Evidence for Professional Practice - Essay Example

SUDIPTAMOY MALLICK DEC 14TH ,2008 Topic Apprisal of Evidence for Professional practice. Evidence based practice is an approach which tries to specify the way in which professionals or other decision-makers should make decisions by identifying evidence , rating it according to its scientific merit based , on qualitative and quatitative analysis. Its goal is to eliminate unsound or excessively risky practices in favour of those that have better outcomes. "Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings. The practice of Evidence-Based Practice includes five fundamental steps. Step 1: Formulating a well-built question Step 2: Identifying articles and other evidence-based resources that answer the question Step 3: Critically appraising the evidence to assess its validity Step 4: Applying the evidence Step 5: Re-evaluating the application "(http://www.lib.umn.edu/, Lesson 1 , page 1) EBP utilises various methods to encourage, professionals and other decision-makers to critically analyse evidence that help them make right decision. Where EBP is applied, it encourages professionals to use the best evidence possible, i.e. the most appropriate information available. For example, in medicine, it is used to make clinical decisions for individual patients. " Evidence-based is one of the most used , and perhaps least understood adjective in heathcare toaday. It was previously applied almost exclusively in the term evidence based medicine , but happily terms such as 'evidence based practice' are becoming more widespread Nurses , the largest group of professionals , who provide health care , have been at the forefront in recognising the need to identify, evaluate & apply test practices to their clinical practice. (Craig J, Smyth R , Preface , page 14) " Evidence based practice involves systematically finding , appraising and using research evidence as the basic for clinical decision making" (Alison Brettle, Maria J. Grant, page 1.) What is the imporatnce of EBP Why the necessity for adoption of EBP arose Evidence-based practice is a philosophical approach that is in opposition to rules of thumb, folklore, and tradition. Examples of a reliance on "the way it was always done" can be found in almost every profession, even when those practices are contradicted by new and better information. " Evidence based practice has been described as 'doing the right things right', ( Murir Gray 1997, page 18 ) .we need the evidence base to know what is 'right' to do , .if we can get it right , evidence-based approach will help to improve people's experiences of illness and health care , and good established nursing practices already does". (Craig J, Smyth R, Page 4- The context for EBP ) The theories of evidence based practice are becoming more commonplace in the nursing care. Nurses who are "baccalaureate prepared are expected to seek out and collaborate with other types of nurses to demonstrate the positives of a practice that is based on evidence. "Looking at a few types of articles to examine how this type of practice has influenced the standard of care is important but rarely internally valid. None of the articles specify what their biases are. Evidence based practice has gotten its reputation by examining the reasons why any and all procedures, treatments, and medicines are given. This is important for refining practice so the goal of assuring patient safety is met.(Duffy P, Fisher C, Munroe D) Evidence-based practice is defined in medicine as 'the integration of best research evidence with clinical expertise and patient values'(Itzia J, Wood N.) Another author(Ailinger RL, Harper D, Lasus H. ) defines evidence-based practice in nursing as 'the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences'. Finally(Silva MC, Cary AH, Thaiss C. ), note that 'evidenced-based practice builds on the nursing literature of research utilization by adding other forms of evidence that can be used in making clinical decisions'. The appraisal of evidence is the most important in EBP . The research involves both qualitative and quantitative aspects. Both the qualitative and quntitative aprroaches are essential for critically appraise an evidence. "The recent focus on evidence-based practice has had a positive influence on clinical practice. The increase in number of well done quantitative research studies has helped to answer clinical questions such as whether one intervention is better than another and by how much. However, much of the practice of medicine and physical therapy is more than a science, it is also an art. For some clinical questions, qualitative research is a better or complimentary approach for obtaining information. If we accept the principles underlying the scientific method, the natural response is to consider quantitative research as objective and qualitative research as subjective. Quantitative research and evidence-based practice presumes an underlying belief in the strength of the scientific method and an acceptance that the deductive process is the ideal method for determining best practice. Qualitative research, using the inductive process, should not be considered a lesser source of evidence on which to base clinical care. Rather, qualitative research provides a different type of evidence, designed to answer clinically relevant questions that cannot be answered with numbers alone. Qualitative researchers seek answers beyond numbers; they seek to understand behaviors, attitudes, and beliefs. They try to "study things in their natural setting, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them.( Scherer, Susan, LaPier, Tanya Kinney) "Qualitative research makes important contributions to the quality of evidence-based practice. Because evidence-based practice is a growing phenomenon in nursing, qualitative research, alone or in combination with quantitative research, helps make visible nurses' goals to provide the best health care within an often fiscally constrained environment. Qualitative research dates back to the 1920s and 1930s when anthropologists and sociologists made inquiries into human groups. As part of their inquiries,social science researchers developed various research methods to study human phenomena, usually in a naturalistic setting and from a holistic viewpoint. Later, other disciplines, including nursing, political science and education, adopted qualitative methods to answer their research questions(Denzin NK, Lincoln YS. Handbook of qualitative research. Sage: Thousand Oaks; 2000.)" (Ailinger RL.) There are some interesting examples that show the importance of both qualitative & quantitative analysis in efficient adoption of EBP. Sitzia & Wood(Sitzia J, Wood N.), for example, reported on the development of an instrument to assess patient satisfaction with chemotherapy treatment. They analyzed quantitative and qualitative data from 173 completed questionnaires to develop the Worthing Chemotherapy Satisfaction Questionnaire. Their qualitative data helped to establish content validity of the instrument. A second example is the development of the Facts on Osteoporosis Quiz, which was based on a review of the qualitative report of the National Institutes of Health consensus conference on osteoporosis(Ailinger RL, Harper D, Lasus H.) When evidence-based practice is implemented, an evaluation of the practice is needed. Usually this evaluation is done in anticipation of adopting the practice change. The evaluation should include process as well as outcome. The outcome may be described both quantitatively and qualitatively; however, the process is usually described qualitatively. For example, recently, a groundbreaking article in the Journal of the American Medical Association was published about breast cancer and women on hormone replacement therapy. Those women who received the estrogen-progestin regimen had a greater chance of breast cancer than those women who received estrogen alone(Schairer C, Lubin J, Troisi R, Sturgeon S, Brinton L, Hoover R. ). Although the quantitative study was sound, numerous qualitative questions related to this issue needed answers. For example, what happened to the women who read the study and then tried to make a decision about hormone replacement therapy What process did they use What concerns did they have Would a qualitative study make a difference in evidence-based practice related to hormone replacement therapy These were questions that qualitative nursing research could help answer.( Ailinger RL.) Let us chose the topic of adoption of hand hygiene as the case study for evidence based practice. The adoption of hand hygiene as a routine practice has phenomenally reduced the contamination rate in medical world and is on of the most important EBP in medical history. In average heath work conditions healthcare workers' hands become contaminated by pathogens after patient contact. When some easy and effective means of decontaminating hands were initiated between patient contacts , controlled trial evidence showed that hand-decontamination substantially reduces infection in many clinical settings. "The first clear evidence of clinical benefit from hand hygiene came from Semmelweis, working in the Great Hospital in Vienna in the 1840s.( Rotter ML. ) The hospital had two obstetric departments, and women were admitted alternately, whatever their clinical condition, to one or the other. In the first, they were attended by medical students who moved straight from the necropsy room to the delivery suite. In the second, they were attended by midwives and midwifery students who had no contact with the necropsy room. The incidence of maternal death was as high as 18% in the first department, with puerperal fever the main cause, but only 2% in the second. Semmelweis observed that a colleague died from an illness similar to puerperal fever after being accidentally cut during a necropsy. He concluded that the infecting particles responsible for puerperal fever came from cadavers and were transmitted by hand to women attended by medical students in the first department. He therefore instituted hand disinfection with chlorinated lime for those leaving the necropsy room, after which maternal morbidity in the first department fell to the levels achieved by the second department. In terms of experimental design Semmelweis conducted more than a pre and postintervention study; he performed, albeit inadvertently, a controlled trial. There is also an element of cross-over. The need to reduce infection and hospital-acquired antimicrobial resistance prompted a systematic review of handwashing by Thames Valley University as part of the EPIC study(Pratt RJ, Pellowe C, Liveday HP). This concluded that there was good evidence that direct patient contact resulted in hand contamination by pathogens. For example, 80% of staff dressing wounds infected with methicillin-resistant S. aureus (MRSA) carried the organism on their hands for up to 3 hours. Immediate washing with liquid soap and water virtually eradicates the organism (Peacock JE, Marsick FJ, Wenzel RP.)(Thompson RL, Cabezudo I, Wenzel RP). An intensive-therapy-unit study showed that 40% of all patient-nurse interactions resulted in samespecies transmission of Klebsiella to healthcare workers' hands, lasting up to 150 minutes, even after contact as slight as touching a patient's shoulder (Casewell M, Phillips I.) A study of healthcare workers' hands sampled within half an hour of contact with patients with Clostridium difficile infection showed samespecies contamination on nearly 60% of hands, even after activities as simple as returning drug charts to the end of beds. Washing with soap and water virtually eradicated the organism( (Samore MH, Venakartaraman L, De Girolami PC, et al.) The EPIC review showed that liquid (even non-medicated) soap and water effectively decontaminates hands, but that 70% alcohol or an alcohol-based antiseptic handrub provides the most effective decontamination for a wide variety of organisms (S. aureus, Pseudomonas aeruginosa, Klebsiella, rotavirus)( Ayliffe GA, Babb JR, Davies JG, et al. )(Bellamy K, Alcock R, Babb JR, et al.) Liquid soap and water, medicated or otherwise, comes into its own where there is physical soiling of the hands, but takes a full 90 seconds to apply in the manner recommended by EPIC . Alcohol handrubs take 10-20 seconds to apply (Voss A, Widmer AF.)and healthcare workers are thus more likely to comply. Indeed, while rubbing the solution into the hands one can be doing something else useful such as communicating with the patient. Time constraints have been identified by EPIC as one of the main barriers to regular handwashing, another being allergies to antiseptic preparations. Allergies are much less likely to arise with alcohol-glycerol preparations, which are now recommended by the Hand Hygiene (formerly Handwashing) Liaison Group for use between patient contacts (Stone S, Teare L, Cookson B.) The EPIC review provided evidence from trials of various designs in a wide range of settings-in particular enteric illness and intensive care-that hand washing reduces infection rates." (S P Stone, MD FRCP) There are several factors which are crucial to the success or failure of implementing evidence based practice related to hand hugeine as discussed below: Deployment of adequate resources devoted to Environmental Services/Housekeeping in all health care settings, including written procedures for cleaning and disinfection of client/patient/resident rooms and equipment; education of new cleaning staff and continuing education of all cleaning staff; and ongoing review of procedures. Promotion of a climate that is conducive to following and maintaining Routine Practices in all health care settings . This includes the set up and organization of the health care setting in order to provide a system that supports and promotes effective hand hygiene. Regular education (including orientation and continuing education) and support to help staff consistently implement appropriate infection prevention and control practices is provided in all health care settings. Effective education programs emphasizing the risks associated with infectious diseases; hand hygiene, including the use of alcohol-based hand rubs and hand washing; Regular education regarding principles and components of Routine Practices as well as additional transmission-based precautions1; Assessment of the risk of infection transmission and the appropriate use of personal protective equipment (PPE), including safe application, removal and disposal; Appropriate cleaning and/or disinfection of health care equipment, supplies and surfaces or items in the health care environment; Individual staff responsibility for keeping clients/patients/residents, themselves and co-workers safe; and Collaboration between professionals involved in occupational health and infection prevention and control. Presence of a process, where applicable, for evaluating personal protective equipment (PPE) in the health care setting, to ensure it meets quality standards. Regular assessment of the effectiveness of the infection prevention and control education program and its impact on practices in the health care setting. The information is used to further refine the program. (http://www.justcleanyourhands.ca/.,http://www.phac-aspc.gc.ca/publicat/ccdr- rmtc/99vol25/25s4/index.html.,http://www.pidac.ca/.) Works Cited Ailinger RL. " Contributions of qualitative research to evidence-based practice in nursing". Rev Latino-am Enfermagem 2003 maio-junho; 11(3):275-9. Ailinger RL, Harper D, Lasus H. "Bone up on osteoporosis: development of the facts on osteoporosis quiz". Orthop Nurs 1998; 17(5):66-73.) Ayliffe GA, Babb JR, Davies JG, et al. " Hand disinfection: a comparison of various agents in laboratory and ward studies". J Hosp Infection 1988;31: 923-8. Bellamy K, Alcock R, Babb JR, et al. "A test for the assessment of hygienic hand disinfection using rotavirus". J Hosp Infection 1993;24: 201-10.) Brettle Alison,Grant J Maria , , "Finding the Evidence for Practice: A Workbook for Health Professionals', Elsevier Health Sciences, 2005 Craig J, Smyth R (2007) "The evidence-based practice manual for nurses", Churchill Livingstone Casewell M, Phillips I. " Hands as a route of transmission for klebsiella species". BMJ 1977;2: 1315-17 [PubMed].) Duffy P, Fisher C, Munroe D (February 2008). "Nursing knowledge, skill, and attitudes related to evidenced based practice: Before or After Organizational Supports". MEDSURG Nursing 17 (1): 55-60. http://www.lib.umn.edu/),"Evidence based Practice" http://www.justcleanyourhands.ca/.,"Just Clean Your Hands" http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99vol25/25s4/index.html. http://www.pidac.ca/ Itzia J, Wood N. "Development and evaluation of a questionnaire to assess patient satisfaction with chemotherapy nursing care". Eur J Oncol Nurs 1999; 3(3):12642.). Peacock JE, Marsick FJ, Wenzel RP. " Methicillin resistant Staphylococcus aureus; introduction and spread within a hospital". Ann Intern Med 1980;93: 526-32 [PubMed]. Pratt RJ, Pellowe C, Liveday HP, et al. "The EPIC project: developing national evidence-based guidelines for preventing healthcare associated infections". J Hosp Infection 2001;47:(suppl. A). Rotter ML. " Semmelweis' sesquicentennial: a little noted anniversary of handwashing". Curr Opin Inf Dis 1998;11: 457-60. Schairer C, Lubin J, Troisi R, Sturgeon S, Brinton L, Hoover R. " Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk". J Am Med Assoc 2000; 283(4):485-91.). Scherer, Susan, LaPier, Tanya Kinney, "When numbers are not enough part I: Understanding qualitative research methods",Cardiopulmonary Physical Therapy Journal, Dec 2001 Silva MC, Cary AH, Thaiss C. " When students can't write: solutions through a writing-intensive nursing course". Nurse Health Care Perspect 1999; 20:142-5. Sitzia J, Wood N. " Development and evaluation of a questionnaire to assess patient satisfaction with chemotherapy nursing care". Eur J Oncol Nurs 1999; 3(3):12642.) Stone S, Teare L, Cookson B. "The guiding hands of our teachers [Letter]". Lancet 2001;357: 479-80. Stone, S P , MD FRCP Academic Department of Geriatric Medicine, Royal Free Campus, Royal Free and University College Medical School, London NW3 2PF, UK, "Hand hygiene-the case for evidence-based education".) Thompson RL, Cabezudo I, Wenzel RP. " Epidemiology of nosocomial infections caused by methicillin resistant Staphylococcus aureus". Ann Intern Med 1982;1987: 309-17.) Samore MH, Venakartaraman L, De Girolami PC, et al. "Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea". Am J Med 1996;100: 32-40 [PubMed]. Voss A, Widmer AF. " No time for handwashing Handwashing versus alcoholic handrub: can we afford 100% compliance"Infect Control Hosp Epidemiol; 1997;18: 205-8 [PubMed].) 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