The Application of Evidence-Based Nursing in Orthopaedics - Essay Example

The Application of Evidence-Based Nursing in Orthopaedics Contents a) Introduction b) What is evidence based nursing? c) Evidence based nursing in orthopaedics: Application and examples d) Advantages of evidence based nursing in orthopaedics e) Disadvantages of evidence based nursing in orthopaedics f) Potential barriers to implementing evidence based nursing in orthopaedics g) Conclusion h) References Introduction Nursing practice today has undergone a revamp as nurses are facing changes as to how nursing should be practiced. Much has been said about evidence based nursing as there is currently an increasing load of information from research which needs to be put in place simultaneously and appropriately with nursing practices. Evidence based nursing whose philosophical and historical origins can be traced to Paris as early as the 17th century (Strauss & McAlister, 1999) and during the times of Florence Nightingale (Nightingale 1863, 1871), remains an aspect of healthcare that nurses cannot do without. The basis of an evidence based nursing practice is that clinical practice should be based on tangible scientific and research based information. In line with the development within the healthcare profession, patients today too are also increasingly becoming aware that the paternalistic and opinion/experience based approach by healthcare personnel is not ideal and that a partnership and evidence based approach should be put in place instead. Today, many countries have centers which are specifically involved in evidence based practice, for example in the field of nursing, internal medicine, orthopaedics and pharmacology. More and more evidence based practice journals are being published for example the Evidence Based Nursing (EBN) journal and there are also organisations catering to the need of evidence based practice for example the Center for Review and Dissemination in York, UK. What is Evidence Based Nursing? Basically, evidence-based decision making is a continuous and interactive process which involves the judicious and conscientious use and consideration of the best available evidence to provide care together with the imperative acknowledgement that the usage of the evidence should correlate with professional clinical judgment (Trammer et al., 1998; Youngblut & Brooten, 2001). Evidence per se can be defined as the information acquired through scientific evaluation of practice and these types of evidence range from studies such as randomized controlled trials, meta-analysis and observational studies. Thus, evidence based nursing can be defined as the process in which nurses make clinical decisions using the best available research evidence together with their own clinical judgment and expertise to tailor it to their patient in order to provide the best of patient care. To help with this practice of evidence based nursing, there are 4 vital components which have to be taken into consideration which would influence how a patient is managed with the use of evidence. These 4 components are clinical expertise, the patient’s preference for the various types of treatment/intervention available, the type of clinical research evidence and the resources which are available within the particular setting (Haynes et al 1996). These 4 components in an ideal setting should overlap one another but in real life, this may not be so. Although an expert based opinion is the lowest form of evidence (Oxford Centre for Evidence-based Medicine Levels of Evidence and Grades of Recommendation), many daily decisions are made in health care centers throughout the world using this form of decision making. The most common cause of why these 4 components are not always used together would be the lack of resources and sometimes, there are cases where the benefits for a particular patient is outweighed by the costs. Whether or not nurses are directly or indirectly involved in the decision making, they still need to be aware of it. Nursing practice itself requires years of professional training where skills, knowledge and expertise is accumulated. Evidence from research can help to supplement this knowledge but nurses should always remember that a proper bedside examination, even talking to a patient cannot be replaced completely by evidence. This separates proper, evidence based nursing from cookbook nursing and the improper usage of practice guidelines. To make an evidence-based nursing decision, some basic steps can be taken. Firstly, the research question has to be defined, followed by the collection of evidence, appraising the evidence for validity and relevance, making a decision on whether the evidence can be applied, applying the evidence and finally evaluating the intervention and if needed, modification. To make things easier, the question which has to be defined necessitates these components: the patient, the intervention, the comparison and the intervention. Next, the results of the study have to be analysed for its validity in terms of the population studied, the intervention given, the outcomes considered and was the right form of study used. In regards to the study itself, it would be best if it was a randomized controlled trial although this is not necessary in some situations. All the patients who were in the trial should also be properly accounted for, followed up adequately and those who were involved “blinded” to the treatment/intervention. All groups, which in many cases include a control group i.e. not receiving intervention should also be treated equally. After this, the results would be analysed to see the effect of the treatment and whether it was a substantial improvement. The precision of the results can be proven statistically by the usage of confidence intervals and p values. With the analysis, the decision is then made on whether it can be applied to the patient and would the benefits fit in terms of resources and minimal harm (Guyatt et al 1993). Resources wise, journal articles are often the best source and fortunately, there are many which are catalogued online which offers easier browsing through the use of key words, topics and specialties. Some of these resources include PubMed, The Cochrane Library, Evidence Based Nursing, The British Medical Journal and The New England Journal of Medicine (Library and Multimedia Services). Evidence based nursing in orthopaedics: Application and Examples In the field of orthopedics, there are many areas where evidence based nursing can be put into practice. It is vital that the implementation of any evidence based practice be feasible, cost effective and does not cause any/minimal harm to the patient. For this paper, 2 common and important areas in orthopaedic nursing would be examined: prevention of deep venous thrombosis (DVT) and early in-patient rehabilitation after orthopaedic surgery. In the case of prevention of DVT, DVT and a complication of DVT which is pulmonary embolism is a life threatening emergency. Some of the risk factors for developing DVT would be orthopaedic surgery itself for example patients who have undergone hip surgery. Many orthopaedic patients are also bed ridden for long periods of time and this is also another risk factor for the development of DVT. Thus, as a nurse, prevention of DVT is crucial to decrease mortality and mortality. In order to answer this question, one can ask if unfractionated heparin (UH), low molecular weight heparin (LMWH) or physical methods for example compression stockings and calf/foot pumps can prevent DVT and PE after surgery for hip fractures in elderly patients. Critical appraisal via a meta analysis of 31 other studies noted that heparin, both UH and LMWH reduced the relative risk of DVT by 40% compared to no intervention whereas the usage of mechanical devices reduced the relative risk of DVT by 69% compared with no intervention. Thus, the evidence from this study can be presented to the team that the current practice of giving UH, LMWH or the usage of mechanical devices should be advocated after hip surgery and nurses should be vigilant when assessing patients after hip surgery to monitor for any signs of DVT or PE (Handoll et al 2002). Early rehabilitation after orthopaedic surgery is vital to minimise disability and to return the patient to daily functioning. However, factors such as the timing of when to begin rehabilitation and the intensity of the rehabilitation programme itself affects the outcome of the rehabilitation process. If rehabilitation is done too early, there is a risk of incurring additional costs if the patient is unable to carry out the therapy and worse, the patient might develop complications. Rehabilitation centres are also overwhelmed by the large number of patients who require rehabilitation as they cater to patients from all specialties, ranging from orthopaedics to internal medicine (stroke) and this may lead to late rehabilitation. One of the ways to solve the overcrowding of rehabilitation centres is to allow rehabilitation to be done in the wards by nurses. In addition to this, nurses spend the most amount of time with the patients, thus, they would know if the patient is actually ready for rehabilitation. It has been shown that early in-patient rehabilitation by trained nurses after elective hip and knee arthroplasty provided the patients with a shorter total length of stay, faster attainment of short term functional milestones and a complete functional outcome after 4 months of follow-up (Munin 1998). Similarly, Cameron et al (1994) also noted that patients with proximal femoral fractures who received timely and accelerated rehabilitation had significant cost reductions (A$10600 vs A$12800) as well as a decreased length of stay compared to patients who received standard care. As nurses could reliably gauge whether or not a patient would be able to tolerate rehabilitation, the patients also benefited from complication-free rehabilitation. Resources wise, the timely decision of when to start rehabilitation as well as the intensity of rehabilitation reduced total cost from orthopaedic and rehabilitation hospital readmissions. Advantages of Evidence Based Nursing in Orthopaedics There are some advantages to the usage of evidence based nursing in orthopaedics. One of it is that it integrates medical education with clinical orthopaedics practice (Rosenberg & Donald, 1995). This allows orthopaedic nurses to have a dynamic and lifelong form of education where they continue to educate themselves rather than to stick to text book information which they had learnt during their educational period. Nurses who learn and practice evidence based nursing become skillful in creating a question, followed by literature review and analysis. They would also be able to pick out good sources of information and how to differentiate between one paper and another even though both are on similar topics. This ability to do so has been clear. During the initial stages of critical appraisal, many people concentrate on only the randomised controlled trials or RCTS. Although RCTs are the highest level of evidence possible and is the most appropriate type of study if there is a need to evaluate the value of a particular modality of nursing intervention, sometimes, this may not be true. For example, there would be cases that on a patient by patient basis which is beneficial may be shown to be harmful in RCTs. An increased understanding of critical appraisal would let one know that qualitative studies are some of the best designs to better understand a patient’s beliefs and attitudes (DiCenso et al 1998). Another advantage of evidence based orthopaedic nursing would be that when taught in a method which is easily understandable and by an experienced tutor, it can be learnt by people from different backgrounds and who do not need to be a healthcare expert. Many critical appraisals are done not only by student nurses but also medical students. This enhances the concept of team work and a team based healthcare delivery system. Evidence based nursing in orthopaedics also offers uniformity of care through the application of common guidelines and even formal clinical practice guidelines/parameters within a healthcare organisation and sometimes at a larger scale, for example a national guideline. As nurses work in shifts, communication and standardisation may be difficult. With an evidence based guideline, there would be uniformity in the standard of health care delivered to the patients. When a particular problem is encountered, evidence based nursing also offers the framework for systematic problem solving which indirectly improves communication between nurses and other members of the healthcare team. Evidence based nursing in orthopaedics can also help nurses to make decisions which are resource oriented. There does not exist a public healthcare system with unlimited resources and a daily battle is fought everyday to maximise these resources without compromising the quality of healthcare. Thus, by using evidence, it would enable nurses, doctors and the management to evaluate the clinical effectiveness of a particular investigation or intervention i.e. drugs or surgery. The judicious use of resources can be seen long term, for example, by providing steroids to women who are at risk of a preterm labor, this reduces the incidence of respiratory distress syndrome which consequently uses up more resources via its higher incidence of morbidity, mortality and also costs of care in the short-term period (Saarela 2001). Disadvantages of Evidence Based Nursing in Orthopaedics As there are benefits to evidence based nursing in orthopaedics, there are also some disadvantages. As much as evidence based nursing as mentioned earlier can be learnt by anyone, it does take a considerable amount of time to learn and practice. For those with less experience, it may easily take up to a few hours to formulate the question, search for supportive literature, appraise the literature and then formulate a plan of action based on the results, taking into consideration the resources and whether it would be feasible to carry out with the intervention. At times, it takes a more senior or experienced person to come up with the question and even to go through with the entire process. Another drawback in regards to evidence based nursing in orthopaedics would be the infrastructure needed to perform it. Basically, the equipment needed include computers, an internet connection followed by subscription to journals. The costs of these subscriptions can run to the thousands per year depending on the quantity and type of journals subscribed to. However, it is also important to note that the costs from an evidence based practice may be many times less than the amount used if there is inefficient practice (Rosenberg & Donald, 1995). As the boom of evidence based nursing and practice has only been in place for the last few years compared to clinical practice, there are a lot of gaps in regards to the evidence itself and the electronic databases. In relation to orthopaedics, a lot of the forms of intervention were actually researched on in the 1980s where the Internet and electronic databases were still in its infancy. When there is a need to reference these older journals, it would not be feasible for one to manually search through stacks and stacks of journals. This issue has been sorted out by the usage of scanned copies of these documents. Unfortunately, with every question asked, one may come up empty even after a proper search (Rosenberg & Donald, 1995). In the field of orthopaedics itself, the nature of a lot of orthopaedic cases is acute i.e. fractures from accidents, falls and the patient’s condition may worsen within a few minutes, for example in the case of a pulmonary embolism secondary to deep venous thrombosis. Thus, there is no time for one to perform a critical appraisal as a decision is needed immediately. Some centers pre-research common scenarios but the downside to this would be that treatment should be tailored and not generalized. Potential Barriers to Implementing Evidence Based Nursing in Orthopaedics In regards to the implementation of evidence based nursing in orthopaedics, there are some barriers. Firstly, there is the issue of the size and complexity of the literature. In many instances, people opt to look at the abstract and make a decision but this is wrong as the entire paper itself should be looked at to note for any factors which may make the paper, even an RCT less reliable, for example a large number of drop outs. With this in mind, it is difficult for someone especially if working alone to analyse dozens of complete papers individually to come up with an answer to the research question. There are also barriers in regards to developing an evidence based clinical policy. As mentioned above, having an evidence based policy allows the standardisation of patient care at all times. However, to actually implement it would be difficult as there would be the need to educate all the staff involved, not only the nurses but also doctors so that there would not be a clash of opinions. To find the time to attend these courses would be difficult for some who have very busy practices. There are also problems in applying the evidence as there may be poor access to the best evidence. Medicine is dynamic and everyday, there is new information. For example, the New England Journal of Medicine publishes weekly. Thus, this means that the person who is performing the critical appraisal should have access to the latest papers. This may not be feasible in smaller centers which have lesser subscriptions, for example a journal which only publishes twice a year. Organizational barriers also hinder the implementation of evidence based nursing. Healthcare is more complex today and many healthcare centers employ management teams which may not be healthcare personnel. True to the concept of management, the utilization of resources should be maximised but this may cause the lack of insight and judgment for certain cases where lives are concerned. Thus, a nurse may want to offer an evidence based modality for his/her patient but the management may not allow this to happen. As nursing practice and medicine is dynamic, there should be continuous education in order to keep everyone on the healthcare team as updated as possible and one of the issues which may be addressed during these sessions would be evidence based practice. However, the lack of time, participation and even space may hinder this. In addition to this, there may be low patient adherence to these forms of evidence based nursing. Why this is so may be due to the lack of proper communication of the information between healthcare personnel and the patient. Evidence based practice and critical appraisal itself is not something which every healthcare personnel understands immediately, what more when translated improperly with medical jargon to the patient (McCabe 2004). Conclusion When nursing is concerned, we can clearly see that there is a large role for evidence based nursing in orthopaedics. To help in this, professional nursing associations, nursing regulatory bodies and nursing schools should share the responsibility of facilitating and promoting evidence based nursing practices and decisions. Nurses should also continuously update themselves on studies, strive to provide only the best and self generate questions and pass the answers of the appraisals to the team. There is also a greater role for educators and educational institutions as many of them are used as teaching hospitals, thus these parties have to ensure that all those who walk through their doors be equipped with at least a basic knowledge on how to perform a critical appraisal and to instill the spirit of critical thinking. Hospitals, governments and policy makers should acknowledge the role of evidence based nursing and provide support in terms of resources of health information. A national database which collects and maintains health data would prove useful to researchers as the interventions and studies can now be tailored to a particular population. At the end of the day, the main goal of nursing is to deliver the best of healthcare to every patient and with evidence based nursing, it supplements what we do best everyday into something even better. (3184 words only) References: Cameron ID, Lyle DM, Quine S. 1994. Cost effectiveness of accelerated rehabilitation after proximal femoral fracture. J Clin Epidemiol. 47:1307-1313. DiCenso A, Cullum N, Ciliska D. 1998. Evidence-Based Nursing.1:38–40 Evidence Based Nursing Information. Library and Multimedia Services. Guyatt GH, Sackett DL, Cook DJ. 1993. Users’ guides to the medical literature. II: how to use an article about therapy or prevention. JAMA 270: 2598-2601 and 271: 59-63. Handoll HH, Farrar MJ, McBirnie J, et al. 2002. 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Evidence-based nursing practice: Why is it important? AACN Clinical Issues, 12(4), 468-476. Read More