research process, Blackwell publishing Ltd. UK ii. Journals Dawes, S., Summerskill, W., Burls, A., & Osborne, J. (2005) Sicily statement on evidence-based practice. BMC Medical Education, volume 5 (1) Ebbeskog, B & Emami, A. (22 June 2004) Older patients’ experience of dressing changes on venous leg ulcers: more than just a docile patient, Journal of Clinical Nursing, volume 14, pp. 1223-1231 Edwards, H., Courtney, M., Grove, K., Finlayson, K., Lewis, C., Lindsay, E. & Dumble, J. (January 2005) Improved healing rates for chronic venous leg ulcers: Pilot study results from a randomized controlled trial of a community nursing intervention. International Journal of Nursing Practice, volume 11, pp. 169-176 Rosswurm, M. & Larrabee, H. (1999). A Model for Change to Evidence-Based Practice. Journal of Nursing Scholarship. 31(4). pp. 317-322. Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., (2004) What counts as evidence in evidence-based practice? Journal of Advanced Nursing, volume 47 (1): 81-90 Sibbald, B. (17 January 1998) Understanding controlled trials: Why are randomised controlled trials important? British Medical Journal, volume 316, p. 201 iii. Journal articles from web-based databases Marks, D. (17 October 2002) Perspectives on evidence-based practice. National Institute for Health and Excellence. Available from: http://www.nice.org.uk/niceMedia/pdf/persp_evid_dmarks.pdf [Accessed 10 April 2010] Queensland Government (September 2006), Ain’t that fact?: Using the evidence to guide planning: Evidence Based Practice. Queensland Government, pp. 1-2. Available from: http://www.health.qld.gov.au/ph/Documents/pdu/31346.pdf [Accessed 10 April 2010] iv. Material on the Internet National Institute for Clinical Excellence, (2010), What we do, Available from: http://www.nice.org.uk/aboutnice/whatwedo/what_we_do.jsp [Accessed 01 April 2010] Nursing and Midwifery Council. (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives, London, Nursing and Midwifery Council Nursing and Midwifery Council (2008) Standards for conduct, performance and ethics, NMC, Available from: http://www.nmcuk.org/aDisplayDocument.aspx?DocumentID=338 [ Accessed 25th January 2010] Joanna Briggs Institute (5 March 2010) Rehabilitation Resources: Searching for the Evidence. Joanna Briggs Institute. Available from: http://gh.jbiconnect.org/rehabilitation/info/about/resources_searching.php [Accessed 10 April 2010] Scottish Intercollegiate Guideline Network, (n.d), What is SIGN, Available from: http://www.sign.ac.uk/about/introduction.html [Accessed 03 April 2010] Scottish Intercollegiate Guideline Network (January 2008) SIGN 50 A guideline developer’s handbook, Available from: http://www.sign.ac.uk/pdf/sign50.pdf [Accessed 03 April 2010] Read More