Planning for Implementing and Evaluation of Practice Change - Case Study Example

NSB502 – Introduction to Evidence-based Practice Proposal for Practice Change Total Number of Words: 2,041 Table of Contents I. Introduction ………………………………………………………………. 3 a. Clinical Nursing Problem …………………………………… 3 b. Importance of Using EBP Process ……………………….. 4 c. Application of PICO Format in Identifying the Terms Useful in Searchable Question that will Address the Clinical Problem ……………………………………………… 5 II. Three Best Available Evidences ………………………………………. 6 III. Planning for Implementing and Evaluation of Practice Change …… 10 a. Strength and Limitations of Gathered Evidences when Applied in a Clinical Practice ………… 10 b. Factors in Nursing Literature that is Difficult to Implement ……………………………………………………... 10 IV. Conclusion ………………………………………………………………. 11 Appendix I – Body of Evidence Matrix ……………………………………….. 12 References ……………………………………………………………………… 13 - 16 Introduction Between the years 2004 to 2005, as much as 3.5 million Australians were reported to have a long-term cardiovascular condition which could eventually lead to hypertension, stroke, and vascular conditions like angina and heart failure among others (Australian Bureau of Statistics, 2006a). Based on Australian Bureau of Statistics report (2006b), heart diseases accounts to 47,637 or 35% deaths in Australia back in 2004. One of the common factors that can trigger the development of heart disease and diabetes mellitus is obesity or excessive weight. Frank Smith has been categorized as obese for at least 10 years. Due to lack of exercise and too much intake of foods that are high in cholesterol or has too much salt (Dodani et al., 2004), Smith can be at risk of having cardiovascular disease. Diabetes mellitus type II often occurs in case the patient has an impaired fasting glucose (≥ 100 mg/dl) or hyperinsulinism which is also known as insulin resistance (fasting insulin ≥ 30 µU/ml). (Hirst, 2006) Similar to the development of heart disease, the lack of physical exercise in the case of Smith also contributes to the development of diabetes mellitus type II (Eisenmann et al., 2007). For this study, the student nurse will state the clinical nursing problem followed by discussing the importance of EBP process in search for academic literature including the use of PICO format in guiding the student with the search for evidence-based practice journals. Clinical Nursing Problem To give the best advice on how Smith can minimize the risk of developing heart diseases and diabetes mellitus II. It is important for health care nurses to be able to prevent and minimize Smith’s risk of developing heart diseases and diabetes mellitus II considering that heart disease and diabetes mellitus II can lead to the patient’s untimely death. Importance of Using EBP Process Using the evidence-based practice (EBP) process is useful on the part of the student nurse in terms of guiding us to explore the problem which is necessary in maintaining the quality care being rendered to our patients. Since EBP process is based on empirical study, EBP process provides the student nurse with a well-built practice question and critical appraised set of related literature review which are necessary in improving the service being provided to the patients based on their own individual needs (Shlonsky & Gibbs, 2004). Evidenced-based is basically referring to the integration of the best research evidences that are based on clinical expertise and patient values. (Sackett et al., 2000: p. 1) Shlonsky and Gibbs (2004) acknowledges the importance of EBP since EBP process provides the professional nurses with a list of integrated and most recent best evidence, client preferences, and clinical expertise to improve the practical knowledge, skills, and competency of the health care professionals. Information gathered from EBP process is also useful in the decision-making process of the student nurses and other health care professionals in terms of rendering proper caring and treatment to each patient (McCracken & Marsh, 2008). Application of PICO Format in Identifying the Terms Useful in Searchable Question that will Address the Clinical Problem The main purpose of using the PICO format is to guide the student nurses on how to make searches for evidence-based practice much easier. By narrowing down the searchable terms, the student nurse will be able to effectively select the best academic journals that will address the main clinical problem of the study. P = Patient / Problem 1. Obese (> 10 years) 2. High blood glucose levels w/ impaired glucose tolerance (IGT) 3. Has high risk to develop Type II DM & Cardiovascular disease 4. Maternal grandmother has ‘sugar in urine’ which has led to knee amputation. 5. Paternal side has cardiovascular disease I = Intervention / Issue of Interest Weight loss through exercise and diet C = Comparison Intervention or Alternative Intervention Weight loss through pharmacological intervention or surgery O = Outcome Minimize risk of developing DM type II and heart disease. Based on the terms and phrases that were itemized using the PICO format, the student nurse will eventually undergo the EBP process which includes: searching for relevant academic journals, retrieval of these journals, appraisal, and the synthesis of the gathered evidences. Three Best Available Evidences Considering the questions stated on the PICO format, the best three database sources that can be used in addressing the questions are: (1) PubMed; (2) The Cochrane Library; and (3) EMBASE Elsevier. The student nurse entered the phrase ‘diabetes mellitus type II heart disease obesity journal’ in each of the three websites. Using PubMed which is available from http://www.ncbi.nlm.nih.gov/, Cochrane Library http://www3.interscience.wiley.com/, and EMBASE Elsevier http://www.elsevier.com/, the student nurse was able to easily locate a wide-range of related literature review. As compared to other database like Medline, the available information was mostly presented by the health departments in the U.S. rather than providing the researchers with evidence-based journals. Aside from stating the individuals that are included in the scope of a research study, systematic reviewing is importance in the sense that it assist the researcher on how to address issues related to primary health care research (Grimmer-Somers, 2008). Even though it is difficult to search for systematic reviews of diagnostic studies using Cochrane Library, Cochrane Library is known to have a very high-quality and systematic reviews and/or research studies that uses meta-analysis as compared to EMBASE Elsevier and PubMed (Oosterhuis et al., 2004). In relation with the use of EMBASE, Fielding and Powell, (2002) suggest that it is best to use PubMed when searching for either EMBASE Elsevier or Medline reports since PubMed provides a more comprehensive search for peer-reviewed journals. As part of determining which among the three selected sources can be assessed as the best available evidence, there is a need for the student nurse to rate the five major key components of the ‘body of evidence’ as recommended by the National Health and Medical Research Council (NHMRC) in Australia which includes: (1) the evidence base in terms of the number of studies and level of evidences shown in the study; (2) consistency of the study results; (3) potential clinical impact of the proposed recommendation; (4) generalization of the body of evidence as compared to the target population; and (5) the applicability of the body of evidence to Australian health care context (NHMRC Additional Levels of Evidence and Grades for Recommendations for Developers of Guidelines. Stage 2 Consultation. Early 2008 - End Juny 2008, 2008). Considering the body of evidence matrix which is shown in Appendix I on page 12, Cochrane Library provides an excellent evidence in terms of having academic journals that provides adequate explanation behind the selected research method and findings followed by PubMed and EMBASE Elsevier. With regards to having a good consistency in terms of the research study results, the student nurse finds the evidences gathered from Cochrane Library better than other peer-reviewed journals which are available at EMBASE Elsevier. The problem with the evidences gathered from the selected databases is the fact that most of the peer-reviewed journals are not applicability with Australian healthcare setting since most of the studies that are submitted to these databases did not use Australian population or health care setting. Upon gathering some evidence-based practice from the three databases, the student nurse highly recommend that Mr. Smith should gradually lose weight in order to prevent the risk of heart disease and the development of diabetes mellitus type II. (Thomas et al., 2006; Norris et al., 2005c; Padwal et al., 2003; Mulrow et al., 1998) Proper health counselling will enable Mr. Smith to lose weight effectively (regular exercise and low-calorie diet). (Christian et al., 2008; Davies et al., 2008; Ebrahim et al., 2006) It is also necessary for Mr. Smith to undergo a regular diagnosis like blood pressure and sugar test among others to ensure that his health is well-maintained. Intervention / Issue of Interest Comparison Intervention or Alternative Intervention Expected Outcome What is the diagnosis for heart disease? 1. Regular assessment like blood pressure. (Ebrahim et al., 2006) What is the best treatment for heart disease? 1. Weight loss through low-calorie diet, behavioral intervention & exercise (Thomas et al., 2006; Norris et al., 2005a) 2. Health education or counselling like avoid smoking, alcohol, & excessive fluid intake. (Ebrahim et al., 2006) Treatment for Heart Disease: 1. Pharmacotherapy using Fluoxetine, Orlistat, Rimonabant, and Sibutramine will result to significant weight loss over 12 to 57 weeks but long-term effects remain unclear. (Norris et al., 2005b; Padwal et al., 2003) Heart Disease: 1. Minimize the risk of developing heart disease. (Padwal et al., 2003) 2. Four to eight percent of weight loss decreases blood pressure between the range of 3 mmHg systolic and diastolic. (Mulrow et al., 1998) Intervention / Issue of Interest Comparison Intervention or Alternative Intervention Expected Outcome Diagnosis for DM Type II: 1. Regular weight measurement & blood test Treatment for DM Type II: 1. Weight loss through low-calorie diet, behavioral intervention & exercise (Thomas et al., 2006; Norris et al., 2005a); However, exercise is more effective in improving glycated haemoglobin of patients with DM type II than low-calorie diet (Nield et al., 2007). 2. Health education or health lifestyle counselling can increase patient’s physical activity, weight loss, and smoking cessation. (Christian et al., 2008; Davies et al., 2008) Treatment for DM Type II: 1. Pharmacotherapy using Fluoxetine, Orlistat, Rimonabant, and Sibutramine will result to significant weight loss over 12 to 57 weeks but long-term effects remain unclear. (Norris et al., 2005b) 2. Surgery for morbid obesity but safety is unclear. (Colquitt et al., 2005) DM Type II: 1. Normalize blood sugar level, improves glycaemic control, and reduce visceral adipose tissue and plasma triglycerides that prevents prediabetes incidence. (Thomas et al., 2006; Norris et al., 2005c) Between the use of evidence-based practice process and non-evidence-based information, health care professionals are more likely to trust a research study results that has adopted scientific methods. For this reason, I do not recommend any changes in the practice of evidence-based process. Planning for Implementing and Evaluation of Practice Change Strength and Limitations of Gathered Evidences when Applied in a Clinical Practice The gathered evidences is useful in the case of Mr. Smith since the main cause that triggers the higher risks that he will experience heart disease and diabetes mellitus type II is his excessive weight. For this reason, the evidences gathered focuses on how the student nurse can advise Mr. Smith to effectively lose weight. Considering that Mr. Smith prefers to exercise rather than going through low-calorie diet, the student nurse highly recommends that Mr. Smith should engage more on physical activities combined with low-calorie diet since high calorie and salty foods intake increases his risk of developing heart diseases. Taking into consideration that Mr. Smith’s maternal grandmother who was blinded with both legs amputated because of diabetes mellitus and the fact that his father side has a strong history of cardiovascular disease is a factor that increases Mr. Smith’s risk to develop heart disease and diabetes mellitus type II. However, the gathered evidence is limited in terms of addressing the impact of hereditary factor over Mr. Smith’s health condition. Factors in Nursing Literature that is Difficult to Implement Mr. Smith is hesitant and finds it difficult to control his diet. For this reason, it is necessary for the student nurse to assist and inform the patient about the consequences of not going through a low-calorie and limited salt intake diet. Since Mr. Smith has to undergo regular exercise, the student nurse should consider the health condition of the patient before allowing him to undergo a more tedious exercise. Lastly, the student nurse should make a regular appointment with the patient to give him a one-on-one health counselling. The student nurse will be able to determine the progress of the intervention plan by regularly monitoring his blood pressure, changes in weight, and blood sugar level each time Mr. Smith would see her for health counselling or check-up appointments. Conclusion Practice change using EBP process is beneficial to Mr. Frank and the development of staff knowledge since intervention plan gathered for this study was based on the most recently integrated best research evidences that are available from the three database sources. *** End *** Appendix I – Body of Evidence Matrix Component A B C D Excellent Good Satisfactory Poor Evidence Base1 Several level I or II studies with low risk of bias One or two level II studies with low risk of bias or a SR/multiple Level III studies with low risk of bias Level III studies with low risk of bias, or level I or II studies with moderate risk of bias Level IV studies or level I to III studies with high risk of bias Consistency2 All studies consistent Most studies consistent & inconsistency may be explained Some inconsistency reflecting genuine uncertainty around clinical question Evidence is inconsistence Clinical Impact Very large Substantial Moderate Slight or restricted Generalisability Population studied in body of evidence are the same as the target population for the guideline Population studied in the body of evidence are similar to the target population for the guideline Population studied in body of evidence differ to target population for guideline but is clinically sensible to apply this evidence to target population3 Population studied in body of evidence differ to target population and hard to judge whether it is sensible to generalize to target population Applicability Directly applicable to Australian healthcare context Applicable to Australian healthcare context with few caveats Probably applicable to Australian healthcare context with some ceveals Not applicable to Australian healthcare context 1 Level of evidence determined from the NHMRC evidence hierarchy 2 If there is only one study, rank this component as ‘not applicable’. 3 For example, results in adults that are clinically sensible to apply to children OR psychosocial outcomes for one cancer that may be applicable to patients with another cancer Source: NHMRC additional levels of evidence and grades for recommendations, 2008 References: Australian Bureau of Statistics. (2006a, September 15). Retrieved September 21, 2008, from 4821.0.55.001 - Cardiovascular Disease in Australia: A Snapshot, 2004-05: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4821.0.55.001 Australian Bureau of Statistics. (2006b). Retrieved September 21, 2008, from National Health Survey: Summary of Results, Australia, 2004-05: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4821.0.55.001 Christian, J., Bessesen, D., Byers, T., Christian, K., Goldstein, M., & Bock, B. (2008). Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Archives of Internal Medicine , 168(2):141 - 146. Colquitt, J., Clegg, A., Royle, P., & Sidhu, M. (2005). Surgery for morbid obesity. Cochrane Database of Systematic Reviews , Issue 4. Art. No.: CD003641. DOI: 10.1002/14651858.CD003641.pub2. Davies, M., Heller, S., Skinner, T., Campbell, M., Carey, M., Cradock, S., et al. (2008). Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ , 336(7642):491 - 495. Dodani, S., Mistry, R., Khwaja, A., & al., e. (2004). Prevalence and Awareness of Risk Factors and Behaviours of Coronary Heart Disease in an Urban Population of Karachi, the Largest City of Pakistan: A Community Survey. Journal of Public Health , 26(3):245 - 249. Ebrahim, S., Beswick, A., Burke, M., & Smith, G. (2006). Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database of Systematic Reviews , Issue 4. Art. No.: CD001561. DOI: 10.1002/14651858.CD001561.pub2. Eisenmann, J. C., DuBose, K. D., & Donnelly, J. E. (2007). Fatness, Fitness and Insulin Sensitivity Among 7- to 9-Year-Old Children. Obesity , 15:2135 - 2144. Fielding, A., & Powell, A. (2002). Medline to achieve an evidence-based approach to diagnostic clinical biochemistry. Annals of Clinical Biochemistry , 39:345 - 350. Grimmer-Somers, K. (2008, July). The Internet Journal of Allied Health Sciences and Practice. Retrieved September 21, 2008, from Systematic Reviews. Vo. 6. No. 3: http://ijahsp.nova.edu/articles/vol6num3/grimmer-somers_6_3.htm Hirst, K. (2006). Presence of Diabetes Risk Factors in a Large U.S. Eighth-Grade Cohort. Diabetes Care , 29:212 - 217. McCracken, S., & Marsh, J. (2008). Practitioner Expertise in Evidence-Based Practice Decision Making. Research on Social Work Practice , 18(4):301 - 310. Mulrow, C., Chiquette, E., Angel, L., Cornell, J., Summerbell, C., Anagnostelis, B., et al. (1998). Dieting to reduce body weight for controlling hypertension in adults. Cochrane Database of Systematic Reviews , Issue 4. Art. No.: CD000484. DOI: 10.1002/14651858.CD000484. NHMRC Additional Levels of Evidence and Grades for Recommendations for Developers of Guidelines. Stage 2 Consultation. Early 2008 - End Juny 2008. (2008). Retrieved September 21, 2008: http://www.nhmrc.gov.au/guidelines/_files/Stage%202%20Consultation%20Levels%20and%20Grades.pdf Nield, I., Moore, H., Hooper, L., Cruickshank, J., Vyas, A., Whittaker, V., et al. (2007). Dietary advice for treatment of type 2 diabetes mellitus in adults. Cochrane Database of Systematic Reviews , Issue 3. Art. No.: CD004097. DOI: 10.1002/14651858.CD004097.pub4. Norris, S., Zhang, X., Avenell, A., Gregg, E., Brown, T., Schmid, C., et al. (2005a). Long-term non-pharmacological weight loss interventions for adults with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews , Issue 2. Art. No.: CD004095. DOI: 10.1002/14651858.CD004095.pub2. Norris, S., Zhang, X., Avenell, A., Gregg, E., Schmid, C., & Lau, J. (2005c). Long-term non-pharmacological weight loss interventions for adults with prediabetes. Cochrane Database of Systematic Reviews , Issue 2. Art. No.: CD005270. DOI: 10.1002/14651858.CD005270. Norris, S., Zhang, X., Avenell, A., Gregg, E., Schmid, C., & Lau, J. (2005b). Pharmacotherapy for weight loss in adults with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews , Issue 1. Art. No.: CD004096. DOI: 10.1002/14651858.CD004096.pub2. Oosterhuis, W. P., Bruns, D. E., Watine, J., Sandberg, S., & Horvath, A. R. (2004). Evidence-Based Guidelines in Laboratory Medicine: Principles and Methods. Clinical Chemistry , 50(5):806 - 818. Padwal, R., Rucker, D., Li, S., Curioni, C., & Lau, D. (2003). Long-term pharmacotherapy for obesity and overweight. Cochrane Database of Systematic Reviews , Issue 4. Art. No.: CD004094. DOI: 10.1002/14651858.CD004094.pub2. Sackett, D., Straus, S., Richardson, W., Rosenberg, W., & Haynes, R. (2000). Evidence-based medicine: How to practice and teach EBM. 2nd Edition. Edinburgh: Churchill Livingstone. Shlonsky, A., & Gibbs, L. (2004). Will the Real Evidence-Based Practice Please Stand Up? Teaching the Process of Evidence-Based Practice to the Helping Professions. Brief Treatment and Crisis Intervention , 4(2):137 - 153. Thomas, D., Elliott, E., & Naughton, G. (2006). Exercise for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews , Issue 3. Art. No.: CD002968. DOI: 10.1002/14651858.CD002968.pub2. Read More