Principles of evidence based practice

Introduction

Evidence based practice is a complex experience that requires synthesizing study findings to
establish the best research evidence and correlate ideas to form a body of empirical
knowledge (Burns & Grove 2007). There are many definitions but the most commonly used
is Sackett et al (1996).

The importance of evidence based practice is to enable nurses to provide high quality care,
improve outcomes for patient and families and to run a more efficient health service.
Therefore other agencies within the health service will benefit when interventions and care is
based on research (Burns & Grove 2007). According to the Nursing and Midwifery Council
(NMC) code nurses are accountable to society to provide a high quality of care so therefore it
is important that nurses reflect, evaluate the care and keep abreast of new knowledge and
evidence that is available (Burns & Grove 2007). Providing a streamlined service, which is
cost effective and based on current evidence based practice has shown to reduce cost but also
to enhances the quality of care the patient receives (Melnyk et al2010). Working in
partnership with the nurse the patient is able to participate in decisions about their care. This
is not only beneficial for the patient but also increases the satisfaction of the nurse treating the
patient (Craig & Smyth 2007). Furthermore Craig & Smyth (2007) suggests evidence based
practice is a problem-solving approach to the delivery of health care. In using a problem
solving approach the nurse is able to integrate clinician expertise and patient preferences to
provide individualized care suitable for the patient.

To acquire knowledge in the past, nurses have relied on decisions based on trail or error,
personal experience, tradition and ritual. Parahoo (2006) suggests learning by tradition and
ritual are important means of transferring knowledge, for example learning the ward routine.
According to Brooker and Waugh (2007) Students learn from effective colleagues who
practice safety and on the basis of best evidence. However, a disadvantage of this method of
learning may lead to transmission of invalid information and may put the patient and nurse at
risk (Brooker & Waugh 2007). According to Burns and Grove (2007) to generate knowledge
a variety of research methods are needed. The two different research methods are quantitative
and qualitative. According to Burns and Grove (2007) quantitative research is an objective
formal systematic process and demonstrates its findings in numerical data. According
Munhall (2001) qualitative research is gathering information to describe life experiences
through a systematic and subjective approach and does not use figures or statistics to produce
findings. In nursing practice the quantitative approach has been considered to provide
stronger evidence than qualitative (Pearson, Field, & Jordon, 2007). Pearson, Field, & Jordon
(2007) suggest health professionals and servicer users require a variety of information to
facilitate change and to include evidence not only of effectiveness but feasibility,
appropriateness and meaningfulness to achieve evidence based health care practice.

Evidence based practice promotes the application of research evidence as a basis on which to
make health care decisions so it is important to search for the truth and knowledge logically.
Robust research which may draw on expertise and experience represent a higher level of
evidence because of the discipline involved (Burns &Grove 2007). There are thirteen steps in
the quantitative research process and one step gradually builds on another (Burns &
Grove2007). The beginning of the research process starts with a problem which usually
highlights a gap in knowledge (Melnyk & Fine-Overholt 2005). The next step is the purpose
of the research. This is produced from the problem and identifies the aim of the study (Burns
& Grove2007). To build a picture up of what is known or not known about the problem a
literature review is conducted. This will provide current theoretical and scientific knowledge
about the problem and highlight gaps in the knowledge base (Burns & Grove 2007). This is
followed by the study framework and research objectives, questions and hypotheses. This
continues to the end till all the steps are covered. The final step is the research outcome.

Hierarchy of evidence is generated from the quality of information from different evidence.
Practitioners are able to use the hierarchy of evidence to inform them on which information is
most likely to have the maximum impact on clinical decisions (Leach 2006). Leach (2006)
suggests hierarchy of evidence may be used to discover research findings that supersede and
invalidate earlier accepted treatments and change them with interventions that are safer,
efficient and cost-effective. If findings from a controlled trial are inadequate, choices should
be guided by the next best available evidence (Leach 2006).

According to Scottish Intercollegiate Guidelines Network (SIGN 2009) the revised grading
system is planned to place greater weight on the quality of the evidence supporting each
recommendation, and to highlight that the body of evidence should be considered as a whole,
and not rely on a single study to support each recommendation. The grading system currently
in use with the SIGN guidelines starts with 1++ and ends in 4. For the evidence to be rated at
1++ it must include a high quality meta-analyses, systematic reviews of random controlled
trails (RCT) or RCT with a low risk of bias. Level 4 is based on expert opinion (SIGN 2009).

There are many barriers to implementing evidence based practice. One of the common
barriers is staff information and skill deficit. Health professionals lack of knowledge in
regarding results of clinical research or current recommendations may not have the sufficient
technical training skill or expertise to implement change (Pearson, Field, & Jordon 2007).
Nurses have also highlighted lack of time as a barrier in applying research to practice. As the
number of patients increases nurses face the challenge of providing safe, high-quality care
within a short time frame. Nurse educators and researchers have developed a “toolkit” to ease
the implementation of evidence based practice into nursing (Smith, Donez & Maghiaro
2007).

According to Gerrish and Lacey (2006) dissemination is a process of informing people about
the results of a particular research. There are many ways to present results, video, seminars
and the most accepted is through professional journals. However with the internet being more
assessable the researcher is able to post details on the website hosted by NHS trust or
university. One disadvantage in using the internet is that it provides no guarantee of quality
(Gerrish & Lacey 2006). SIGN guidelines are circulated free of charge throughout Nation
Health Service (NHS) Scotland. For this to happen they must be made widely available as
soon as possible to facilitate implementation. Furthermore guidelines on their own have
proved ineffective and more likely if they are disseminated by active educational intervention
and implemented by patient-specific reminders relating directly to professional activity
(SIGN 2009).

Critique 1
Rydstrom I, Dalheim-Englund A, Holritz-Rasmussen B, Moller C, Sandman P-O (2005).
Asthma - quality of life for Swedish children.Journal of Clinical Nursing 14, 739-749.
Blackwell Publishing Ltd.

As the title suggests this was a research to find out how Swedish children with asthma
experience their quality of life and to look for potential links between their experience of
quality of life and some determinants. This study was accomplished by using a quantitative
research approach which adhered to the aims and objectives. Quantitative research is formal,
objective, systematic inquiry that involves numerical data (Burns & Grove 2007). The two
stages used in the quantitative research were correlation and quasi-experimental (Burns &
Grove 2007). This is an acceptable method to use as the study was trying to explore the
relationship between two variables and the findings were produced in a numerical format.

In previous literature it was noted investigations in children with asthma around the world all
had similar experiences (Rydstrom et al2005).It also highlighted that girls and boys perceived
asthma in a different way and girls were more likely to include asthma in their social and
personal identities where boys would exclude the condition (Williams 2000). The researchers
wanted to ask the children how they experience their life living with asthma. Also to look at
possible links between children's quality of life and determinants such as age, sex, pets,
siblings, location and social status (Rydstrom et.al. 2005).

Some common types of sampling used in quantitative research are random and non-random
samples (Burns and Grove 2007). In the article for the purpose of this study all hospitals and
clinics were used and fifteen were chosen randomly for the study (Rydstrom et al2005). Both
children and parents were asked to participate in the study but children had to meet the
inclusion criteria before being selected (Rydstrom et al2005). By using a random sample the
general population becomes representative of the larger whole (Parahoo 2006).

Validity was established by cross-matching Paediatric Asthma Quality of life Questionnaire

(PAQLQ) with About my Asthma (AMA), by Mishoe et.al.(1998). Warschburger (1998)
recommended that PAQLQ was a reliable instrument and Reichenberg & Brogerg (2000)
found that there was no difference concerning reliability between the Swedish and the
original PAQLQ.

The study was approved by The Ethics Committee at the Medical Faculty of Umea
University in Sweden and consent was received from parents and children. Burns and Grove
(2007) define sampling as a process of selecting groups of people who are representative of
the population.

Data was collected through self administration questionnaires. There advantages and
disadvantages in using questionnaires. Advantage firstly, the data is gathered is standardised
and therefore easy to analyse. Secondly, respondents can answer anonymously which may
produce more honest answers. A disadvantage is the responses may be inaccurate especially
through misinterpretation of questions in self completing questionnaires. (Gerrish & Lacey
2006). Children age seven to seventeen were required to fill in Paediatric Asthma Quality of
life Questionnaire (PAQLQ) which was used to measure the children's quality of life in
different domains. Parents were required to fill in Paediatric Asthma Caregivers Quality of
life Questionnaire (PACQLQ) (Rydstrom et al2005). Children and parents filled in
questionnaires separately and a nurse was on hand to help children who could not manage on
their own.
The researchers clearly identify what statistical tests were undertaken. However the results
are presented in a complex manner. The results showed the majority of children estimated
their quality of life at the positive end of the scale. Children reported impairment in the
domain of activities than emotions and symptoms for example not being able to run around.
Living in the south of Sweden and being a boy were reported to have a better quality of life.
Furthermore children living with a Mum over forty or with cohabiting parents had a better
quality of life (Rydstrom et al2005).

The researchers brought to the attention of the reader the laminations within the study.
Children view friends and their social environment being important to them however there
were no questions relating to this and also it did not take into consideration the child's stage
of development (Rydstrom et al2005). Also the research was done within a week, therefore
would the results be different if it was done over a longer period. This was not a controlled
research so there is a possibility that some data may be missing as nobody was checking to
see if the children had filled in all the questions.

The findings highlight it is important for the nurse to look at all aspects of the child
development. Furthermore caring tends to focus on the patients' limitations, another
important issue for nurses is to try to discover those aspects in a child's daily life that
contribute to a high QoL in order to improve and maintain the child's wellbeing.

Critique 2

Lyte, Milnes, Keating & Finke 2007. Review management for children with asthma in
primary care: a qualitative case study.Journal of Nursing and Healthcare of Chronic Illness in
association with Journal of Clinical Nursing 16, 7b, pp123-132

As the title suggests this research article will focus on review management for children with
asthma within a primary care setting. This study was accomplished by using a qualitative
case study design. In using a qualitative case study design it can provide much more
comprehensive information than what is available through other methods, such as surveys
(Neale, Thapa & Boyce 2006). Neale, Thapa & Boyce (2006) suggest case studies also allow
one to present data collected from multiple methods (i.e., surveys, interviews, document
review, and observation) to provide the complete story. Qualitative research is systematic,
subjective approach (Burns & Grove 2007) which describes life experiences, meanings,
practices and views of those involved (Craig & Smyth 2007).

In the UK one in eight children suffers from the effects of asthma and the majority of cases
are now being managed in the primary care setting (National Asthma Campaign 2001). With
improvement in management of asthma over the years there is still a high level of morbidity
and mortality (Lyte et al2005). Out of Sight, Out of Mind (Asthma UK 2005) agrees with
Lyte et al(2005) that death rates are high. In Scotland the death rates due to asthma vary each
year. Furthermore inquires have shown at least 90% of those deaths could have been avoided.
However child admissions to hospital due to asthma have fallen slightly (Out of Sight, Out of
Mind Asthma UK 2005). Furthermore it was highlighted through a systematic review of
literature published at the time of research that it was unknown whether primary care based
asthma clinics were effective. Additionally it concluded that patients' views on asthma clinics
were also unknown (Fay et al2003). One cannot ignore the fact that there are evident gaps in
generic knowledge of primary care asthma services for children in the UK (Lyte et al2005).
Therefore the aim of the study is to investigate current review management of children's
asthma in one primary care trust and to consider the views of children, their parents/carers
and the role of the practice nurse in asthma care in one primary care trust (Lyte et al2005).

For the purpose of this research Lyte et al(2005) used purposive sampling to gather
information. Craig & Smyth (2007) suggests there are various methods can be applied to data
collection. Lyte et al(2005) used interviews, observations and reviews of available
documentation regarding asthma (Artefactual). In using this type of sampling the researchers
can be specific on the groups they wanted to target. However they may be an element of bias
as the practice nurse selected the parents and children for this research. To strengthen the
research the researchers used triangulated methods for data collection. According to Craig &
Smyth (2007) the theory behind triangulation if multiple sources, methods, investigators or
theories provide similar findings their creditability is strengthened.

The study was approved by the Local Research Ethics Committee and the University's Senate
Ethics Committee. Throughout the research during the data collection consent was treated as
an ongoing process. However there was difficulty in communicating with children. To solve
this problem, when meeting with the children the researchers would go through the informed
consent and voluntary participation again. Confidentially of all participants were protected
and guaranteed by the Data Protection Act.

Children expressed a wish to participate and share information in the research (Lyte et al
2005). However some children felt through the research of not being involved. Lyte et al
(2005) suggested it is the child's personality that determines how much response the practice
nurse receives. It is often said good communication in nursing is crucial and is the foundation
of building trust and encourages children to seek advice. It is important to communicate with
children appropriately to match the stage of development (The Common Core of Skills &
Knowledge 2010). Ultimately effective communication allows for the exchange of
information, needs and preferences of the patient between herself and the patient (The
Common Core of Skills & Knowledge 2010). However Hobbs (1995) suggests that some
practice nurses may not have the training in regarding complexities of caring for children and
their families. One cannot deny that it is important for practitioners to have the appropriate
training (Alderson 2000) because children have equal rights to contribute to their care as well
as adults (Save the Children 1997).

It was noted that children did not have sufficient knowledge about asthma. Furthermore
parents and children highlighted that there was insufficient information on asthma in the
primary care setting. For children and adults to make informed choices regarding their asthma
they require having up to date information to help them in making decisions. Equally in one
practice it was identify that the practice nurse lack confidence in caring for children with
asthma and Hobbs (1995) confirms this lack of confidence and points out that practice nurses
deal with arrange of illnesses.

Parents and children in the study both agreed that one area for improvement was the waiting
room (Lyte 2005). Some children may find going to the doctor a very frightening experience.
The first expression needs to be reassuring and non-threatening. (Making Your Waiting
Room Kid-Friendly 2006). The waiting room should be child friendly and also have books,
television/video for older children. With today's technology many children use computers in
the classroom. Some computer programs are touch-screen driven, making them friendly to all
levels. Providing a computer in the waiting room may be ideal opportunity to encourage
children to show off their technical skills by accessing the computer for health-related
information (Making Your Waiting Room Kid-Friendly 2006).

It might be concluded from this research the strengths outweigh the weaknesses, despite the
research being conducted in one primary care trust. The most satisfactory conclusion that can
come from this, to facilitate children and parents a comprehensive package of care needs to
be put in place in order to manage their asthma effectively.

References

Burns N, Grove S, (2007). Understand Nursing Research, Building an Evidence-

BasedPractice. Fourth Ed

Craig J V, Smyth R L (eds). (2007). The Evidence-Based Practice Manual for Nurses. China:
Churchhill Livingstone Elsevier.

Leach M J (2006). Evidence -based practice: A framework for clinical practice and research
design. International Journal of Nursing Practice. 12, pp 248-251

Lyte, Milnes, Keating & Finke 2007. Review management for children with asthma in
primary care: a qualitative case study.Journal of Nursing and Healthcare of Chronic Illness in
association with Journal of Clinical Nursing 16, 7b, pp123-132

Melnyk, Mazurek , Fineout-Overholt, Ellen, Stillwell, Susan, Williamson, (2010). Evidence-

Based Practice: Step by Step: The Seven Steps of Evidence-Based Practice. AJN, American
Journal of Nursing: January 2010 - Volume 110 - Issue 1 - pp 51-53

Mishoe SC, Baker RR, Poole S, Harrell LM, Arrant CB & Rupp NT (1998). Development of
an instrument to assess stress levels and quality of life in children with asthma.Journal of
Asthma 35, 553-563.