Category: Evidence based practice

Evidence-based practice (EBP) has become central to nursing practice and is actively promoted in both nursing education and real-world procedures to ensure that the latest and most accurate scientific data, clinical expertise, and methods of healthcare delivery are incorporated into practice. However, there are inherent barriers present at institutional and individual levels to adopt EBP. These may be systemic or cultural factors in the workplace that do not support change or promote nursing enhancing their knowledge. In addition, practitioners may lack access to appropriate technology, computer systems, or databases to engage in research or adopt EBP practices. Time management can be a barrier as well as nursing workflow and scheduling simply does not allow the time to engage in research or advocacy for EBP. Individual factors may be a lack of knowledge regarding conducting high-quality research as well as a lack of personal motivation for improvement (Tacia, Biskupski, Pheley, & Lehto, 2015). One can promote the adoption of EBP in the organization by advocating and establishing interdisciplinary communication. Commonly, support from physicians and management is vital for successful EBP implementation. Driving these initiatives through petitions and conference is important.

The use of 12-hour nursing shifts is becoming increasingly common in hospitals across the world. This tendency became a standard due to management approaches that view such long shifts as an opportunity to reduce interruptions and handovers that are often detrimental to care delivery while increasing productivity in overlaps that occur between shifts. Some view it as beneficial for nurses as well since compressed working week results in more days off, increased flexibility, and lower commuting costs. However, evidence from large-scale studies, such as the one by Dall’Ora, Griffiths, Ball, Simon, and Aiken (2015) suggests several negative outcomes as a result of such long shifts. Shifts that are 12 hours and longer are directly associated with job dissatisfaction, extreme burnout, high turnovers, and overall disgruntlement with work schedule flexibility. Psychological well-being suffers as well as physical fatigue are common symptoms of burnout in 12-hour shifts.

This can lead to adverse outcomes ranging from medical error and decreased quality of care to economic loss and increased turnover rates. Such evidence suggests that managers and hospital administrations should reconsider traditional scheduling and routines. In the context of nursing shortages, overtime may persist, but other strategies should be implemented regarding managing handovers and disruptions. Furthermore, policymakers should be influenced to provide greater funding and improved regulation for nursing practice.

References

Dall’Ora, C., Griffiths, P., Ball, J., Simon, M., & Aiken, L. H. (2015). Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open, 5(9), 1-7. Web.

Tacia, L., Biskupski, K, Pheley, A., & Lehto, R. H. (2015). Identifying barriers to evidence-based practice adoption: A focus group study.Clinical Nursing Studies, 3(2), 90-96. Web.

Evidence-based medicine provides a variety of tools to help practitioners achieve the main objective of any intervention, which is measurable improvements in the health outcomes of the patient. Supporting the claims with data from the latest scientific research allows these methods and technics to be easy to evaluate. Successful implementation of an evidence-based project will require taking steps addressing clinical, financial, and quality aspects of care.

Creating a healing environment is an important clinical aspect of evidence-based practice that has to be taken into account during the work on a project. Jean Watson’s theory of human caring can be used to take adequate steps while addressing this issue.

The theory emphasizes the importance of the overall wellbeing of a patient and the necessity of creating a positive social and emotional environment (Watson, 2015). Focusing on these aspects of treatment will directly impact and improve the health outcomes of patients.

Proving that implementing a particular project will lead to measurable improvements in patients’ health outcomes is a major quality aspect of medicine. Relying exclusively on evidence-based approaches and techniques that are well-studied will guarantee their efficiency (Malik, McKenna, & Plummer, 2016). Working on a project will require handling the financial aspect of medical practice and find sources for its funding. Focusing on cost-effective technics and using research data to show the benefits of the project will help obtain the necessary support of stakeholders and receive the financial resources needed to implement a proposal.

Thus, reliance on evidence-based practices and implementing them with the help of nursing theories is an efficient strategy for work on a proposal. In addition to that, focusing on cost-effective techniques will help address the financial aspect of care and make the implementation of a project less difficult. Promoting such an approach will help improve the quality of care and lead to better health outcomes among the patients.

References

Malik, G., McKenna, L., & Plummer, V. (2016). Facilitators and barriers to evidence-based practice: perceptions of nurse educators, clinical coaches, and nurse specialists from a descriptive study. Contemporary Nurse, 52(5), 544-554.

Watson, J. (2015) Jean Watson’s theory of human caring. In M. C. Smith & M.E. Parker (Eds.), Nursing theories and nursing practice (pp. 321-341). Philadelphia, PA: FA Davis.

Because enhancing patient outcomes is the main objective of any evidence-based nursing endeavor, it is imperative to measure the effects of introduced changes to be able to determine whether the new intervention or strategy is beneficial to practice. Impact analysis using patient recorded outcomes (PROs) can be used to to identify and introduce the necessary changes to the nursing profession (Jensen et al., 2015). It is a holistic approach for analyzing the effectiveness of changes because it concentrates not only on quality indicators but more thoroughly on the actual patient outcomes. Therefore, impact analysis is appropriate to use to determine the effectiveness of introduction of AccuVein in hospitals.

Impact analysis is not limited to only qualitative or quantitative methods. Instead, it uses a comprehensive approach to describe the accurate picture of current patient outcomes. There are different ways of how a study can be conducted, but the most cost-effective and efficient one is when nurses are part of the evaluation team. Because the data will be collected from patients themselves, nurses are the most appropriate choice for gathering the information because of their exceptional relationship with patients. The patients will share their experiences with invasive methods of inserting a intravenous catheter and their counterpart – AccuVein. The data will be collected throughout a certain period as nurses gain experience working with AccuVein. The information will be then compared to the results of invasive methods.

Measuring impact is critical when it comes to assessing effectiveness both in the context of a single intervention and an entire organization. PROs provide tools for yielding accurate information on patient outcomes. This information can be used to determine if the introduction of AccuVein is producing favorable results and if the organization is using the resources efficiently. Nurses are more suitable for data gathering because they are closer to patients than any other personnel.

Reference

Jensen, R. E., Rothrock, N. E., DeWitt, E. M., Spiegel, B., Tucker, C. A., Crane, H. M.,… Cella, D. (2015). The role of technical advances in the adoption and integration of patient-reported outcomes in clinical care. Medical Care, 53(2), 153-159.

Nowadays, Evidence-based practice (EBP) has become a crucial element of providing patients with excellent healthcare. Registered nurses (RN) study this concept during their Bachelor of Science in Nursing (BSN) curriculum to figure out the best ways to service a patient. EBM in nursing is the concept of making a decision based on the importance of practical knowledge and taking into account the interests of the patients to provide an individualized approach (“Why is evidence-based,” 2018). In order to make well-grounded decisions based on scientific researches, nurses shall include EBM in their routine.

The two ways, or models, which might be the most appropriate ones to integrate evidence into nursing practice are the ACE Star Model of Knowledge Transformation (ACE) and the Advancing Research and Clinical Practice Through Close Collaboration (ARCC) (Melnyk, Fineout-Overholt, Giggleman, and Choy, 2016). The models have a similar step-by-step structure: identifying the problem, review researches that may solve the problem, assessing the necessity for change and possible obstacles; consulting with stakeholders; undertaking the change; evaluating results (Melnyk et al., 2016). However, there is a considerable difference between these two approaches. ACE aims to implement the change in a simple, comprehensive way, which is appropriate for fast decision-making. The ARCC model is used to achieve improvements in healthcare systems generally, which is suitable for meeting long-standing goals. So, the combination of the models is needed to diversify the ways of the evidence integration into nursing practice.

Nevertheless, there are some obstacles that may challenge the mentioned plan. The most crucial might be the wrong interpretation of research articles and the lack of time for EBP during the work. The steps to minimize their impact are as follows: to work on a reasonable time-management basis, constant self-development, scientific research in the free time, and discussing complicated terms and issues with competent mentors.

In conclusion, it seems reasonable to assume that the two appropriate ways in which nurses may integrate evidence into their work are the ACE and the ARCC models. Notably, these approaches have a significant difference that determines their uniqueness and a need to combine them. Some difficulties may occur while implementing the plan of EBP; however, a proper time-management, mentors’ consultations, and self-development might be a decision.

References

Why is evidence-based practice in nursing so important? (2018). Web.

Melnyk, B. M., Fineout-Overholt, E., Giggleman, M., Choy, K. (2016). A Test of the ARCC Model Improves Implementation of Evidence-Based Practice, Healthcare Culture, and Patient Outcomes. Worldviews on Evidence-Based Nursing, 14(1), 5–9.

While short-term results of EBP change implementation may be promising, the pace may change after the initial six months. While the reasons may vary, there are two primary barriers that can prevent the EBP change from producing desired long-term results. First, the lack of knowledge and experience can directly influence the outcomes. According to Fisher, Cusack, Cox, Feigenbaum, and Wallen (2016), the inadequate competence level of change agents may cause EBP initiative to fail in the long run. Second, the absence of motivation among the medical staff may also negatively influence the implementation process. Tacia, Biskupski, Pheley, and Lehto (2015) state that nurses may become stagnant in their careers, performing the same tasks over many years of practice. According to their qualitative study, “managers described nurses as not motivated to implement EBP because of the length of time between formal academic training and current employment” (Tacia et al., 2015, p. 94). However, the barriers are well studied, and therefore they can be easily addressed.

The problem of the lack of knowledge can be averted by collaborating with senior personnel and employing strategic planning. The study by Fisher et al. (2016) confirms that EBP changes require senior leadership support to supplement for the lack of knowledge in less experienced staff members. Moreover, the same study supports the notion that top-down strategic planning facilitates the sustainability of EBP culture (Fisher et al., 2016). As for the lack of motivation, setting small measurable goals, celebrating success, and recognizing the impact of every employee is a viable strategy for addressing the matter (Ganta, 2014). While the practices mentioned above seem to be common-sense solutions, they are often ignored, which negatively affects the results.

References

Fisher, C., Cusack, G., Cox, K., Feigenbaum, K., & Wallen, G. (2016). Developing competency to sustain evidence-based practice. JONA: The Journal of Nursing Administration, 46(11), 581-585. Web.

Ganta, V. C. (2014). Motivation in the workplace to improve the employee performance. International Journal of Engineering Technology, Management and Applied Sciences, 2(6), 221-230.

Tacia, L., Biskupski, K., Pheley, A., & Lehto, R. (2015). Identifying barriers to evidence-based practice adoption: A focus group study. Clinical Nursing Studies, 3(2). Web.

To become a good and qualified nurse means to deal with several tasks, and one of them is to be sure of the quality of offered information. There are many approaches to evaluating patients, their values, and clinical guidelines. According to Melnyk and Fineout-Overholt (2018), evidence-based practice (EBP) aims at delivering the highest quality of healthcare information and achieving the best patient outcomes. In this discussion, attention will be paid to EBP and the levels of evidence to be applied to personal and professional life.

A nurse has to be good at determining the quality of information and understanding its validity and accuracy. Validity is explained as the “extent to which an instrument measures what it purports to measure” (Kimberlin & Winterstein, 2008, p. 2278). As a rule, it is necessary to check the author’s credentials and read the abstract of an article to find out the purposes of a project. A list of references to other works is another proof that the chosen source is valid. Finally, the article’s publication date and the years of publication of referenced articles define its accuracy.

There is also a hierarchy of evidence in healthcare research, according to which studies are ranked and chosen by students and other researchers. Level I presents data from systematic reviews and randomized controlled trials, proving its high quality and validity. Level II usually contains a smaller number of sources to support a discussion compared to a previous level. In Levels III and IV, controlled trials and cohort studies are used as evidence. Level V and VI introduce the results of qualitative and descriptive studies. Finally, Level VII includes the results of reports and the personal opinions of experts in the chosen sphere. Any level of information is an example of EBP that is a constituent part of effective nursing care (Morton, 2013). However, people who prefer to seek credible information for personal or professional development prefer to choose Levels I and II sources.

My personal experience in working with different sources shows the true worth of EBP in nursing. I learned what I know using books and peer-reviewed journals and memorizing details to use them in my cooperation with other nurses. It is not enough to give definitions and cite different authors. My awareness is based on my ability to interpret information. As soon as other nurses or students agree with my opinions and offer similar evidence, I understand that I was able to introduce accurate information.

I think that there is no best practice to gain information. Each time, I get an opportunity to visit a library, surf the web, or talk to a healthcare expert with several options to rely on and prove my position. To be successful means to never stop on one option. However, in nursing practice, attention should be paid to pertinent knowledge that includes accurate publication dates, authors’ information, and geographical locations.

In general, a requirement for nurses to use various EBP strategies is a great chance that should never be ignored. Despite several tasks and characteristics, this practice provides an effective overview of recent studies and current research in the field of nursing. My personal and professional life has already been improved and supported by credible facts and data. I do not want to set deadlines or limitations on my work in the field of nursing because it is my opportunity to become a better and more proficient nurse.

References

Kimberlin, C. L., & Winterstein, A. G. (2008). Validity and reliability of measurement instruments used in research. American Journal of Health-System Pharmacy, 65(23), 2276–2284. Web.

Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing and healthcare (4th ed.). Philadelphia, PA: Wolters Kluwer.

Morton, K. (2013). Implementing evidence-based health promotion strategies. Nursing Standard, 27(33), 35–42. Web.

Nowadays, there are a considerable number of research types in medicine. One of the most accepted practices in nursing is evidence-based practice. According to Roussel et al. (2016), “EBP (evidence-based practice) is a process involving the examination and application of research findings or other reliable evidence that has been integrated with scientific theories.” (p. 4). This method can lead to increased requirements for medical personnel, as they will need to develop their critical thinking and improve the quality of scientific knowledge.

Evidence-Based Theory

EBP developed as a result of a synthesis of the strict American system and European freer medicine system. Doctors and nurses can achieve the most effective treatment by combining an individual approach to each person and rigorous medical algorithms. This type of medicine involves the collection of all available data and their subsequent analysis. As Ellis (2019) claims, “nurses need to develop a reflective approach to their practice, which includes finding out about the latest research and evaluating findings, so people’s needs are responded to using the best available evidence. (7)”

For sufficient examination and subsequent treatment, medical personnel should be able to think critically and highlight essential evidence from secondary sources. Nurses can acquire this skill and develop their scientific knowledge using expert opinions, libraries, and online resources. Doctors need to analyze the received information after active data collection. Since the collected evidence covers not only the research data but also the patient’s personal information, the analysis stage will be more helpful and informative.

Star Model of Knowledge Transformation

The Star Model of Knowledge Transformation includes five steps of examination and treatment. Nurses are conducting discovery research, which means doing a survey using medical equipment. Then, there is a general assessment of the obtained data and summing up the intermediate results, and redirection of the patient to the appointed specialist. The fourth step is the integration of substantial evidence into a theoretical basis. In the end, there is a treatment process and analysis of the results obtained at the exit.

Iowa Model of Evidence-Based Practice

Scientists developed the described model as an aid for the implementation of nursing care for a patient. The first step is a clinical survey; the specialist must conduct a verbal study and identify the patient’s problem. The second step is a traditional study of the received data with the usage of professional literature and online sources. Then there is a critical assessment of the evidence obtained and the introduction of changes in the ongoing treatment. The last step is the evaluation and analysis of nursing care.

Model of Diffusion of Innovations

First of all, researchers receive knowledge, which means a medical examination, a clinical survey, and obtaining all possible evidence about the patient. Then a scientific analysis of the gained knowledge is made, and a thesis is put forward in need of confirmation. Further, the nursing staff makes a particular decision after the meetings, and the medical personnel puts ahead a treatment strategy. Evidence is continuously collected and data recorded with a periodic conclusion of effectiveness, during the treatment process. Ultimately, the clinical team receives confirmation of the efficiency or inefficiency of the treatment.

Combined Effectiveness of the Presented Models

In conclusion, we can state that the presented models that are using the developed theory are active in their way, and each model is most effective in specific conditions. The effectiveness depends on the location of the medical institution as well as on the mentality of clinical staff and patients. The availability of innovative medical equipment and the degree of qualification of specialists are also crucial.

References

Ellis, P. (2019). Evidence-based practice in nursing. Learning Matters.

Roussel, L., Thomas, P. L., & Harris, J. L. (2016). Management and leadership for nurse administrators. Jones & Bartlett Learning.

Schmidt, N. A., Brown, J. M. (2017). Evidence-based practice for nurses: appraisal and application of research. Jones & Bartlett Learning.

This plan aims to improve the preoperative health status of orthopedic surgical patients to improve surgical outcomes in a hospital setting. The implementation plan will take 2 months as shown in the table below:

A systematic review will be used to guide this implementation plan because it is more informative. After all, it is a summary of existing studies so that only the best evidence is available to guide decision-makers (Smith, Devane, Begley, & Clarke, 2011). This review will target well-designed controlled trials only, regardless of randomization. The target population is the orthopedic surgical population; thus, only studies that have tested the efficacy of the MRSA screening protocol will be included in this review. In addition, the study will entail a comparison of the screened population using the MRSA tool to an unscreened population.

Articles published since 2006 (in the last 10 years) will be included in the study. Only studies that have adapted a controlled trial will be included in this review. A data extraction form will be used to determine the imperative facets of the different studies. Also, a quality appraisal checklist will aid in determining the quality of the studies included in this review. Upon reviewing the methodology, the precision, as well as generalizability of the results, only a certain number of studies will remain. A PRISMA flow diagram will be used to give a pictorial representation of the literature search process.

Two reviewers will be selected and briefed on how to select the studies about the inclusion and exclusion criteria. Differences between the two reviewers will be settled through discussion and consensus (National Heart, Lung, and Blood Institute, 2014). Subsequently, the identified studies will be tabulated, and a test for homogeneity will be carried to determine the need for meta-analysis. Significant results that highlight the need for MRSA screening will guide the rest of the process.

Integration of the significant findings will begin with awareness, where the findings would be communicated to the entire team involved including surgeons, lab personnel, nurses, and the quality improvement committee. Considering the associated barrier of time, the implementation agenda would be introduced to the staff during the routine meetings within the hospital and would entail demonstrations. To avoid poor communication and misinterpretation, a small test would be administered to the staff after discussing what each department would be required to do during the implementation of the MRSA screening protocol.

The library is the basic resource to aid in the gathering of the required articles for the systematic review. Nasal swabs and medication for decolonization are will help to identify MRSA infections and counteract their effects. Subsequently, the healthcare workers involved in the concerted efforts of implementing the solution are important. The location where the solution is to be implemented is in a hospital among orthopedic surgical patients. Time is another important resource that will need proper planning as shown in the table above.

The preoperative assessment procedure, which usually entails an array of activities as discussed by Akhtar, MacFarlane, and Waseem (2013), will change notably. The component of MRSA screening, which is lacking in the standard preoperative assessment process, will be incorporated into the hospital’s policy after a pilot to determine the logistics and level of impact on the surgical outcomes.

Orthopedic surgical patients will be divided into two groups. The experimental group will be screened for MRSA and treated for the infection before surgery. The control group will undergo the usual routine that does not have the component of MRSA screening. Once the MRSA infection has cleared, the experimental group will undergo the surgery. Since this implementation plan seeks to determine the prevalence of MRS infections after the surgery, administration of a questionnaire will not be necessary (Mehta et al., 2013).

Nonetheless, two nurses will be used in the identification and decolonization of the MRSA. In addition, the two nurses will determine the occurrence of MRSA after surgery between the two groups for comparison. An independent t-test will be used to compare the means of the two groups as indicated by the University of West England (2016).

The nurses involved in the quasi-experimental study will be asked to uphold privacy about the treatment procedure. Patient information regarding the occurrence of MRSA infections will be noted in the patient’s files and will be useful for determining the prevalence of these infections. Another type of information required for the study will be kept anonymous and only used by individuals involved in the study and bound by the research code of ethics (Resnik, 2015). The proposed budget for this plan is as follows:

The solution will be extended by scaling it up through a change in the hospital’s preoperative assessment policy.

References

Akhtar, A., MacFarlane, R. J., & Waseem, M. (2013). Pre-operative assessment and post-operative care in elective shoulder surgery. The Open Orthopaedics Journal, 7, 316–322.

Mehta, S., Hadley, S., Hutzler, L., Slover, J., Phillips, M., & Bosco, J. 3^rd. (2013). Impact of preoperative MRSA screening and decolonization on hospital-acquired MRSA burden. Clinical Orthopaedics and Related Research, 471(7), 2367-2371.

National Heart, Lung, and Blood Institute. (2014). Quality assessment of systematic reviews and meta-analyses. Web.

Resnik, D. B. (2015). What is ethics in research & why is it important? Web.

Smith, V., Devane, D.,Begley, C. M., & Clarke. M. (2011). Methodology in conducting a systematic review of systematic reviews of healthcare interventions. BMC Medical Research Methodology, 11(15). Web.

University of the West England. (2016). Independent samples t-test. Web.

Introduction

The sphere of nursing undergoes several changes, improvements, and evaluations constantly. Many professional researchers offer their own ideas and suggestions on how it is possible to optimize the system and provide patients with appropriate treatment and care. In this article, certain attention is paid to evidence-based research (EBR) in nursing practice, several particular sources of evidence, and ethical issues which may be aroused in nursing practice.

EBR is considered to be a powerful step for many current and future nurses to realize how it is possible to manage various health problems of patients and prove that nursing care corresponds to special standards and expectations (Dickson & Flynn, 2008). For current EBR, four different sources are evaluated as well as personal communications with parents who have brought their children to the clinic to solve the problems caused by acute otitis media.

Evaluation of watchful waiting is another important aspect that has to be taken into consideration in this paper. Some clinical guidelines admit that this kind of attitude to patients is more effective in comparison to immediately beginning treatment. It is not always correct to provide children with some treatment in order to do something.

This is why a particular group of nurses finds the ideas of evidence-based research more appropriate for this practice and try to prove that the chosen methods should properly influence a child’s condition considering such crucial ethical issues like confidentiality, vulnerable population, and informed consent of parents. Evidence-based research in nursing practice is a new tendency that has to support and improved from time to time to help patients be confident in the care provided and in a healthy future for them.

Evaluation of the chosen sources of evidence

The theme of the chosen evidence-based research is children with acute otitis media and the decision to use watchful waiting to provide patients with appropriate treatment or to start treatment with antibiotics immediately. There are five sources of evidence chosen for this project. Each source introduces a separate attitude to the problem of acute otitis media in children; the diversity of suggestions should help to define what kind of treatment is more appropriate in this case and how it is better to implement new ideas into the already established system. The nurses brought sources of evidence of different types for their first meeting.

One online source, two articles from Pediatric Infectious Journal, the chapter from the book by Hay, Levin, Sondheimer, and Deterding, and personal communications with parents are considered to be the sources of evidence for the nursing situation where children with acute otitis media have to be treated.

Classification of sources by information type

The first source under analysis is the American Academy of Pediatrics and the American Academy of Family Physicians from the Clinical Practice Guideline. This source of evidence contains reliable and educative information about treatment to children with acute otitis media (AOM) that is defined as a common infection that is characterized by antibacterial agents (Clinical Practice Guideline, 2004). The authors find it possible to use the already achieved results by other researchers as well as promote new ideas to manage AOM. Taking into consideration the informative side of the article, this article should be identified are one of the filtered resources in this research.

Other two sources are taken from Pediatric Infectious Disease Journal. Block (1997) evaluates the new macrolides as an appropriate alternative to manage AOM among little children and considers the already known facts about Haemophilus and Chlamydia pneumonia in young children. McCracken (1998), in his turn, introduces six factors that play an important role in therapy for AOM. To achieve success in the chosen activity, he had to evaluate the already identified facts and share a new vision of the problem. This is why these two sources should be regarded as filtered sources as well as they have an issue to be analyzed and conclusions which are given in regard to the question posed.

The chapter Kelley, Friedman, and Johnson informs the reader about some basics about AOM and clinical findings with the help of which this disease may be treated. As this source provides detailed background information about AOM, it should be classified as general information source. Finally, the results of personal interviews with parents (Smith, 2010) help to comprehend that sometimes immediate treatment is required, still, it is obligatory to remember about ethical issues which improve the system. As this source provides the most recent information about the disease under consideration and is based on some questions from the interviewer, it is identified as the only unfiltered source of evidence in this research.

Chosen sources and appropriateness for nursing practice

Each of the above-mentioned sources may be appropriate for the nursing practice situation when the decision in defense of watchful waiting or defense of immediate treatment with antibiotics for children with acute otitis media should be made. The chosen sources help to realize that AOM is an infection that has to be treated within a short period of time. Still, there is a burning need to identify the causes of the infection as well as its outcomes on the organism before a particular treatment is prescribed. It is known that AOM may be of severe and non-sever type (Rosenfeld & Bluestone, 2003), this is why it seems to be wrong to provide the same immediate treatment in case it is not always easy to identify the type of the disease.

Clinical Practice Guideline (2004) states that several discussions concerning antibacterial agents during the process of diagnosis take place recently. In spite of the fact that American clinics refer to this routine activity, the representatives from European countries do not trust the effectiveness of various antibacterial agents with the help of which treatment is possible. In the United States of America, 2/3 of all American children suffer from acute otitis media at least one time in their lives during their first year of life, and 80% of children have some problems because of AOM by their 3 years of age (Natal & Chao, 2009).

Such frequency of the disease makes the vast majority of nurses take appropriate care for children and evaluation of the conditions under which the infection may be spread. This is why the work by Kelly, Friedman, and Johnson (2007) where the elements of AOM are discussed is one of the most appropriate information sources with the help of which AOM signs, symptoms, and development are defined.

Personal communication with the Smiths, the parents of the child who is delivered to the clinic because of first symptoms of acute non-sever otitis media, shows that even current technologies and professionalism of the staff cannot serve as powerful evidence of successful treatment. As a rule, parents try to overcome the challenges caused by their children’s health problems and support the idea of watchful waiting to get certain and correct diagnosis. McCracken’s investigations explain how the safety profile of a patient should be considered to the same level the issue of compliance is. Antibiotic selection needs to be supported by practical approach, parental tolerability, and clinical experience (McCracken, 1998). Nurses should take into account that management of pain that is caused by AOM in children is the primary task to be accomplished (Clinical Practice Guideline, 2004; Block, 1997), but still, the decision to treat with antibiotics has to be made only after careful analysis of the case.

Classification of sources according to evidence type

The chosen sources of evidence for this particular research may be classified in accordance with the type of evidence provided. The identification of evidence should help to comprehend what information is more appropriate and reliable for certain evidence-based research. American Academy of Pediatrics and American Academy of Family Physicians is regarded as the evidence-based guideline within the frames of which several problems are identified as well as several types of recommendations are given. The management of AOM requires much time and effort, and this source may become a good guide for nurses to rely on.

The article by McCracken is also considered to be of the evidence-based guideline by means of which the author gives appropriate recommendations as for medicines to be used for children with AOM. Newhouse et al (2007) say that primary evidence is the data that is gathered as a result of contact with patient, this is why any type of personal communication that takes place in the clinic and the chosen for this project communication with Mr. and Mrs. Smith are considered to be primary research evidence because their personal experience, emotions, and knowledge are evaluated. There are no special theoretical approaches and strategies, just what happens around and what needs to be done.

The work by Kelley, Friedman, & Johnson has to be identified as evidence summaries because it provides broad foci on a particular topic of AOM. The article written by Block in the journal is also of evidence summary type with the help of which the author evaluates the already known facts about diseases of little children and provides a treatment that may be used in this situation.

Clinical Practice Guideline with its own position in regard to EBP

Watchful waiting as an appropriate approach for treating children with acute otitis media

Nowadays, in the vast majority of clinics, nurses try to practice as many effective approaches to treat children as possible. The evaluation of the already achieved results shows that much depends on the situation under which a child is treated, this is why it is wrong to make some decisions and be sure of its appropriateness to all situations. To comprehend better how watchful waiting may be used as appropriate means to treat children with acute otitis media, the ideas offered in the article American Academy of Pediatrics and American Academy of Family Physicians by Clinical Practice Guideline have to be taken into consideration.

One of the methods discussed in the article is all about observation without use of some antibacterial agents. One of the most important conditions identified by the authors of the article is that child’s age, the severity of the infection, and diagnostic certainty should be considered before the decision to observe a child watchfully is made (Clinical Practice Guideline, 2004). In this article, the idea of watchful observation is not argued, still, a number of precautionary steps have to be taken. This is why this type of watch could be an appropriate and safe approach for treating children with AOM in case certain means of communication and the system that supports re-evaluation of child’s condition are established accordingly. The last point plays the most important role in the research.

In comparison to other studies as a result of which the use of antibacterial agents in children with AOM is reduced to 20-25% (Mintegi-Raso et al., 2007), the achievements of the Clinic Practice Guideline were not that positive. In fact, due to the increased risk of failure of the chosen watchful waiting, the decision to rely on immediate antibacterial therapy has been made in order to save children’s lives. This is why there is no certain rule that may forbid the use of observations as a good method to treat children successfully; however, at the same time, there is no evidence that may explain the correctness of the chosen approach. This is why it is better to regard the process of watchful observation as an appropriate approach to treat children only after all precautionary measures are taken into account.

The chosen article is a considerable improvement to nursing practice

Nursing practice in the clinic may be improved in a variety of ways. Still, the nurse who is going to suggest some ideas has to be ready to evaluate the situation from all perspectives and have several additional options just in case. The findings of the article under consideration contribute a lot to the sphere of nursing. There are several powerful recommendations with the help of which treatment is possible. Any nurse has to diagnose the patient to identify the signs of the disease and evaluate all symptoms both of which are evident and which are not. Only after this step is taken, the management of pain should be started. If watchful observation is not harmful to the patient, it is possible to try this approach and comprehend what treatment methods are more appropriate. Finally, nursing practice should be based on prescription particular antibacterial agents.

Ethical issues and evidence-based research

Current clinical research studies have to be developed taking into consideration a number of ethical principles. In the project under discussion, several ethical issues could be raised in order to achieve better communication with patients, evaluation of personal activities, and cooperation with other nurses. It is necessary to underline that nursing care is offered to all people including those who are not capable of providing informed consent, who are also called the representatives of vulnerable populations considering the issues of confidentiality and respect.

Confidentiality is an ethical issue that has to be considered by any nurse

For a long period of time, the issue of confidentiality is regarded as an integral part of nursing process. In spite of the fact that significant challenges define the way of how nurses protect patients’ confidentiality, nurses try to maintain confidentiality and help patients achieve the desired care and understanding. The evident-based research under analysis may be considerably changed in case some ethical principles are taken into account. For example, the issue of confidentiality should not be neglected by nurses, still, to comprehend whether children with AOM should be treated immediately or after watchful observation promote breaking some confidential information about the patient.

This is why, in the chosen EBR, the idea to maintain information confidence should be reevaluated. It is also necessary to admit that this case touches upon children’s treatment, this is why the role of parents should be admitted: children are the representatives of vulnerable populations, and it is better to comprehend how they should be treated and how informed consent may be sedated for procedures.

Vulnerable population and informed consent: the issues to be remembered

Nursing is the sphere of life that divides people into special groups; this division provides nurses with a chance to identify the level of treatment and steps which have to be taken. In nursing, a vulnerable group of people may consist of children, people with doubtful capacity to consent, prisoners, and even students. These people are not able to protect their interests, this is why there is another group of people who have to participate in treatment. Children as the representatives of vulnerable populations should be treated in accordance with information offered by their parents or legal guardians.

These people should also be responsible for informed consent, a document that has some legal power and proves parents’ agreement for their child’s treatment or nontreatment. With the help of this document, an informed patient may be involved in decisions concerning his/her health condition.

All nurses have to consider the all above-mentioned ethical issues in their practice. Children who suffer from AOM are in need of appropriate treatment, still, there are several instances that have to be overcome before the final decision concerning activities in regard to a child is made. Still, it is very important to evaluate the situation and the conditions under which a patient is at the moment. There are some cases when immediate activities and treatment are favorable to save a human life; at the same time, these immediate decisions may negatively influence the human condition and lead to some unpleasant results which could hardly be understood by parents or by any other person.

Conclusion

In general, the idea to evaluate the case when children with acute otitis media are required for immediate antibiotic treatment or watchful waiting seems to be powerful from numerous perspectives. On the one hand, such a definite case helps to consider a number of ethical issues like vulnerable population (children are the representatives of such population) and informed consent that has to be presented by children’s parents or guardians. The necessity to maintain confidence is also burning in the chosen evidence-based research. With several informative pieces of literatures, the comparison of two different methods of treatment is evaluated.

As a result of the comparison, it is stated that watchful waiting may become an appropriate approach to treat young children with AOM under specific conditions such as appropriate diagnosis, age identification, and systems that may reevaluate child’s conditions in case it is necessary. Evidence-based research is a unique chance to understand how it is better to succeed in nursing practice, and this paper properly analyzes the approaches which may be used in regard to a particular group of patients under specific conditions.

Reference List

American Academy of Pediatrics and American Academy of Family Physicians. (2004). Clinical practice guideline: Diagnosis and management of acute otitis media. Web.

Block, S. L. (1997). Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. Pediatric Infectious Disease Journal, 16, 449–456.

Dickson, G.L. & Flynn, L. (2008). Nursing policy research: Turning evidence-based research into health policy. New York: Springer.

Kelley, P. E., Friedman, N., Johnson, C. (2007). Ear, nose, and throat. In W. W. Hay, M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.), Current pediatric diagnosis and treatment. New York: McGraw-Hill.

McCracken, G. H. (1998). Treatment of acute otitis media in an era of increasing microbial resistance. Pediatric Infectious Disease Journal, 17, 576–579.

Mintegi-Raso, S., Benito-Fernando, J, Fuente-Diez, I., Garcia-Gonzalez, S., & Mora-Gonzalez, E. (2007). Antibiotic treatment vs. watchful waiting in non severe acute otitis media: a retrospective study from an emergency department. Italian Journal of Pediatrics, 33, 17-21.

Natal, B & Chao, J. (2009). Otitis media. eMedicine from WebMD. Web.

Newhouse, R.P., Dearholt, S.L., Poe, S.S., White, K.M. (2007). John Hopkins nursing evidence-based practice model and guidelines. Indianapolis, IN: Sigma Theta Tau.

Rosenfeld, R.M. & Bluestone, C.D. Evidence-based otitis media. Hamilton: BC Decker.

Smith, J (2010). Parent of the Child, Private Clinic. Personal Interview.

Introduction

Evidence-based clinical practice is a derivation of evidence-based medicine. It involves conscious and judicious judgment based on existing evidence to come up with rational decisions regarding a particular case. This approach involves the collection, interpretation, and gathering of information which are relevant, valid and applicable to patient case scenario. The resulting report is based on clinician observed, tested and research driven information as evidence to the selected line of treatment. This method emphasizes on incorporation of particularized clinical expertise and external clinical evidence into interpretation and analysis of collected data in order to come up with relevant diagnosis (Buysse & Wesley, 2006).

In general, this practice is based on evidence and independent analysis of each patient case. It explicitly acknowledges the roe of evidence in assisting decision making with regard to patient case treatment (Buysse & Wesley, 2006). Clinical decisions are to a large extent based on the level of collected evidence. However, it is important to note that such evidence is evaluated against available research evidence (Duffy, Fisher & Munroe, 2008). The clinical cases study presented in this paper takes a step by step approach towards evidence based clinical practice.

Clinical Case

Clinical situation

The patient in this case is a 52 year old female with an educational level 8. She is a smoker and does not take alcohol. However, the patient takes heavy dosage of caffeine on daily basis. Additionally, the patient occasionally engages in exercises. The patient previously took up to 12 sodas per day and had been advised to cut down her soda intake take ice tea and sugar. Being in postmenopausal period, the patient has had no abortions/miscarriages during her life. She weighs 162lbs with a height of 5 ft 1, translating into a BMI of 30.6. Her pulse is 80.

The patient attends the clinic for follow-up previous visits medical tests. These included lab/imaging results, follow-up on unspecified hyperlipidemia, essential hypertension, and mood disorders. The patient complains of wanting to go through his blood work and discuss his medications. Indications show that the patient has been working out diets and has cut smoking to two to three cigarettes a day. She has lost weight though she does not report any kind of fatigue or fever. She complains of muscle pain but the joints have no pain.

A physical examination of the patient reveals no signs of illness, obesity, no signs of acute distress and she is wearing appropriate dress and is hygienically fine. His head shows a normal appearance with a stable midline posture. The eyelids are normal and the conjunctiva is clear. The patient’s pupils are equal, round, reactive to light and accommodation. The eye, nose, and throat are clear and non-tender. No inflammation is recorded and neither are lesions.

The neck appears normal and the lymph nodes show no signs of enlargement remains supple and show no tenderness. The respiratory system is unlabored, clear on auscultation and the patients do not cough. Cardiovascular inspection reveals no jugular venous distention and the carotid auscultation returns a normal verdict. Visual inspection of the gastrointestinal systems returns a normal verdict and active bowel sounds are recorded from all the four quadrants with no bruits.

Cranial nerves examination shows that they are all grossly intact. The Deep Tendon Reflex exam shows symmetry and 2+. Musculoskeletal shows no weakness, spasms, atrophy or any form of tenderness. The tone is normal. The pain shows no signs of pain on movement. Her skin is also normal. She experiences generalized warmth and normal turgor. Her speech is logical, relevant and organized.

The patients past medical history revealed that she has suffered allergies, high blood pressure, high cholesterol levels/hyperlipidemia, and asthma. The patient has also suffered emphysema, reflux, arthritis, several headaches, migraines, and insomnia. Family history also reveals that the patient’s father has suffered heart disease, while the mother has suffered breast cancer and diabetes while the sister was diagnosed for diabetes. The patient has also been previously reviewed for mood disorders, chronic airway obstruction, impaired fasting glucose and allergic arthritis in addition to the aforementioned conditions.

Hypothesis

Based on the collected evidence the investigation was narrowed down to three possible conditions. Having complained of muscle pains, a possibility of hyperlipidemia is considered for further evaluation and possible confirmation or disqualification (Project MATCH Research Group, 2007). Additionally, mood disorder is considered given her sudden visit to the hospital on the pretext of wanting to follow up on her medical condition.

Analysis of hyperlipidemia: Ideally, the patient’s history formed the basis for this analysis. She was noted as having not lost any significant weight and not suffering from any acute illness. In general, her state was steady. To come with a diagnosis, a number of tests were conducted. The patient is also tested for diabetes based on her medical history.

Diagnostic tests

To come with appropriate diagnosis, a number of tests were conducted which include a check in the level of glucose, urea nitrogen and creatinine among others. While most were found to be normal, interested areas include potassium which was found to be low, cholesterol levels which were found to high, triglycerides, which were found to be high, and LDL cholesterol which was found to be high. The results indicated that the levels of cholesterol total, HDL cholesterol, triglycerides and LDL cholesterol were 257, 50, 198, and 167 respectively. Another area of interest was hemoglobin with a value of 6.4 signaling increased diabetes risks.

It is important that in such situations the suspected ailments are weighed against the existing literature to come up with the best diagnosis. Conducted test include the following: Lipid profiles testing in the laboratory: the test conducted here include cholesterol screen HDL as well as triglycerides testing. VLDL is also calculated by division of the obtained value for triglyceride by 5 (Project MATCH Research Group, 2007). Subtraction of HDL cholesterol and VLDL gives the LDL value. It is often desirable that cholesterol levels are kept at levels below 200mg/dL (Smith, 2009). Between 200 and 239 mg/dL are termed as high concentration borderlines.

At eves greater than 240mg/dL. Hypercholesterolemia is said to be present. As total cholesterol levels fall, cardiac occurrence risk is greatly minimized. Values less than 150mg/dL are said to be normal triglyceride values. Borderline concentrations range from 150 to 199mg/dL while values of between 200 to 499mg/dL are considered high (Smith, 2009). Values greater than 500 are extremely high. For HDL concentration, 60mg/dL are considered high. Values below 40mg/dL pose a greater risk of the patient suffering coronary attack. For women though the value is marginally set at a value of less than 50.3 mg/dL. Given its interpretation on the basis of total cholesterol as well as LDL, the value of HDL may prove insignificant in those incidences where the value of LDL is very low.

For less than 100mg/dL cholesterol levels, the situation is considered optimal. Between 100 to 129 and between 130-159 mg/dL are considered near optimal and borderline respectively. Values ranging form 160 to 189 are considered high. Emerging evidence however, indicate that normal human LDL cholesterol concentration may be as low as 70mg/dl. Coronary heart disease risk is believed to decrease as the concentration of LDL cholesterol also decreases.

Diabetes is related to blood glucose levels. A number of tests are useful in order to come up with conclusive evidence that a patient is diabetic (Cooke & Plotnick, 2008). Fasting plasma glucose (FPG) test is useful in measurement of a person blood glucose level if the person ahs not eaten within the previous 8 hours. Oral glucose tolerance test (OGTT) on the other hand provides a measure of an individual glucose levels after the individual has fasted for at least a period of 8 hours or has drank a beverage containing glucose 2 hours prior to the test. Another test performed in testing diabetes is the random plasma glucose test which test blood sugar levels regardless of the time the person being tested last ate.

All these tests are useful in diagnosis of both pre-diabetes condition as well as the condition itself. For persons recording positive diabetes test results, a similar test should be repeated on another day to confirm the test results.

FPG is the preferential testing method given its low cost and increased convenience. It’s however less precise as compared to OGTT and can easily miss some cases which are detected by the latter. It is more reliable when conducted in the morning hours. Its results are as summarized in the table below:

Table 1: FPG test.

Compared to FPG, OGTT is more sensitive in re-diabetes diagnosis. It is however, less convenient. Like FPG it is subject to at least 8hours of fasting prior to the test. The level of plasma glucose is then measured 2 hours after the person being tested has drunk 75gms glucose content liquid dissolved in water. Table 2 illustrates the results of this test in a better light.

Table 2: OGTT.

Pre-diabetes, also referred to as impaired glucose tolerance, indicated that the individual in question suffer elevated risk of developing diabetes though at the time of test he/she has not actually developed the condition. Like the case of FPG, once levels found to be beyond 200mg/dl, the test is repeated another day to confirm if indeed the person has the condition or it was just a case of spontaneous blood glucose elevation.

Random plasma glucose tests concludes diabetic condition of an individual if a 200mg/dl, glucose level is recorded and accompanied by a number of symptoms including increased urination, high thirst rates and loss of weight that is not accounted for. Other possible symptoms associated with diabetes include general fatigue, allured vision, high rates of hunger and non-healing sores (Cooke & Plotnick, 2008). The results are confirmed on a different using the other testing techniques.

The basis for testing the patient for diabetes was drawn from his obese condition, more so with regard to age. Additionally, the patient’s family history indicated that both the mother and the sister had previously suffered diabetic condition. The patient’s history also indicated that she had previously been diagnosed with high blood pressure. The father has also previously suffered a cardiovascular disease. These factors informed the decision to consider diabetes as one of the possible ailments that the patient could be suffering.

As earlier mentioned, another possible condition investigated if the patient could be suffering from was mood disorders or depressions. Depression is often characterized with a number of functional disabilities that that of a normal person. Depression was considered due to a number of factors that the patient had recorded based on his medical history. These include obese condition, previous suspected cases of arthritis, hypertensions and diabetes.

All of which are related to depressions. Diagnosis of depression includes both physical and psychological evaluation. Its possibility can only be ruled out based on physical examination, patient-physician interviews and tests conducted in the laboratory. Screening is a common too used for its diagnosis. A through diagnostic evaluation traces the patient’s history from the time the earliest signals were observed, their severity, to the mode of occurrence. Drug abuse is an important factor considered in diagnosis of depression. It is also worth establishing if other family members have previously suffered from similar conditions.

Other laboratory test may be performed which include CT, MRI, SPECT among others though not yet widely used. It is however, important to note that though the laboratory test are more efficient and reliable, they have high costs attached which limits their usage to only sever cases. Unlike physical examination and oral interviews which are less costly they increased the patient’s medical bill enormously. It is on this basis that in this case, laboratory test received little focus.

Diagnostic and treatment plan

After a thorough and careful analysis of the possible diagnosis, hyperlipidemia was chosen as the diagnostic problem that the patient was suffering from. This was after it was established that the patient’s glucose level was normal and hence she was not diabetic. However it is important to note that the patient suffers increased risk of diabetes based on the result obtained from hemoglobin test. This is considered as an under factor that could further increase the effect of hyperlipidemia. Additionally, the patient experiences logical and appropriate decision making. He presents logical and relevant thoughts as well as perceptions.

This is in addition to giving organized speech ruling out the possibility of depression. However, all indication point towards hyperlipidemia with lots of discrepancies recorded in cholesterol levels. A treatment plan is therefore developed for hyperlipidemia as shown below:

• Step 1: obtaining of complete and fasting lipids: This step involves obtaining laboratory information of lipids with regard to the patients. In this case the obtained results are that the levels of cholesterol total, HDL cholesterol, triglycerides and LDL cholesterol were 257, 50, 198, and 167 respectively. LDL recorded is 167 which is high. Likewise is the total cholesterol level as well as triglycerides.
• Step 2: CAD identification in patients: Coronary heart disease is associated with hyperlipidemia. It poses an unfavorable prognosis and the need for early identification cannot be overstated.
• Step 3: assessment of risk factors: This is fundamental steps which involves identification of possible risk that patients are subjected to. Based on identified condition, medical intervention measures which may pose risks to the customers are identified to ensure that the treatment approach employed does pose risks to the client.
• Step 4 assessment of increased number of risks

Table 3: Framingham Ten Year Risk.

• Step 5: therapeutic lifestyle changing initiatives undertaken: These include dietary changes, consumption of soluble fibers (10-25gm/day), plant sterols for lower LDL, increased exercise by the patient, and weight management initiatives.
• Step 6: drug therapy alongside therapeutic lifestyle changes. After three months and TLS fails to yield changes, introduce a drug regime. As mentioned earlier, drugs vcan either be administered independently or jointly depending on the diagnosis. Based on this case, the patient showed increased signs of hyperlipidemia while at the same time showed increased risk of diabetes. She is therefore to be started with pravastatin and metformin. Other possible drugs in case of unsuccessful results are indicated below:
  • Atorvastatin – Lowers LDL and TG to a great level.
  • Lovastatin: Allows one to take whole foods
  • Pravastatin: Has least interaction with the pathway used in elimination, its taken on empty stomach.
  • Simvastatin: potent and requires lots of prevention data.
  • Fluvastatin: has lesser potency and reduced prevention data.
  • Rosuvastatin: increasingly potent. Raises HDL and lowers TG.
• Step 8: metabolic syndrome identification: Underlying cause of obese are treated as well as inactivity physically.
• Step 9: treatment of elevated TG >150: After lowering LDL, if TG remains higher than 200, drug therapy is increased. For TG greater than 200, initially lower triglycerides t eliminate possibilities of pancreatitis. Once maintained at below 5000, LDL treatment is resumed.HDL<40 is treated after LDL is lowered.

Legal and/or ethical concerns

Physicians owe a legal duty to the patients with regard to provision of healthcare and confidentiality of information. Under no circumstances is a physician allowed to divulge patient information except is such circumstances are aimed at improving the patients welfare. Additionally, the physicians have a legal mandate to ensure that the diagnosis they come up with and its relevant treatments are as accurate and precise as possible. The medication prescribed to a client should not be detrimental to that client.

Conclusion: In general, it may be concluded that evidence bas nursing practice is time intensive and requires a lot of dedication. However, its success has seen a number of organizations adopting it and incorporating it into its medical practice. It popularity continues to grow by the day. Patients are treated based on a number of factors that may contribute to the ailments they suffer there by making it a wholesome treatment approach as compared to the other techniques available in nursing practice.

References

Buysse, V. & Wesley, P. W. (2006). Evidence-based practice: How did it emerge and what does it really mean for the early childhood field? Zero to Three, 27(2), 50-55.

Cooke D. W. & Plotnick, L. (2008). “Type 1 diabetes mellitus in pediatrics”. Pediatr Rev 29 (11): 374–84.

Duffy, P., Fisher, C. & Munroe, D. (2008). “Nursing knowledge, skill, and attitudes related to evidenced based practice: Before or After Organizational Supports”. MEDSURG Nursing 17 (1): 55–60.

Project MATCH Research Group. (2007). Matching Alcoholism treatments to client heterogeneity: Project MATCH post treatment drinking outcomes. Journal of Studies in Alcoholism, 58(12): 7-29.

Smith, L. L. (2009). “Another cholesterol hypothesis: cholesterol as antioxidant”. Free Radic. Biol. Med. 11 (1): 47–61.