Applying research to practice and introducing change - Essay Example

Chris Moysey Professional Nursing 135-C (Write your Prof. D. Maddox (Write your teacher's June 14, 2006 From Research to Practice and Change Re: Isotretinoin and Depression If research were to inform practice using recent research findings, then it is at best evidence-based. Research informing practice, in fact, is a current issue in nursing that led to the conceptualization of evidence-based nursing (Drury, 1998). Applying research findings to practice can result in improved patients' outcomes and satisfaction (Endrawes, 2000). The path towards this, however, can be very difficult but expedient (McCarty, Edmundson, Jr. and Hartnett, n.d.). Nurses who are able to use research to inform their practice may enhance the professional status of nursing, and advance nursing knowledge. (Endrawes, 2000). Much preparation and patience, however, are required, paying attention to factors that facilitate the adoption of desired practices. Accordingly, if there are barriers in this end, clinicians can embrace such barriers, learn from their failure, and continue on to nourish their skills (McCarty, Edmundson, Jr. and Tim Hartnett, n.d.). This paper is an offshoot of Moysey's (2006) study on Roaccutane (Isotretinoin) and Depression. It details barriers to applying research to practice, suggests practical alternative strategies for disseminating research knowledge, then explores strategies that can facilitate the introduction of change into the clinical area and finally, give an analysis of the role of change agent as applied to Isotretinoin. Barriers to applying research to practice A study by Bostrom, MacDougall, and Hargis (1989) found that a large group of nurses without degrees showed less interest in research and for them research is not an important activity for nurses. According to these authors, this is related to the fact that the majority of the current undergraduate courses include more research subjects in their curriculum now than offered in the past. Fear of the unknown also prevents nurses from exploring new ideas and change in their practice. Accordingly, the nurses' lack of motivation for change was due to their lack of authority to change practice and lack of organizational support - virtually the same organizational reasons mentioned by Funk et al. (1991). Funk (1991) and his team of researchers investigated the barriers that practicing nurses perceived to their using research findings in practice. They came up with 18 barriers as reported by 50% or more of the respondents. Most of these barriers are organizational like lack of cooperation, but others are on the attributes of the research, itself, and the condition of the nurse. Of the latest, the following are stated as barriers, mentioned in descending order: Nurse is unaware of the research (74.7%), Nurse does not have time to read research (67.2%), Nurse is isolated from knowledgeable colleagues with whom to discuss research (65.2%), Nurse does not feel capable of evaluating research quality (59.3%), and Nurse feels benefits of changing practice will be minimal (51.8%). As regards research, in descending order, the following are perceived barriers by nurses: Results not generalizeable to own setting (68.3%), Statistical analyses not understandable (67.8%), Relevant literature not compiled in one place (63.1%), Implications for practice not made clear (61.5%), Research has not been replicated (56.1%), Research not reported clearly and readably (53.6%), and Research not relevant to nurse's practice (53.5%). Organizational factors mainly point to lack of cooperation and problems in implementation. Table 1 shows the summary of the perceived barriers. Table 1. Perceived Barriers by Nurses to Use of Research Findings (Funk et al., 1991) 1 Not enough authority to change patient care procedures 75.2% 2 Insufficient time to implement new ideas 75.1% 3 Nurse is unaware of the research 74.7% 4 Physicians will not cooperate with implementation 71.2% 5 Administration will not allow implementation 70.6% 6 Other staff are not supportive of implementation 70.5% 7 Results not generalizeable to own setting 68.3% 8 Facilities inadequate for implementation 67.9% 9 Statistical analyses not understandable 67.8% 10 Nurse does not have time to read research 67.2% 11 Nurse isolated from knowledgeable colleagues with whom to discuss research 65.2% 12 Relevant literature not compiled in one place 63.1% 13 Implications for practice not made clear 61.5% 14 Nurse does not feel capable of evaluating research quality 59.3% 15 Research has not been replicated 56.1% 16 Research not reported clearly and readably 53.6% 17 Research not relevant to nurse's practice 53.5% 18 Nurse feels benefits of changing practice will be minimal 51.8% Outside of Funk's et al. (1991) study, Poster et al. (1992) found that 25% of psychiatric nurses were not interested in reading professional journals regularly, 81% reported that they have never published an article, and almost 50% expressed spending less than 10% of their nursing time in research. Poster et al. (1992) attributed this attitude to lack of time, lack of knowledge and lack of administrative support, which were considered major barriers to the conduct of research. alternative strategies for disseminating research knowledge Strategies that can counter these barriers mentioned so that one may be able to disseminate knowledge may include research, collaboration, mentorship, educational sessions, reading, reaching various media, and writing. Research. One of the best means of being able to disseminate research knowledge is for the nurse, herself, to engage in research (Govoni and Pierce, 1997; Hicks, 1995, Mottola, 1996, and Tierney and Taylor, 1991). As such, she would have first hand knowledge about her topic, giving her competitive advantage, which can help inform her practice. Collaboration. Bridging the gap between nursing research and nursing practice requires collaboration between both the nurse researcher and the nurse practitioner (Govoni and Pierce, 1997; Tierney and Taylor, 1991). Both practitioner nurse and academic nurse, from this approach, can learn from each other. Mentorship. The use of mentorship and role modelling can play a role in changing nurses' attitudes towards the conduct and use of research (Poster et al., 1992). By example, nurses can also teach peer nurses what they know. Educational sessions. Endrawes (2000) recommends that nurses provide educational sessions to fellow nurses in the areas of research skills and writing for publication. Reading. If unable to conduct research, nurses should at least read research articles and be open to new ideas. According to Akinsanya. (1993), majority of research disseminated in journals is not read by the practicing clinician. Reaching various media. Nurses need to write and speak in various media to reach the public as well as policy makers. These strategies can disseminate research findings more widely, and enhance the possibility that others will use the knowledge. Health promotion research can teach the public applications that cultivate personal habits and practices (Endrawes 2000). Writing to disseminate. Disseminating the findings of systematic reviews to policymakers, health professionals, and consumers is an essential to changing practices (Garner et al. 1998). If nurses can cultivate their writing skills, they can add to the pool of writers of society. introducing change into clinical area: the Isotreinoin case Background knowledge. A different barrier was mentioned by Garner et al. (1998) who observed that large obstacles impede the implementation of evidence-based practices such as the unethical promotion of drugs. Such problems, they said, are gargantuan that they need to be addressed by regulation (Garner et al. 1998). In the case of isotretinoin, this issue is important in light of what a nurse as change agent can probably do. As mentioned by Moysey (2006), the Food and Drug Administration (FDA) required Hoffman-La Roche, the manufacturers of Isotretinoin, to include precautions on possible adverse effects on their labels which they did (Ng et al., 2001). These were part of their management of risks. The promotion part on Isotretinoin, however, was left touched because findings of it being linked to depression were inconclusive (Advice, BAD, 2005). Despite the adverse drug reaction reports on this drug (ADRAC, 1998; Wysowski et al., 2001) the British Association of Dermatologists (Advice, BAD, 2005) has been writing about possible psychiatric effects on their labels, but are including in their conclusion that whether isotretinoin can produce mood change or not is still unproven. At least this balances off whatever promotion is there on the drug. To date, regulation on Isotretinoin took the following forms: Despite the lack of any definitive causal link, the response of the Food and Drug Administration (FDA) has been to honour the reported incidents of depression and suicide as side effects of Isotretinoin use. Several precautions have been taken by both the FDA and the manufacturer Roche, to inform potential consumers of the psychiatric risks (Ng 2002). An "informed consent" form is currently provided to all patients prescribed Isotretinoin, serving the dual purpose of informing the consumer and doctor at the same time protecting Roche from liability (Roaccutane, LEDA 2005). Failure to warn is the major basis of liability for manufacturers of prescription drugs and medical devices. Insuring that the patient has been informed of all the risks, the informed consent form then protects both the doctors and the manufactures from liability. Moreover, another requirement of the FDA was the published "advice on the use of Isotretinoin" (BAD, 2005). The current UK summary of product characteristics (SPC) from Roche (last reviewed January 2002) contains a warning that "Roaccutane (Isotretinoin) may cause depression, psychotic symptoms and rarely suicidal attempts and suicide. Particular care needs to be taken in patients with a history of depression and all patients should be monitored for signs of depression and referred for appropriate treatment if necessary" (Cotterill and Cunliffe 1997) Strategies in the clinical area. In sum, basic readings and research knowledge that any Isotretinoin nurse should be knowledgeable of are: 1) The informed consent form (Ng 2002) that patients of Isotretinoin should meaningfully fill up; 2) The published advice on the use of isotretinoin (BAD, 2005), the contents of which patients of isotretinoin should know; 3) Adverse drug reaction (ADR) reports (ADRAC 1998). The nurse can still go further to read, 4) Information on Isotretinoin from the Roche Drug Safety Database (1998 and onwards). Since action is required at all levels of healthcare systems, from consumers through to health professionals, ministries of health, and international organisations (Garner et al. 1998), whatever the nurse learns from here, she should apply in her practice. The Nurse as Change Agent with Isotretinoin Rogers (1995) defines change agents as "individuals who use their knowledge of the change process to influence decisions, thereby creating desirable change." Accordingly, the change agent seeks to "fully understand the individual or community, in a process of change (if any), and then use this knowledge to create focused goals and link together the most appropriate resources, technologies, and information available to achieve the needed change" (Katzenbach, 1996). The change agent helps in problem-solving, strategic planning, and change projects (Kaplan, 1990). My work is a cross between mental health and skin health where Isotretinoin is concerned. This is due to the nature of this drug. My study on Roaccutane (Isotretinoin) and Depression (Moysey, 2006) found that the dangerous side effects of isotretinoin use regarding psychiatric side effects including depression is inconclusive, despite several adverse reports sent to the Food and Drug Administration (FDA). The FDA preferred to honour these adverse reports but only required the manufacturer, Roche, to issue adequate information to the public of possible side effects. Against this backdrop, I carve my role as change agent. I knew for a fact that much of what was being said about Roaccutane or Isotretinoin being linked to depression have anecdotal evidences as reported by Ng et al. (2001). However, by the numbers, they are best anecdotal. The British Association of Dermatologists (BAD, 2005) had said 8000 subjects are required for a conclusive study to detect depression. In my study on Isotretinoin and Depression (Moysey, 2006), I had stated that no matter how many adverse drug reaction reports (ADRs) suggest a link between isotretinoin and depression, if it cannot be validated by tenable research as well as by clinical practice, it cannot be safely concluded that there indeed is a link or association. I would say this again at this point. Putting myself as change agent and to effect changes in my work, I would do the following - First, I should be armed with correct information regarding Isotretinoin. The basic literature should include history of isotretinoin, the cases, the reported adverse effects, the Accutane Hearings of Congress, and everything related to contentions on this drug so that I could tell facts from perception or opinion. From my research, I believe I am armed with enough vital information that I can apply and disseminate as I come in contact with Isotretinoin patients. If ever I should prescribe Isotretinoin, I should follow the clinical guidelines as required by the Food and Drug Administration (BAD, 2005) and would encourage my peers as follows - i) A direct enquiry about previous psychiatric health should be made of all patients who are being considered for isotretinoin and the facts recorded fully in the notes. ii) All patients, and their parents in the case of minors and adolescents, should be made aware of the potential for mood change in a realistic, non-judgmental way, and should be advised to ask their family and friends to comment if such change should occur. iii) Direct enquiry about psychological symptoms should be made at each clinic visit. Second, and as recommended by Halstead et al. (2005), I could develop networks, collaborations, and partnerships to enhance my nursing influence within the community and disseminate knowledge regarding this drug to various audiences and through diverse means. In this regard, I can use my network of friends, acquaintances, and family. Third, I should devote time to reading current research findings and exhibit a spirit of inquiry or a commitment to life-long learning. At this point, Roaccutane or Isotretinoin is not considered linked to depression conclusively. In the future, however, should there be positive findings, I should not hesitate to change my views and thereby act accordingly. In my own little way, I would use feedback gained from peer, student, and administrative evaluation to improve the effectiveness of my role as nurse. There are so many ways of using information if one keeps an eye to the meaning of real health. Health is what should motivate all my clinical actions and I would encourage others as well, in relation to isotretinoin - not the lopsided version of having a smooth face as a result of isotretinoin, but inwardly one is suffering from some unknown pain as those reported in adverse drug reports (Ng et al. 2001). I know that with this drug, it is not a matter of taking sides regardless of who has the upperhand in advertisements. Unethical promotion of drugs can have the effect of drowning one's perspective if one is not careful enough to read research updates. In fact, this is the barrier warned of earlier by Garner et al. (1998). In trying to respond to the barriers mentioned in the Funk et al.'s (1991) study, I would do my best to be aware of research, have time to read them, be knowledgeable of evaluating research quality, and feel that changing practice can have benefits. By doing these to the best of my ability, I can also effect change. Works Cited "Advice on the Safe Introduction and Continued Use of Isotretinoin in Acne." Clinical Guidelines. British Association of Dermatologists (BAD). 01 Oct 2005. http://www.bad.org.uk/healthcare/guidelines/acne.asp. "Roaccutane (isotretinoin) and depression." LEDA at Harvard Law School. 02 Oct 2005. http://leda.law.harvard.edu/leda/data/594/Lee.html. Adverse Drug Reactions Advisory Committee (ADRAC). "Depression and Isotretinoin." Australian adverse drug reactions bulletin. 1998. 17. 11. 515 - 519. Bostrom, A. C., M. Malnight, J. MacDougall, and D. Hargis. "Staff Nurses' Attitudes toward Nursing Research: a Descriptive Survey." Journal of Advanced Nursing, 1989. 915-922. Cotterill, J. and W.J. Cunliffe. "Suicide in Dermatological Patients." British Journal of Dermatology 137, issue 2, 1997, 246-250. Drury, Peta. "Barriers to Evidenced-based Nursing Care: Listen to the Clinicians!" Nursing Monograph. St Vincent's Healthcare Campus, 1998. 14 Jun. 2006 . Endrawes, Gihane. "Research Informing Practice." Central Sydney Area Mental Health (CSAMHS) Winter Symposium, Jul 2000. ISBN 1 876147 20 2. 14 Jun. 2006 . Funk, S.G., M.T Champagne, R.A.Wiese and E.M. Tornquist. "Barriers to Using Research Findings in Practice: The Clinician's Perspective." 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"Charting a Path between Research and Practice in Alcoholism Treatment." National Institute of Alcohol Abuse and Alcoholism. 14 Jun. 2006 . Mottola, C. A. "Research utilization and the Continuing/Staff Development Educator." The Journal of Continuing Education in Nursing, 1996, 27, 168-175. Ng, C.H., M.M.Tam, and S.J. Hook. "Acne, Isotretinoin Treatment and Acute Depression." Work Journal of Biological Psychiatry, 2001. 2. 159 - 161. Poster, E. C., C.L. Betz, and B. Randell. "Psychiatric Nurses' Attitudes Towards and Involvement in Nursing Research." Journal of Psychosocial Nursing, 1992, 30, 26-29. Rogers, E. Diffusion of innovations. New York: Free Press, 1995. Tierney, A. J. and J. Taylor. "Research in practice: an 'experiment' in researcher- practitioner collaboration." Journal of Advanced Nursing, 1991, 16, 506-510. Wysowski, D.K, M. Pitts, and J. Beitz. An analysis of reports of depression and suicide in patients treated with isotretinoin. Journal of the American Academy of Dermatology, 2001. 45. Read More