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Transparent clinical decision making process

Introduction

This paper explores the concept of Evidence Based Practice (EBP) in depth by exploring its meanings, detailing its origins, as well as describing its current application within the healthcare system of the UK. More specifically, it narrows in on the application of EBP in nursing and its applications in creating viable interventions. The paper also provides a sample of an evidence critique to demonstrate how to identify the “best evidence” as well as its subsequent implementation in daily nursing practice. Finally, it discusses how to implement EBP in nursing practice.

Background to EBP

“Evidence Based Practice” has appeared as a common term in modern healthcare and has been receiving increased attention from individual researchers and institutions over the past few decades. To explore the nature of EBP, it is imperative to consider the origins of the idea. According to Fowler (2001), EBP emerged from Evidence-based medicine; a concept that primarily took off in the 1990s despite being developed in the 1970s for improving clinical practice. The prime and most common definition of evidence-based medicine remains as “the conscientious, explicit and judicious use of current best evidence about the care of individual patients” (Sackett, et al., 1997, p. 2). The concept was then applied to the whole of the healthcare profession where it came to be labelled as evidence-based healthcare which “takes account of evidence at a population level as well as encompassing interventions concerned with the organisation and delivery of health care” (Silagy & Haines, 1998). EBP resulted from a synthesis of the aforementioned concepts and can be defined as “the process of creating a work environment that enables the job to be done effectively by consciously and explicitly integrating professional expertise, informed patient choice, and the best available evidence” (Fowler, 2001, p. 94). In this case, it becomes clear that EBP not only involves evidence but an amalgamation of excellent clinical skills and consideration of the client’s context.

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Currently, EBP is a well-acknowledged concept at both global level with institutions such as the World Health Organisation (WHO) labelling it as a pivotal element in contemporary healthcare practice (WHO, 2014). In England, the National Health Service (NHS) - one of the largest and oldest healthcare system globally – also acknowledges the value of EBP in healthcare practice. It is regarded as an integral component towards the provision of quality, effective and patient-centred care as stipulated in the NHS executive policy guidelines (Brún, 2013). The purpose of EBP is expounded in the following section.

The importance of this examination is also informed by insights gained from the sick city hypothesis. According to the hypothesis, urban population health is poorer when compared to the rest of the national population (Townsend et al. 2012). With this trend, it becomes imperative to examine some of the major risk factors associated with conditions such as CHD in contexts such as Leytonstone Ward. The hypothesis states further that big cities tend to be environmentally less friendly, pedestrian less friendly, motor-vehicle dependent, and spatially vast or disconnected. On the other hand, small cities are documented to be more pedestrian-friendly, connected, compact, and less pollutant. According to the Department of Health (2012), these characterised posed by the sick city hypothesis reflect on the health statuses and outcomes of residents living in big and small cities. The following figure indicates a comparison of indicators in which urban-based settings tend to perform poorly when compared to the national average.

Significance of EBP in Contemporary Nursing Practice in the UK

The main purpose of EBP is to generally use already existing knowledge to ensure the most effective outcomes in clients. More specifically, Cluett (2008, p. 35) asserts that EBP is aimed at “doing the right thing, at the right time and for the right person.” EBP allows clinicians to assess ideas, practices and preceding experiences and learn from them to apply to future practice. Consequently, this has seen health professionals change from a culture of delivering care based on conventional techniques that relied solely on pathophysiological criteria, authority, intuition, and limited experience, to one where clinical judgments are made on the basis of best evidence (Leach, 2006). In essence, EBP is purposed to reinforce, and not replace clinical experience and judgment. There is a general consensus that EBP aids in the creation of a more transparent clinical decision-making process (Sackett, et al., 1997; Achterberg, et al., 2008). According to Sackett et al. (1997), EBP increases accountability in the decision-making; although the process may be associated with increased scrutiny, it is likely to ensure better care service for consumers. According to Bennett & Bennett (2000), the ever-changing nature of treatments increases client expectations and large volumes of research data have placed a large load on clinicians in providing effective service. In this case, EBP challenges the current procedures and accelerates the incorporation of modern and more effective interventions into healthcare practice. Additionally, adoption of EBP allows for the proper use of already existing resources. However, Grol & Wensing (2002) noted that in order for healthcare personnel to utilise EBP in providing better treatment, they must be well-informed and motivated.

EBP is deemed as a valuable to the clients through several benefits. According to Leach (2006), the concept allows reductions in the risk of medical errors and patient mortality and improves the quality of care hence improving client outcomes. Moreover, Reynolds (2000) assert that EBP may also be cost saving due to the provision of efficient interventions that reduce unnecessary treatments. Despite the assertions of cost effectiveness, Sacket (1996) asserts that the best way to find out a cost is through cost-benefit analysis. In the case of cases where several disparate departments in healthcare are required to develop an intervention, the application of EPB has been labelled as a viable method to improve patient outcomes (Rolfe, et al., 2008). The lack of application of an EBP approach may cause long delays in the implementation healthcare plans necessary to contribute to positive patient outcomes (Grol & Wensing, 2004). The use of research data allows easier incorporation of innovative strategies as well as the integration of multiple intervention strategies without increasing the risk of experiencing adverse outcomes.

EBP plays and important role in maintaining the credibility of the nursing profession. In a study by Romyn et al. (2003), failure of nursing professionals to utilise EBP may lead to isolation from the rest of the multi-disciplinary healthcare team thus may not confidently continue practicing their clinical skills. In the UK, the National Health Service (NHS) (2014) asserts that the use of evidence primarily fosters a learning culture and a collaborative working environment that allows dynamism within the workplace. Additionally, it accentuates the importance of research in health and social care. It is based on assessing what is done or already experienced, and uses the knowledge obtained to make clinical judgements. In this case, EBP is integrated is part of the healthcare system in the country.

Despite its significance, EBO has come under criticism due to various reasons. Yet, most of these arguments do not hold water. To begin with, the concept has been cited to be rooted in the positivist philosophy. Critics have cited that this reductionist approach often has major shortcomings in addressing complex client situations (Lin, et al., 2014). Additionally, there is the common belief that empirical investigations (Brún, 2013), or hard science (Leach, 2006), such as RCTs, are more valid as evidence than other sources. However, the belief is a misconception since other qualitative methods may be more effective in answering subjective questions about patient outlooks, experiences, predictions, and diagnoses. Rycroft -Malone et al. (2004) present the argument might be viewed against the evidence accepted in EBP and not the model itself. Therefore, it is recommended that the evidence adopted should be congruent to the research question.

Therefore, the challenges presented in practicing EBP are relatively less important about its benefits. EBP continues to be a useful scientific framework to improve on healthcare in multiple fields. The integration of research into practice ensures a relatively dynamic and contemporary healthcare system that ensures numerous benefits to the healthcare providers, clinicians, and clients of the medical services.

Critique

Critical appraisal is among the main processes of identifying the best evidence to be considered for clinical decision making. It is defined as “the process of carefully and systematically examining research to determine its trustworthiness, value and relevance in a particular setting” (NHS, 2015). According to Sackett et al. (1997), critical appraisal is a two-step process that involves (1) deciding whether the information is valid, and (2) deciding if the information is clinically relevant. In recent years, several checklists have been developed to evaluate published studies and reports. They are provide a sequence of key questions that can help the practitioner institute the cogency and medical practicality of an item's results (Bennett & Bennett, 2000). It is typically designed to be sued with various research methodologies. The Critical Appraisal Skills Programme (CASP) (2013) checklist is among one of the most recognised instruments used in appraising evidence (NHS, 2015). It is endorsed by the NHS as a valuable tool in filtering evidence to ensure the best evidence for health practitioners is obtained (NHS, 2015). In this case, the CASP tool was used to analyse an RCT; “A randomized controlled trial of a nurse-led case management programme for hospital-discharged older adults with co-morbidities” by Chow & Wong (2014).

Screening Questions

  1. Did the trial address a clearly focused issue? The trial addressed a clearly focused issue as stated in its title. The aim of the research was to investigate the effects of nurse-led management programmes for hospital-discharged older adults with comorbidities. The thesis statement is well-articulated to summarise the relevance of the topic, as well as the nature of the investigation being carried out.
  2. Was this an RCT and was it appropriately so? The authors clearly state that the research design adopted was a randomised controlled trial involving three different patient groups obtained from the sample population and followed up for a period of three months from August 2010–June 2012. Ethics were considered as the study was approved by the Research Ethics Committees of the university and the study hospital as the researchers. Additionally, the researchers excluded patients suffering from cognitive illnesses from the sample and sought caregiver consent before inclusion into the RCT. According to Akobeng (2005), an RCT is “a type of study in which participants are randomly given one of two or more clinical interventions and the groups followed up for a specified period.” It is often characterised by a very rigorous methodology that eliminates the possibility of bias. In this case, Chow & Yong show that the RCT methodology was followed thus the RCT was appropriately so.
  3. Methodology

  4. Were participants appropriately allocated to intervention and control groups? The positivist paradigm asserts that studies follow an empirical approach that includes application of mathematics and statistics in carrying out tests, modelling, and testing environments for proving a theory (Keele, 2012). The participants were allocated to two intervention groups and one control group using random computer-generated numbers in an equal ratio 1:1:1. However, the numbers were not equal as the researcher was able to get a ratio of 96:108:108. This was carried out until all the baseline data was completed. However, participants were selected from a single hospital thus decreasing the transferability of the study to other settings.
  5. Were participants, staff and study personnel “blind” to participants study group? Chow & Yang (2014) state that all participants and data collectors (questionnaires were administered) were blinded on the group allocations. The authors do not report any cases of observer bias. In this regard, the researchers made significant effort mitigate the probability of bias.
  6. Were all patients accounted for? The RCT sample was randomly selected from the medical department of a general hospital. The researchers assert that their research was ingrained with the CONSORT 2010 statement in the design and implementation of the RCT. It was carried out on the outpatient and ward settings in practical clinical situations and all elements including study protocols, patient recruitment, blinding, interventions, participant drop-outs and patient confidentiality were monitored by the researchers. The researcher reported 31 patients lost during the follow-up.
  7. Did the study have enough participants to minimise the play of chance? The study had enough participant to minimise the play of chance; the researcher used alpha and power calculations tome up with the ideal sample size. Although the sample size of the study was deemed as sufficient, the research did not consider the mixed probabilities of such interventions outside the present setting. However, this may be attributed to the fact that the RCT was the first of its kind in clinical history and therefore had no existing reference standards.
  8. Results

  9. How large was the treatment effect? Data analysis was carried out via the Statistical Package Social Sciences (version 19) where the Kruskal-Wallis test and the Chi-square test were used to analyse baseline data for continuous and categorical variables. Measures of variance (ANOVA) were also carried out to investigate the differences in clinical readmission, self-efficacy perceived health and the quality of life (QOL) among the participants and determined the size effects of the RCT. Analysis were based on the intention-to-treat approach. The results were presented in a tabular form which allows summarisation of rather bulky information.
  10. How precise are these results? The researchers set a significance level at P < 0.05 where all results obtained were subjected to the two-tailed tests. Moreover, paired t-tests were utilised to make comparisons in data among the three arms. Missing data as a result of follow-up were replaced by the group mean. In this regard, the researchers tried to be as statistically significant as possible.
  11. Relevance

  12. Were all important outcomes considered so the results can be applied? The research completed all outcomes of the research and concluded that nurse-led post-discharge interventions utilising approaches of empowerment were viable in providing effective outcomes for older patients with co-morbidities. The topic is relatively new and the findings provide valuable evidence that indicates that empowerment approaches utilised by the nurses can aid in improving client outcomes. The research was carried out in China, a relatively different locale from that of the UK. Brink et al. (2006) asserts that quantitative research designs such as RCTS tend to be procedural, neutral and empirical in their problem-solving process. However, given that the baseline considerations of the research are not congruent with those in different locales, the results may not be applicable in the UK. The researchers affirmed the need for further empirical investigations to confirm the relationship between self-efficacy, hospital readmission and quality of life in different settings. Overall, the RCT offered valuable insight on the role of nurses and patient collaboration in case management. The evidence may be used in the UK as a stepping stone to begin follow-up studies related to the topic in the UK to come up with a contextualised solution to the proposed intervention.

Implementation of EBP

Although the field of EBP has been rising widely and given gold standard status in various healthcare systems, there has been a great deal of confusion in the implementation of evidence in practice. In a study done by Rolfe et al. (2006) to investigate the perspectives of nurses on EBP, the authors found out that nurses in the UK relied little on quality evidence. Worse still, several studies have found out that nurses use relatively low-quality evidence in the contemporary age of the internet (Keele, 2012). Achterberg et al. (2008) also cite complexity, time needed, costs, and risks in implementation evidence into practice. Complexities arise from situations which require nurses’ reliance on conventional medical practice despite the existence of evidence. According to Cluett (2008), this claim can be addressed by the fact that EBP is a considered as a concept consisting of professional expertise, informed patient choice, and the best available evidence. Arguing only in terms of evidence limits the role of the nurse in his/her professional practice The scarcity of high quality, lucid and dependable scientific evidence in nursing also presents difficulties for nurses who engage in EBP (Brún, 2013). These interrelated factors often cause formidable barriers for practitioners willing to integrate EBP. Several measures to eliminate the barriers in EBP have been developed. According to Lin et al. (2014), effectively putting evidence into practice requires appropriate communication, teamwork, funding and inclusion of all stakeholders. In their views, the authors assert that EBP principles should be initiated by educators when teaching students about EBP. This would ensure that they possess the necessary skills and experience in practice and their experiences as future practitioners (Grol & Wensing, 2004). EBP should also be encouraged from administrative levels which include hospital managers and administrators in government level. This is well demonstrated in the UK where the National Institute for Health and Care Excellence (NICE) is mandated to provide national guidance and advice to improve health and social care (NICE, 2017).

Evidence based practice requires evidence based implementation. Achterberg et al. (2008) assert that the root of all the problems in initiating EBP is the lack of evidence regarding the implementation of EBP. Keele (2012) seconds this opinion stating that there is the need to link determinants of health to evidence-based strategies to formulate optimal plans. Common determinants consist of resources, organisation, social influences, routines, viewpoints, cognitions and knowledge. Additionally, there is a general consensus from various stakeholders -consumers, clinicians, associations and healthcare organizations (WHO, 2014; Brún, 2013) - within the nursing practise that the field of EBO implementation requires further research Therefore, the implementation of EBP in nursing not a straightforward process. It is a holistic process that needs to ensure that requires full participation from the nurses in valuing the role of scientific output. It also requires considering the role of determinants in bringing initiating successful changes in nursing practice. Support from various stakeholders from the level of educators to administrators has also been identified as a key point. Finally, research to grow the implementation of evidence based implementation of EBP is essential for innovative ways to increase the level of adoption of EBP in nursing practice.

Conclusion

The analysis above represents EBP as a concept that is still developing. It represents an amalgamation of the best available research and appropriate application at the right time and for the right person. Nurses and other clinicians are required to practice EBP in their routines for the sake of several benefits to stakeholders with them included. As a dynamic practice, EBP is not fully developed and requires additional research to support its justification and implementation.

References

Achterberg, T. v., Schoonhoven, L. & Grol, R., 2008. Nursing Implementation Science: How Evidence-Based Nursing Requires Evidence-Based Implementation. Journal of Nursing Scholarship, 40(4), pp. 302-310.

Akobeng, A. K., 2005. Understanding randomised controlled trials. Arch Dis Child, Volume 90, p. 840–844.

Bennett, S. & Bennett, J. W., 2000. The process of evidence-based practice in occupational therapy: Informing clinical decisions. Australian Occupational Therapy Journal, Volume 47, pp. 171-180.

Brún, C. D., 2013. Finding the Evidence: A key step in the information production process, London: The Information Standard Guide.

Chow, S. K. Y. & Wong, F. K. Y., 2014. A randomized controlled trial of a nurse-led case management programme for hospital-discharged older adults with co-morbidities. Journal of Advanced Nursing, 70(10), p. 2257–2271.

Cluett, E. R., 2008. Evidence-based practice. In: E. R. Cluett, ed. Principles and practice of research in midwifery. London: Churchill Livingstone, pp. 33-54.

Fowler, G., 2001. Evidence-based practice: Tools and techniques, Dublin: . Grol, R. & Wensing, M., 2004. What drives change? Barriers to and incentives for achieving evidence-based practice. Medical Journal of Australia, Volume 180, p. 8–12.

Keele, R., 2012. Nursing Research and Evidence-Based Practice. Las Cruces: Jones & Barlett Learning.

Leach, M. J., 2006. Evidence-based practice: A framework for clinical practice and research design. International Journal of Nursing Practice, Volume 2006, p. 248–251.

Lin, S. H., Murphy, S. L. & Robinson, J. C., 2014. Facilitating Evidence-Based Practice: Process, Strategies, and Resources. The American Journal of Occupational Therapy, Volume 64, pp. 164-171.

NHS, 2015. Critical Appraisal: A brief guide to resources for critical appraisal. [Online] A`vailable at: https://www.networks.nhs.uk/nhs-networks/nwas-library-and-information-service/critical-appraisal [Accessed 20 February 2017].

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Rolfe, G., Segrott, J. & Jordan, S., 2008. Tensions and contradictions in nurses' perspectives of evidence-based practice. Journal of Nursing Management, Volume 16, pp. 440-451.

Romyn, D., Allen, M., Boschma, G. & et al, 2003. The notion of evidence in evidence-based practice by the nursing philosophy working group. Journal of Professional Nursing, Volume 19, pp. 184-188.

Rycroft-Malone, J. et al., 2004. What counts as evidence in evidence-based practice?. Journal of Advanced Nursing, 47(1), p. 81–90.

Sackett, D. L. et al., 1996. Evidence-based medicine: what it is and what it isn't. British Medical Journal, Volume 312, p. 169–171.

Silagy, C. & Haines, A. eds., 1998. Evidence-Based Practice in Primary Care. London: BMJ. Stokke, K., Olsen, N. R., Espehaug, B. & Nortvedt, M. W., 2014. Evidence based practice beliefs and implementation among nurses: a cross-sectional study. BioMed Central, 13(8).


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