Understanding Evidence Based Practice in Healthcare

Introduction

Evidence-based practice (EBP) is referred to the implementation of most effective research evidence with proper clinical expertise and patient values so that when it is applied by the medical practitioners it would provide improved patient outcome (Townsend and Morgan, 2017). The external evidence in EBP involves systematic reviews, best practices, randomised control trials and clinical guidance which support any change in practice provided in the medical field. The internal evidence in EBP involves healthcare quality improvement reports, clinical expertise and outcome management initiatives (Mackey and Bassendowski, 2017).

The significance of using EBP in nursing is that it leads to create improved health outcomes for the patients. This is because in EBP the most current healthcare information is used by the nurses to lower complication in care for chronic illness as well as prevent additional diseases to be caused to the patient by implementing proper preventive approaches in care (Spooner et al. 2018). As mentioned by Saunders and Vehviläinen-Julkunen (2016), the use of EBP helps the nurses to lower care costs. This is because it leads the nurses to eliminate using unnecessary healthcare intervention, in turn, acting to lower the linked costs eventually reducing the overall care expenses for the patients. As argued by Aglen (2016), EBP results the nurses develop superior skills to offer care. This is because the information gathered through the research in EBP makes the nurses utilise the data to adapt to care situations, develop communication with patients and interdisciplinary teams and improve skills in offering care. In addition, EBP offers the nurses develop greater confidence in offering care as the evidence informs valid ways in which high-quality care can be provided to service users (Ryan, 2016).

The NMC Code for Evidence-Based Practice under “Practice effectively” informs that needs of the patients is to be assessed effectively and treatment is to be delivered without much delay with the best of the ability by the nurses on the basis of best available evidence (NMC, 2018). The evidence for EBP is to be collected through proper nursing research which is the analytical process to be implemented by the nurses for answering raised questions regarded the nursing practice (Aglen, 2016). In this assignment, the systematic review process of nursing research is to be implemented for gathering information regarding the way malnutrition in elderly patients can be identified and assessed in hospital. The inclusion and exclusion criteria for the search strategy in performing the review are to be mentioned. In addition, the findings for all the papers are to be discussed and use of PARIHS tool is to be made for discussion of key barriers to be experienced on implementing the findings of the review in practice.

Search

The data in the study is gathered by executing electronic searches in the online database and search engines for collecting updated information and data regarding the study topic. The significance of using electronic search from online database is that it helps the researcher to collect wide variety and amount of updated evidence from different sources in easier manner, in turn, avoiding the difficulty to physically analyse and determine information on each page of books and journals (Kruse and Beane, 2018). The two key online databases used in this study Cumulative Index to Nursing and Allied Health Literature (CINHAL) and Medical Literature Analysis and Retrieval System Online (MEDLINE). The CINHAL is used as the online database because it contains nearly 3075 nursing and allied clinical journals providing opportunity to the nurses, health professional and researchers gather required evidence and data needed for providing quality care to the service users (Scala et al. 2016). The MEDLINE is the electronic database which contains bibliographic data for journals and articles used in academic writing and gathering information regarding any topic related to nursing, medicine, pharmacy, dentistry and others (Lin et al. 2016). Thus, due to the wide availability of updated information regarding the study topic, the CINHAL and MEDLINE are the online databases to be used in this review.

The inclusion criteria are referred to the attributes in the research that are essential to be present whereas the exclusion criteria are referred to attributes which are to be avoided from involvement in the study as it would lead to raise error in research (Amundsen et al. 2018). The inclusion criteria for the review include articles that are published after 2010, written in the English language, used primary research methods and academic. The exclusion criteria for the review involves articles that are published before 2010, written in languages others than English, used secondary research methods and non-academic. The article after 2010 is used and before 2010 is avoided so that the researcher is able to gather most current information regarding the topic, in turn, avoiding the collection of backdated information which may have ruined the validity and reliability of the study. The researcher has proper knowledge regarding English Language only and therefore journals written in English are used whereas others are avoided so that proper determination of information can be made through effective understanding of the facts presented in the article.

The articles that have used primary research methods are included in the study because such articles provide direct information regarding the study topic allowing the researcher to present the findings in the accurate way (Newson et al. 2018). The articles which used secondary research methods are excluded because the findings in such studies contain information that is presented through personal perspective of the researcher, in turn, manipulating the true sense of the data. Moreover, at times articles using secondary research methods have incomplete data which leads to hinder the validity and reliability of the study (Moule et al. 2016). The academic journals are included whereas non-academic articles are excluded in the review as academic journals provide in-depth information and knowledge regarding study topic which non-academic articles fail to do so (Moule et al. 2016).

The search terms are referred to as the words that are used by the researcher for retrieving relevant articles and journals required to develop comprehensive research. The search terms to be used in the study includes “malnutrition in elderly”, “hospitalised older patients”, “identify malnutrition among elderly patients in hospital”, “malnutrition in hospitalised older patients” and others. The search terms are customised accordingly to suit the database so that relevant informative articles can be identified. The three basic Boolean operators include AND, NOT and OR. In the study, the search terms are to be interrelated and redefined by using AND and OR to develop proper findings and gather required studies. The exhaustive search of databases that is CINHAL and MEDLINE is done to collect articles that are published from January 2010 and January 2020. The studies which involved the use of primary data collection method are included in the review to avoid error. In searching for the studies, no limitation of time and geographic location were faced. For this review, 143 articles in total are found out of which 5 articles are selected as they are found to be most appropriately related to the study and follows the inclusion criteria. In the selected articles for the review, each of them used the quantitative data collection method under primary research methods. (Refer to Appendix 1)

Discussion

The article by Calvo et al. (2012) is a quantitative study which is conducted in three different medical units for 2 months of La Paz University Hospital. As asserted by Chamberlain et al. (2016), quantitative study is the systematic investigation of any phenomenon by collecting numeric data through the use of mathematical, statistical or computation techniques. The key purpose of this nature of the study is to gather data by performing interview or survey of potential participants related to the study. The benefit of using quantitative study is that it allows the collection of data from wider subjects and enhances the generalisation of findings (Chamberlain et al. 2016). The aim of the study is to examine the implementation of the Mini Nutritional Assessment Tool in the hospital for older people to rapidly evaluate nutritional risks for them.

The study is conducted by collecting data from 106 participants who were availing care in the internal medicine ward of the tertiary care hospital of La Paz University Hospital and were 65 years and older. The data gathered regarding the patients were collected within the first 24 to 48 hours of their admission in the hospital. The interview of the participants was made and Mini Nutrition Assessment (MNA) tool was used for gathering information. The MNA tool consists of the screening phase, assessment phase and subjection assessment. In the first 48 hours, the full questionnaire related to MNA tool was implemented and laboratory tests along with dermatological analysis were made. The score from the MNA tool expressed that 77% of the patients are at risk of facing malnutrition. The quantitative variables are analysed by use of ANOVA test and student T-test whereas the qualitative variables are analysing by use of Chi-square test.

The results revealed that low level of albumin along with less cholesterol and vitamin A & D are significantly related to malnutrition risk among the patients. The MNA tool when separately evaluated showed it is sensitive and accurate in nature along with has proper predictive value for the process of screening of patients.

The article by Wham et al. (2017) is a quantitative study which is performed in Auckland, New Zealand. As commented by Giacchero Vedana et al. (2017), quantitative research is referred to the process in which the research problem is resolved by generating numerical data that can be changed into usable data for the study. This nature of study is used for quantifying variables and generalise results from huge sample population. The aim of the study is to identify the prevalence of risk of malnutrition among older people in three different settings.

A descriptive multi-setting cross-sectional study is executed in the Waitemata District Health Board located in Auckland. The people who were aged 65 years and above as well as have the ability to understand and give consent towards the study are included in the research. The validated Min-Nutritional Assessment (MNA) tool was used to collect data from the recruited participants in the study. The statistical analysis of the gathered information is made by using version 23 of SPSS software.

The results inform that out of 167 participants nearly 23% of the patients were malnourished and 35% of the patients were at high risk of malnutrition. The participants who were most recently admitted to the residential care (47%) versus the community or hospitals settings (23%) are found to show greater prevalence of malnutrition.

The study by O’Shea et al. (2017) is quantitative research and it was executed in five public along with one private hospital in Ireland. As stated by Ota et al. (2018), quantitative research is the method in which numerical systems are used for analysing variables and measurements in the study along with various statistical models are used for reporting relation between variables. The key purpose of the quantitative data gathered in this type of research is to determine, comprehend and predict the phenomenon. The aim of the study is to determine the prevalence of malnutrition among elderly patients in hospital settings.

The study is conducted by gathering demographic data along with hospital admission data from 606 adults who were all above 70 years of age. The participants from all elective as well as acute admission were included in the study. The illness for each of the patients was recorded from case notes and nutritional status of the patients was determined by using Mini-Nutritional Assessment (MNA). The six sections to be evaluated under the MNA tool include food intake, mobility, weight loss, neuropsychological issues, psychological stress and body mass index (BMI). The data gathered is analysed by using version 22 of SPSS software and the differences between groups are examined by using Chi-square test in regard to categorical variables and ANOVA test in relation to continuous variables.

The results inform that 37% of the participants have normal nutrition, 45% are at risk of malnutrition and 18% of the participants are malnourished. In addition, the females are found to be at greater risk of facing malnutrition. The findings mentioned that malnutrition is related with new institutionalisation (p =<0.001), in-hospital morbidity (p < .001) and increased hospital stay (p < .001).

The article by Holst et al. (2013) is quantitative study and is performed in Denmark and Sweden. As commented by Missen et al. (2016), quantitative study is the process in which deductive logic is used by the researcher to gather statistical and numerical data for explaining the phenomenon in the study. The aim of the study is to determine the invalidity of different nutrition screening tools for a broader population of hospitalised elderly patients.

The study is conducted by the inclusion of 233 patients from three separate departments in university hospitals located in Sweden and Denmark. The data collection involved nutritional assessment and nutritional screening which were obtained in the first 72 hours after the admission of the patients in the hospital. The patients are screened for determining their nutrition level by using the Malnutrition Universal Screening Tool (MUST), Nutritional Risk Screening (NRS-2002) and Mini-Nutritional Assessment (MNA) tool. In the Danish Cohort, the 12-month mortality was examined.

The results of the study mention that 68% of the patients were found to be at risk of malnutrition when the screening was done by MNA tool whereas only 47% were identified to be at risk of malnutrition when screen through MUST and 54% patients were determined at risk when screened through NRS-2002 tool. The invalidity results of the three tools mention that good agreement is present between NRS versus MUST and MNA tool whereas less agreement is found between MUST and MNA tools.

The study by Hanisah et al. (2012) is quantitative research and it is executed in Malaysia. As commented by ten Hoeve et al. (2016), quantitative research is the systematic way of gathering and analysing data from various sources to quantify the research problem for understanding the relevance of the projected results on a larger population. The aim of the study is to identify validation of appetite screening tools such as Simplified Nutritional Appetite Questionnaire (SNPQ) and Nutritional Appetite Questionnaire (NAQ) against the nutritional status; Appetite, Hunger and Sensory Perception Questionnaire (AHSPQ) and nutrient along with energy intake in patients.

The study is conducted by selecting 145 elderly patients who are having poor appetite and admitted to the hospital in Malaysia. The selected participant’s statuses regarding appetite are screened through the use of SNAQ, CNAQ and AHSPQ. The Dietary History Questionnaire (DHQ) is used for gathering data regarding food intake by the patients for the past seven days. The data analysis is executed by using SPSS software and Mann-Whitney test along with Integrated T-test is used for determining test differences in gender. The Binary regression analysis is implemented to identify factors related to poor appetite among patients.

The results inform that 50.4% of the patients are found to be mild to moderately malnourished, 11.6% highly malnourished and 38.6% are found to be normal. It was identified that 79.3% of the patients were having poor appetite by using CNAQ tool and 57.2% of the patients are identified to have poor appetite by using SNAQ tool. The CNAQ tool is found to have increased sensitivity compared to SNAQ tool when they are validated for nutritional status.

Conclusion

The above discussion informs that evidence-based practice (EBP) is essential in nursing research to provide error-free care and improve the expertise of the nurses in providing high –quality care. The systematic review is done by collecting 5 primary research articles through online search created by using CINHAL and MEDLINE as electronic databases. The finding by the studies by O’Shea et al. (2017), Calvo et al. (2012) and Wham et al. (2017) informs that Mini-Nutritional Assessment is the most effective tool for determining and assessing the risk of malnutrition among older patients who are admitted to the hospital. The MNA tool mentions six key questions to be answered which is food intake, BMI rate, weight loss, psychological stress or any form of acute illness, presence of dementia or depression and mobility. The study by Holst et al. (2013) informed that good agreement is present between NRS versus MUST and MNA tool indicating the use of Mini-Nutritional Assessment and Malnutrition Universal Screening Tool (MUST) are effective to be used for determining nutritional risk for patients.

The studies also informed that female are more prone to be at risk of facing the risk of malnutrition compared to men. In addition, increased length of stay in the hospital and in-hospital morbidity along with new instutionlisation of older patients is found to the factors which create risk of malnutrition for them. The Simplified Nutritional Appetite Questionnaire (SNPQ) and Nutritional Appetite Questionnaire (NAQ) are the tools that can be used in determining poor appetite among elderly patients in turn helping to identify which or how many of the patients in the hospital settings are at risk of malnutrition and require effective care for ensuring their quality healthy condition.

Implication for practice

The data collected from the studies would act as essential evidence for offering quality nursing services as the tool to be used for identifying and assessing the risk of malnutrition among elderly patients in hospital settings is identified that is Mini-Nutritional Assessment. In addition, the information to be collected through the tool is also mentioned and it would act to provide effective direction to the nurses in practice about the vital data to be gathered for determining risk of malnutrition among elderly patients in proper way. In addition, the implication of collected findings is that the identified tools such as Simplified Nutritional Appetite Questionnaire (SNPQ) and Nutritional Appetite Questionnaire (NAQ) are to be used by nurses to determine poor appetite in elderly patients providing them with the opportunity to determine which patients are at risk of malnutrition. However, there is lack of evidence regarding the gold standard screening tool to be used for determining the risk of malnutrition among elderly patients. In addition, the studies used in the systematic review provided primary information only and there is lack of qualitative data due to which narrative information regarding the efficiency and way of using malnutrition risk tool are not gathered. Therefore, in future, secondary research studies along with qualitative studies are analysed to develop narrative information regarding the study topic.

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