Evidence-Based Practice - Research Paper Example

Running head: Evidence-based practice Evidence-based practice [The name of the writer appears here] [The name of institution appears here] Introduction Evidence-based practice is an approach that uses the best scientific evidence available to help deliver the best patient care at both an individual and a population level. However, evidence-based practice is not restricted to these types of studies but is more encompassing in that it involves tracking down the best evidence that is available about the assessment and management of specific health care problems. The approach of evidence-based practice is based on the principles that it is better to know, rather than believe, what the likely outcome of any intervention will be. Judgments of likely effectiveness are best achieved by using systematic methods to appraise the literature in order to provide valid answers to specific questions about patient care. This process has developed from the acknowledgement that increasing numbers of research studies are being published that has not been conducted to a sufficiently high standard to warrant the incorporation of their results into clinical care practices. In the approach of evidence-based practice, both clinical and research experience is needed in order to frame the questions, interpret the evidence, and make decisions about treatment policies and direct relevant research questions and research skills. Using this combined approach, a body of corporate knowledge from many diverse experiences can be synthesized to answer questions about health care. Use of scientific reviews of the evidence to assess the effectiveness of clinical practices increases the likelihood that the benefits for patients will be maximized and the use of health services will be more efficient. These processes are facilitated by ready access to systematic reviews, and by the publication of appraisals of studies in journals such as Evidence-Based Medicine. Components of care that can be scrutinized using an evidence-based approach include the usefulness of diagnostic tests and the effectiveness of all medications, treatments or health care interventions. However, any changes to health care practice must also take account of other integral factors such as clinician and patient preferences, cost, risk, quality of life, and ability to provide. Because of this, clinical decision-making will always remain a complex process and evidence-based practice should be seen as a reliable tool that helps to facilitate better health care rather than a definitive process that dictates health care practices. Florence Nightingale & Evidence-based practice Florence Nightingale is now a much ignored historical figure. Her work in nursing and social reform was informed by a religious faith or philosophy that favored a systemic approach: God made the world and runs it by laws, which we can discover by research in both the biophysical and social spheres. Nightingale's leadership style was very much knowledge based. Several examples clearly reflect an evidence-based framework, ranging from Nightingale's first work after her return as a heroine from the Crimean War in 1856, to a late attempt to influence social policy with a proposal for a chair in "social physics" at Oxford University in 1891 http://ebn.bmjjournals.com/cgi/content/full/4/3/68. Example of Evidence-Based Practice Professor Richard Smith, editor of the British Medical Journal, in a report of his speech at an annual conference of the Royal College of Psychiatrists (Boseley 1998b), acknowledged the poor scientific quality of medical knowledge. He stated that less than 5 per cent of articles from the 20,000 published medical journals worldwide are scientifically rigorous. The results of studies reported in these journals were often contradictory, biased, ungeneralisable, and some may also be fraudulent. He suggests 'evidence-based medicine' is likely to falter unless standards in research improve. For example, on the page of an edition of the Guardian (4 December 1999) newspaper two articles appeared. The first concerns a hospital where children had died and their internal organs had been removed by a pathologist for the purposes of medical research, but the parents had not been either asked their permission or informed of this procedure. The parents buried their children believing that the bodies were intact. Ten years after her one-day-old son had died; they were informed by the hospital authorities about the organs that had been retained: This is a horrendous tale of unethical medical practice. Furthermore, within the same story, reference is made to the medical malpractice that occurred at the Bristol Royal Infirmary cardiac unit where surgeons had been accused of incompetently carrying out surgery on babies with heart problems. But the evidence-based movement in medicine and nursing is vulnerable to criticism for its reliance on the randomized control trial (RCT) as the gold-standard of research methodology. RCTs involve supplying one group of people a drug, surgical treatment, or psychotherapy while a placebo is given to another group. Neither group is aware of whether they are receiving real or spurious medical intervention. Responses from both groups are then compared, and possibly these are then compared with a 'control group' which has received no interventions at all. However, most trials conducted in this way have small samples, or are confined to particular groups of people. Therefore, it is exceptional to be able to make generalizations to the whole of the population unless trials have been conducted repeatedly over a long period of time and in conjunction with other methods such as epidemiological studies. Hence, conclusions from research trials cannot be held as infallible realities. However, it is somewhat disingenuous to accuse scientists of making such affirmations. The results of testing hypotheses in scientific publications are usually couched in tentative terms. The media not scientists announce that red wine, meat, margarine, coffee or tea can cure disease, and at some time later inform the public that these products are too dangerous to consume even in moderate amounts. The public, understandably, are not interested in deciphering complex research reports, but take an overall impression from what is being presented. This leads to facile interpretations of research outcomes. Scientists are well used to not declaring causal pathways between, for example, cholesterol and fatty foods, but to speculate on what the 'associations' might be between these substances. The media and the public, however, infrequently discriminate between 'causality' and 'correlation'. Clinical Practice & Evidence-Based Practice Much of nursing as well as medical practice is predisposed to an unsuspecting acceptance of science. Nursing in addition to medicine (and all other health-care disciplines) are engaged in the elucidation of scientific suppositions and methods to defend the care and treatment that is dispatched to patients in the health service. Research-based 'evidence' is given main concern over other approaches to understanding the patient's situation. The sociology of science, nevertheless, aims to analyze significantly the foundation of scientific knowledge. At the core of this analysis is the constructionist proposal that knowledge of any sort, whether emerging from a traditional source, co-existing wisdom, or science, is bound by temporality as well as culture. But, whilst superstitious attitude may still be held by some people in the West, and 'new-age' ways of viewing the world are growing in popularity, scientific thought has become the major epistemology, and therefore the most thriving construct in determining what is believed to be legitimate knowledge. Conversely, sociological thinking has challenged the genuineness of the pre-eminent position of scientific knowledge. At its most virulently post-modern, sociology claims that science is not accurate but simply one of many belief systems. That is, scientific knowledge is considered as socially manufactured. As part of its identity as well as power structure, any professional group seeks to institute a unique body of knowledge. This involves first, either completely or unambiguously identifying what counts as a convincing knowledge claim, and second, placing the activity of its members into a particular background, be it moral or scientific. The ascend of the ‘evidence-based’ movements in the 1990s has offered the clinical professions with chances for intensified identity and for re-establishing power in the face of increases in lay knowledge and warning from managerial control. Nursing’s instituted clinical efficiency programs meant that many nurses were well prepared for this new movement. Nevertheless, clinical effectiveness/EBM creates a conventional of credible health care from which no practitioner or professional group dare be debarred. To not fit in is to risk being relegated to a disparaged position without significance, reliability, morality, future or funding. Certainly, in one sense, efficiency and results are suitable things to be talking about. What is of interest is the way that this talk has become included within, or one might say has colonized, the building of ‘professional development’. One aim, as a minimum, of professional development is the nurse who can articulate her objectives, demonstrate and measure her impact using particular criteria, perhaps legitimized by managers (Bloomfield et al. 1992), can manage a team of lesser skilled workers, and who is continuously questioning whether the same effect can be attained more professionally (Johns 1995). This discussion may take on the language of professional development but this tends to mask its conditional nature as a response to particular economic situation, signifying that such an approach is enviable in a related way. Kuhn's contribution to a well-known debate that arose between Popper and himself was to project science and scientists as rather less than concerned in the rational questioning of theories on a constant journey towards truth - or at the very least traveling away from falsehoods. What Kuhn portrayed were long periods of 'normal science' in which researchers merely established the assumptions of their predecessors. Scientists operated within an accepted model, and for the most part did nothing more than deal with particular puzzles that were internal to that model. Only those problems are researched, and conclusions sanctioned, that are 'believable' within the principles of the paradigm. Any evidence that springs up during the 'normal science' that contradicts its precepts are dispensed with through derided or is contained by the setting up of theories that are adjusted with the paradigm. But, at different times in the history of science, the build-up of evidence rejecting the accepted paradigm becomes so great that it starts to disintegrate, and an era of 'revolutionary science' ensues. The revolutionary period will be a time of disorder in the scientific world, with much doubt and argument regarding what can be classified as genuine knowledge. At the end of the revolutionary interval, a new paradigm will come out, and a period of 'normal science' will subsist for as long as this paradigm can claim to enlighten natural, human or social phenomena. The new paradigm, nonetheless, is not any more 'rational' or 'developed' than previous views of the world. For example, from the Kuhnian viewpoint, socio-environmental explanations of disease are being relocated by neo-evolutionary theorizing and research into genetic causation. Nursing, built on an epistemology of intuition as well as caring, has been replaced by the 'new brutalism' of evidence-based practice (Clarke 1999). It is likely, though, that the current approval of 'evidence-based practice' will reach its retribution, and be substituted by a vogue knowledge-cult. In addition, it may be that what post-modernists have recognized as an age of cultural anarchy when all 'truths' are rejected is really just a protracted revolutionary era in the Kuhnian sense, and that ultimately there will be a resolution to, and calming of, such epistemological trouble. The history of the discipline of sociology is affirmed openly as one of disagreement, political in-fighting, questionable theorizing, insufficient empiricism, perpetual modification in addition to occasional epistemological disorder. Natural science has had a similar history, but tends to disguise such turmoil with a linear description of its advancement. Science is represented as growing shakily but steadily towards uncovering more and more truths, until finally a theory - backed by empirical evidence - will be obtained to 'explain everything'. Conclusion To summarize nursing leaders have continually reshaped discourse about the profession—the way it is talked about and how it is valued —in response to changing discourses in society at large, for example discourses of morality, science, feminism, consumerism and most recently economic rationalism. These discourses have also influenced nursing education and research issues. Such discourses often have functioned in a way that has marginalized particular values or groups within nursing. Reference: Bloomfield, B., Coombs, R., Cooper, D. and Rea, D. (1992) ‘Machines and maneuvers: responsibility accounting and the construction of hospital information’, Accounting, Management and Information Technologies 2(4):199. Boseley, S., 1998. 'Medical studies "rubbish"', Guardian, 24 June. Clarke, L. (1999) 'Nursing in search of a science: the rise and rise of the new nurse brutalism', Mental Health Care, 2 (8), 270-2. http://www.ebn.bmjjournals.com/cgi/content/full/4/3/68 Johns, C. (1995) ‘The value of reflective practice for nursing’, Journal of Clinical Nursing 4(1):23-30. Read More