Finding, Evaluating and Applying Evidence - Term Paper Example

Finding, Evaluating and Applying Evidence Student’s Name Institutional Affiliation Abstract Health professional are tasked with the provision of evidence-based care. Therefore, identification, evaluation and implementation of evidence is a prerogative among health professionals including nurses. The topic identified for evidence evaluation and application is the significance of skin disinfection prior to administration of intradermal, intramuscular and subcutaneous injections. A search criteria for the relevant articles was employed, and articles searched in databases such as Cochrane Library and PubMed database. An article that was a systemic review was identified. The article was authored by Coloman and Murray (2007), and it was a review of whether or not swabbing is necessary to disinfect the skin prior to injections. The review showed that skin disinfection is not a significant procedure in preventing local or systemic infections. The article was limited by the unavailability of sufficient evidence, but its results are trustworthy. The evidence obtained from the review was then strategized on how it shall be diffused or disseminated to the target audience which include health professionals and diabetes patients that are required to administer injections frequently. The various evidence implementation methods are discussed to ensure a successful implementation. Finding Evaluating and Applying Evidence Nursing practice is hugely informed by evidence well known as evidence-based practice. This requires that any form of care or intervention performed by a health professional or nurses should have a background foundation that support the efficacy and safety of the care or intervention (Flemming 2007). Various nursing professional bodies also have competency standards that advocate for constant acquisition of new skills and knowledge regarding nursing practice and a practical application of the same in healthcare (Nursing and Midwifery Board of Australia [NMBA], 2008). To utilise available evidence to guide nursing practice, the literature or research concerning the evidence has to be searched first among the various databases available. The research articles have to be evaluated to ascertain if the evidence found in the articles is credible and reliable before been applied in practice. During my placement in most wards, I notice that skin disinfection before administration of injections be it subcutaneous or intramuscular is common practice. It so common among doctors and some nursing students just acquire the practice after seeing some health care staff do it. However, is this practice evidence-informed or is it just based on anecdotal evidence? This got me interested in doing research on the validity of skin disinfection before administering injectable medications. Development of the Research Question Using the PICO format, the research question was formulated. PICO, a mnemonic for "population, intervention, control or comparator and outcome", is commonly used to detail and specify the research question (Aslam & Emmanuel, 2010; Gerrish & Lathlean, 2015). In this research, the population involved comprises any patient who may require administration of intradermal, intramuscular or subcutaneous injections. The intervention at hand is whether skin disinfection procedure prior to the administration of injectables, a practice commonly known as swabbing, is a necessary intervention. The comparator in this research is not applying the procedure or not swabbing the skin prior to injecting therapeutic substances into the body. The outcome to be assessed is whether infections are prevented by swabbing the skin prior to injections. Based on the PICO format the formulated research question was: "Does implementing skin disinfection prior to the administration of subcutaneous, intradermal and intramuscular injections to patients a significant preventive measure against infections?” It is a quantitative question because am seeking to analyse existing evidence to ascertain the significance of the procedure prior to injections. Search Strategy Databases searched for the relevant articles include Cochrane Library and PubMed due to credibility and accessibility of their articles. The search words utilised employing the appropriate truncation include "skin AND (disinfection$ OR preparation$)", administration$ OR injections$, and infection$. The initial search was limited to randomised controlled trials, but there was none regarding this topic hence the search was expanded to include systematic reviews. In Cochrane Library, the search was restricted to title abstracts and keywords used in the research while in PubMed database the search was done in all fields. Cochrane library search gave 48 results while PubMed database gave 54 results. Most of the research articles were not related to skin disinfection prior to intradermal, subcutaneous and intradermal procedures but were was related to skin disinfection prior to surgical procedures. One article was chosen, and it was a review article by Cocoman and Murray (2007) titled “intramuscular injections: to swab or not to swab” (Cocoman & Murray, 2007). Article Summary Clinical Question: Does skin disinfection before administration of intramuscular, intradermal and subcutaneous injections lower the risk of local or systemic infection. Study Background The article introduces the background of the study by giving a summary of an approximate number intramuscular injections administered annually in the whole world and the fact that there has been significant development towards evidence-based practice. However, according to Cocoman and Murray (2007), a dearth of evidence regarding the efficiency of the procedure in preventing infections has placed nurses in an indefinite state of whether to use or not to use the procedure with many having different interpretations of it. Study design Not specifically described but it’s a review of literature. It is not clear whether the research design was quantitative or qualitative due to the limited explanation of the methodology. The literature available on this topic as of 2007 was very limited with no randomised trials identified. Main Results The researchers suggest that most of the reviewed studies suggest that skin disinfection is not significant in preventing infections prior to injections. In one study, at least 5000 injections were given to patients of different ages, and there was no single case of a systemic or local infection on the skin identified during the study period. It was suggested that skin disinfection was not a necessary procedure before administering injections. In another study done on diabetes patients, it was found that using alcohol swabs to prepare the skin for about five seconds led to a reduction in the bacteria on the skin by more than 82%. However, the authors also suggested that the disinfection is not a necessity in preventing either systemic or local infections at the site of injections (Cocoman & Murray, 2007). In another review study spearheaded by World Health Organization, it was recommended that skin swabbing before injection be no longer a routine procedure during practice. It is argued that there are no sufficient bacteria colonising the skin surface to result in an infection with or without swabbing the skin (Cocoman & Murray, 2007). Cocoman and Murray (2007) mention that other studies seem to support these findings but hygiene before administration of injections is paramount. Conclusion Cocoman and Murray (2207) concluded that there is need for more credible research to inform the need or exclusion of skin disinfection prior to the administration of injections due to the limitedness of existing research findings. Article Evaluation Evaluation of the article by Cocoman and Murray (2007) will be based on the CASP tool (Hoffman, Bennett & Del Mar, 2010). The CASP tool assesses the validity and applicability of the results in a given setting. The review has addressed a succinct and focused question as it has identified the intervention under assessment that is skin disinfection prior to administration of injections with an outcome of whether the intervention significantly reduces the chances of local or systemic infections. The authors have addressed the review questions in their study citing all possible relevant articles although they were hampered by the unavailability of the relevant articles. Considering the time the study was done, all the significant studies done on the issue before 2007 were included in the review even though some were just cited in the discussion. Due to the limitedness of highly credible and reliable articles, the author had to rely on some articles whose study methodology is questionable. The review results have not been combined but have been discussed individually with all of them disputing the need for skin disinfection prior to the administration of intramuscular, subcutaneous and intradermal injections. The study results show similarity in terms of the insignificance of the procedure. The overall results suggest that skin disinfection as a procedure prior to injections should not be necessary due to its insignificance in preventing local or even systemic infections. However, the authors of the article did not present the result in any statistical form to enhance the significance of the results. However, this might because of the limited available studies to be analysed with all of the examined studies demonstrating the unimportance of the intervention in question. Despite the unavailability of sufficient research to be used in the review, the article’s findings are still trustworthy. Applicability of the results to a clinical setup such as in an Australian clinic or hospital setup may not be fully advocated because of the unavailability of reliable studies to support the elimination of the procedure prior to administration of injections. There are clinical settings where the procedure has been virtually accepted and is been used. It may be difficult to persuade such settings to drop the procedure. However, in settings not sure whether to adopt or not to adopt the procedure, they may save some worthy time by avoiding the procedure in cases where the skin is not heavily soiled (Cocoman & Murray, 2007). Visibly soiled skin can be cleaned using water and soap without applying skin disinfection. Knowledge Translation Basis for Knowledge Transfer It is widely known that the skin should be clean prior to administration of intradermal, subcutaneous and intramuscular injections. However, the use of skin disinfectants such as alcohol as a routine practice in skin disinfection has had its clinical significance in prevention of infection during injections doubted (Khawaja, Sikandar, Qureshi & Jareno, 2013). Since nurses are guided by the need to practice evidence-based medicine, it is paramount that every action and omission in the implementation of nursing care should have supporting evidence. However, this has not been the case for skin disinfection prior to injections’ administration. Nurses practicing in different environments or jurisdiction have policies and guidelines that inform various procedures. These guidelines are usually based on researched evidence regarding the significance and efficacy of a particular set of intervention before they are implemented in practice. Without the evidence, it becomes difficult for nurses to make decisions regarding interventions such as skin disinfection and without there been any significant evidence to guide them, different and sometimes conflicting opinions may arise (Cocoman & Murray, 2007). Despite there been no single randomised controlled trials relating to skin disinfection in prevention of infections, available quasi-experimental studies, cross-sectional and cohort studies indicate that the procedure is not an essential infection prevention measure (Cocoman & Murray, 2007; Dann, 1969; Khawaja et al., 2013). The Synthesised Evidence Khawaja et al., (2013) demonstrated through a quasi-experimental study that although skin disinfection using alcohol swabs reduces the number of microorganism on the skin, the procedure is not necessary due to its insignificance in preventing infections. The study found out that the number of bacteria that can be injected into the skin when the skin is not cleaned prior to the injection is quite minimal to cause any pus formation, a manifestation of bacterial infection (Khawaja et al., 2013). This shows that the normal skin contamination is not sufficient to result in any infection if the skin is not disinfected prior to administering injections. Other studies support the findings by Khawaja et al. (2013). For instance, Kshanti & Suyono (2008) also demonstrated that skin disinfection or preparation prior to insulin administration is not an essential infection prevention measure since out of the 1512 subjects that participated in the study, there was not any observed local skin infection or reported signs or symptoms of infections on the subjects. These findings were in support of an earlier study done on diabetic patients that showed no altered infection risk as a result of skin disinfection prior to insulin administration (Koivisto & Felig, 1978). From these studies, the general recommendations are that the skin should be clean prior to injections but disinfection is not necessary. If the skin is soiled, the cleaning can be achieved by use of soap and water even though the evidence supporting this practice is limited (Cocoman & Murray, 2007). Diffusion and Dissemination of Evidence Knowledge translation entails transferring appropriate information obtained through research to the right recipient of the information at the fitting time and in a structure that they can use and apply in influencing decision making (Grimshaw, Eccles, Lavis, Hill & Squires, 2012). The target audience in knowledge translation include researchers, all levels of nurses, physicians, and allied professionals, and patients using needle injections such as diabetes patients self-administering insulin. The knowledge translation shall utilise strategies such as diffusion and dissemination (Hoffmann, Bennett & Del Mar, 2010; Sudsawad, 2007). Diffusion shall be through conference presentations, non-peer reviewed and peer-reviewed publications such as archives and journals with no viewing limitations, and web-based sites such as blogs, podcasts, and professional forum postings (Sudsawad, 2007). Diffusion is meant to convey the information to consumers such as researchers and other health professionals who frequent the web for information. Target audience who shall not be reached via diffusion shall be targeted via dissemination. Dissemination entails conveying the evidence-based knowledge obtained through means such as events or courses such as continuous, medical education forums, symposium and conferences where health professionals that form the target audience routinely meet (Hoffman, Bennett & Del Mar, 2010). Interactive workshop and small group meetings shall also be a means through which the information shall be disseminated. Other means of dissemination include summary briefings to stakeholders, knowledge broker involvement, educational outreach visits, communities of practice, educational materials, reminders, using opinion or champion leaders such as informal leaders to aid in sharing the information, and a combination of these strategies (Hoffman, Bennet & Del Mar, 2010; Sudswad, 2007). Most of these interventions have proven efficacy in disseminating evidence such as educational meetings that provide a forum for interaction of health professionals where discussions on issue pertaining to health, including the adoption of new evidence into practice, are carried out. Educational outreach visits shall be useful in accessible areas where specific visit to health professional in their practice set-ups may be done to educate them on the evidence against the routine skin disinfection before administration of injections. Educational visits target individual knowledge and attitude and utilises social persuasion to influence the health professionals to employ the evidence into their routine practice (Hoffaman, Bennet & Del Mar, 2010). Reminders shall target both patients and health professionals. The reminders shall be encounter-specific and patient-specific. The former shall target health professional tasked with administering injections in the course of their prescribed role and shall include notices of ‘do not disinfect if skin is clean' conspicuously attached in injection room and storage lockers for needles and injectable medications in outpatient clinics and in the wards. The client-mediated information shall target diabetes patients mostly and shall consist of stickers attached to their insulin needles' package and insulin vial with a similar message. Use of reminders has more existing evidence supporting it than the other interventions because of its closeness to the field of evidence application (Hoffman, Bennett & Del Mar, 2010; Grimshaw et al., 2012). Evaluating Utilization of Evidence An evaluation of whether the disseminated evidence is been utilised by the target audience is necessary to assess if the dissemination or diffusion of evidence was successful and identify reasons for an unsuccessful dissemination. The evaluation shall look at elements related to the progress of acquisition and application of the evidence. Therefore, a modification of the Nursing Practice Questionnaire (NPQ) was formulated for the evaluation purpose targeting practicing health professionals (Sudsawad, 2007). The questions adopted for use in the NPQ include: (1) whether the professional has read about the non-significance of skin disinfection prior to injections, (2) whether the professional has heard about it (3) whether the professional has observed it in practice, (4) whether the professional has learned about it from anywhere else (5) whether the professional deems it appropriate to their practice, and if not appropriate, a reason for the inappropriateness shall be given, and (6) the frequency of use of application of the evidence in clinical setup, (Sudsawad, 2007). Each of the seven questions represents a particular stage of adoption of an innovation as identified in the “diffusion of innovation framework [DIF]” (Sudsawad, 2007). The DIF has four stages that include “knowledge (1) awareness, (2) persuasion, (3) decision and (4) implementation” (Sudsawad, 2007). Questions one to four assess the awareness of the intervention among the health professionals and a ‘yes’ answer to any of the questions will be indicative of awareness of the evidence and shall have a 1 score, otherwise the score shall be 0. Question five assesses the persuasion stage and requires an affirmative response for a 1 score. The sixth question assesses the level of use in implementing the evidence scored as 2 for ‘always’ and 1 for ’sometimes’. Based on the scores obtained, it will be possible to ascertain awareness of the evidence disseminated and the usability of the evidence in practice. A similar questionnaire shall be availed to patients but incorporating questions one, two, four and six only. Thus this questionnaire shall assess (1) whether the patient has read about the expunging of skin disinfection as a procedure prior to injection of insulin in patient leaflets and instructions regarding medication administration, (2) whether the patient has heard about it from health professionals, (3) whether the patient has learned about it from anywhere else, and (4) the frequency of the application of the evidence by the patient. The above assessment shall give feedback regarding the adoption of the evidence such as if the evidence reached a substantial number of the targeted audience especially practicing health professionals, if the evidence was considered but rejected, if nothing has been done with regard to the evidence, if it is under consideration, if there are steps geared towards implementing the evidence, and if it has been implemented partially or completely (Sudsawad, 2007). The reason given in the questionnaire regarding the perspective of health professionals regarding the appropriateness or inappropriateness of the evidence shall be analyzed for possible gaps to inform future research. With such feedback, it shall be possible to assess the implementation of the evidence in practice which is the primary aim of research. Conclusion To continuously encourage the use of evidence-based practice among health professionals, it is necessary to identify, evaluate and apply identified evidence. After the reliability of obtained evidence has been obtained, the evidence should be diffused or disseminated to the various audience suited to utilize the evidence. Without proper evidence transfer and implementation in practice, the significance of research findings loses meaning. Therefore, all procedure necessary to identify, evaluate, and implement evidence in health settings should be employed to ensure that the future of health practice is safeguarded, and decisions are supported by credible and reliable evidence. References Aslam, S. & Emmanuel, P. (2010). Formulating a researchable question: A critical step for facilitating good clinical research. Indian Journal of Sexually Transmitted Diseases, 31(1), 47-50. Cocoman, A. & Murray, J. (2007). Intramuscular injections: To swab or not to swab. World of Irish Nursing, 15(8), 26-27. Dann, T.C. (1969). Routine skin preparation before injection: an unnecessary procedure. Lancet, 2(7611), 96-98. Flemming, K. (2007). The synthesis of qualitative research and evidence-based nursing. Evidence-Based Nursing, 10, 68-71. Gerrish, K. & Lathlean, J. (2015). The research process in nursing (7th ed.). West Sussex: John Wiley & Sons Ltd. Hoffmann, T., Bennett, S. & Del Mar, C. (2010). Evidence-based practice across the health professions. Chatswood, NSW: Churchill Livingstone. Khawaja, R.A., Sikandar, R., Qureshi, R. & Jareno, R.J. (2013). Routine skin preparation with 70% isopropyl alcohol swab: Is it necessary before an injection? Journal of Liaquat University of Medical and Health Sciences, 12(2), 109-114. Koivisto, V.A. & Felig, P. (1978). 1978. Is skin preparation necessary before insulin injection, 1(8073), 1072-1075. Kshanti, I.A. & Suyono, S. (2008). Infection at insulin injection sites in diabetic patients with or without alcohol swabs. Maj Kedokt Indon, 58(9), 323-326. Nursing and Midwifery Board of Australia. (2008). Code of professional conduct for nurses in Australia. Melbourne: Australia Nursing and Midwifery Council. Sudsawad, P. (2007). Knowledge translation: Introduction to models, strategies, and measures. Madison: National Center for Dissemination of Disability Research. Read More