” The institute of Medicine has set a goal that by 2020, 90% of all health care decisions will be evidence based” (Mazurek et al. , 2009). On entering the words “Evidence Based Practice” into the Cumulative Index for Nursing and Allied Health Literature( CINAHL) database in December 2012, the amount of articles to be found by the author of this assignment was 5694. It could be said that this shows the importance of evidence based practice in today’s world of nursing. In 2012, the words accreditation, in private health care settings, Health Information and Quality Authority ( H. I. Q. A) standards, in the public sector and indeed Clinical Governance are spoken every day!
Cranston (2002) stated that for the organisation, clinical governance lies at the heart of quality assurance and that clinical governance is linked to clinical effectiveness which is the goal of evidence based practice. Inevitably as a result of this all health care professionals are required to use evidence based practice in their every day working lives. Thus promoting accountability and quality patient care. However we must ask ourselves is there a down side to all this evidence based practice?
What is wrong with the way we always did things? As already stated above it is a necessity for all health care professionals to use evidence based practice, however for the purpose of this assignment the author will concentrate on the nursing profession, looking at how the use of evidence based practice is important for the patient, the nurse and finally the organisation. On the other hand the author will also look at the barriers of evidence based practice for nurses. The methodology used is that of a literature review on evidence based practice in nursing.
In addition a S. W. O. T. analysis was undertaken by the author looking at the strengths, weaknesses, opportunities and also the threats to evidence based practice. At the outset it is important to firstly look at what evidence based practice is. It has been defined as ” the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett D. L, 1996) In addition it is further described as the “integration of best research evidence with clinical expertise and patient values” (Sackett, 2000).
On speaking about Professor Archie Cochrane, Barker ( 2010) stated that “he argued there was a need to ensure treatment was delivered in the most effective way and to ensure that available evidence was used” (p. 5). The dictionary definition of evidence is a “grounds for belief or disbelief; data on which to base proof or establish truth or falsehood” (Collins 1998) So where you may ask do we obtain this evidence? Well ” the range of different sources of evidence that can inform practice includes personal reflection, journal articles, policies, guidelines, reports and professional consensus, as well as research and audit.
However, the literature generally implies research is the strongest form of evidence” (Dale, 2005). So why is it important to use evidence based practice to the nursing profession? For this section the author has divided it into three; the patient, the nurse and finally the organisation. Improvement in the quality of care received by the patient. The Department of Health and Children (2001) stated that improving quality in the Irish Healthcare system requires the implementation of internationally recognised evidence based guidelines and protocols.
Furthermore Craig and Smyth (2007) stated that ” the main aim of evidence based practice is to obtain the best outcomes for patients by selecting interventions that have the greatest chance of success” cited by Leufer and Cleary-Holdforth (2009). Every working day a nurse carries out daily duties; a bed bath, medication administration, mobilising patients post joint replacement, and many more, the list is endless; but how does the nurse know that what he or she is doing is the best way to do it and indeed perhaps what he or she is doing may be impeding the healing for the patient.
Evidence based practice has been demonstrated to yield improved patient outcomes” ( Killeen and Barnfather, 2005). Recent research carried out on the use of anticoagulation therapy for the prevention of post operative development of deep vein thrombosis and pulmonary embolism following a total knee or total hip replacement surgery, showed the effect of the anticoagulants appears to be influenced by the time of initiation of coagulation more than the effect of the drug itself. (Salazar, et al. , 2011).
Therefore it can be said that the previous practice of commencing the anticoagulant post operatively is not the best for the patient. Indeed commencement pre operatively greatly reduces the risk of developing a deep venous thrombosis or a pulmonary embolism, thus improving the patient outcome. When evidence is used to define best practices rather than to support existing practices, nursing care keeps pace with the latest technological advances and takes advantage of new knowledge developments. ( Youngblut and Brooten 2001). Accountability and Ongoing Education for the nurse as a practicing professional.
In addition to the before mentioned benefit to patient outcomes another strength to evidence based practice is that to the nurse as a professional. The Code of Professional Conduct for Nurses in Ireland states that “each registered nurse is accountable for his or her own practice” An Bord Altranais ( 2000). In order for the practicing nurse to be accountable for his or her practice he or she must ” be able to substantiate the decisions they have made on a foundation of professional expertise which clearly includes using relevant evidence to inform practice” (McSherry, et al. 2006) Nurses and midwives form the bulk of the clinical health workforce and play a central role in all health service delivery (Buscher, et al. , 2009).
Therefore it could be said that nurses can improve the quality of healthcare provided to their patients if they were to use the best evidence based practice. Moreover by carrying out evidence based practice the nurse is maintaining and improving his or her knowledge continuously. Therefore increasing his or her confidence while carrying out his or her daily nursing duties, as he or she is confident that the care he or she is administrating is based on researched findings.
Furthermore in their article on a Spirit of Inquiry Melnyk et al. stated that findings in some studies indicated that when nurses engage in evidence based practice, they experience greater autonomy in their practices and a higher level of job satisfaction. This is of huge importance in these difficult times of staff shortages, cost saving and unfortunately emigration. There is a need to retain the nurses that we have and indeed job satisfaction goes a long way to aid this retention. The Organisation:
Finally in this section the author looks at the organisation as a beneficiary of evidence based practice. Leufer et. al (2009) stated that evidence based practice is highly relevant in a social and healthcare environment that has to deal with consumerism, budget cuts, accountability, rapidly advancing technology, demands for ever-increasing knowledge and litigation. Furthermore in the USA there is a “system where health care follows a business model, it is imperative for organisations to provide the best care based on the best available evidence to ‘attract customers’. (Fitzsimmons & Cooper, 2012).
This indeed could also be said for the healthcare system in Ireland at present, with the increasing demands on health care facilities either public or private to show that they are compliant with strict standards of care. Furthermore some of the many health insurance providers in Ireland will not continue to provide cover to the private hospitals if they do not hold an accreditation award. Moreover as has been seen in recent years H. I. Q. A. ill without a doubt close down healthcare facilities if they do not show themselves to be compliant with the H. I. Q. A. standards. It could be said that the best way to ensure obtaining and retaining these standards is through the use of evidence based practice. As already mentioned in the introduction clinical governance is also of paramount importance in today’s hospitals; Sale 2005 stated that ” achieve clinical governance, organisations are expected to set and monitor standards that are evidence-based. ” as cited by Dale (2006).
In addition in these highly litigious times, an organisation that uses internationally approved evidence based practice could perhaps be less likely to attract litigation cases. However if such a case were to arise the organisation could successfully defend itself, again if it is providing care which is of international best practice standard. Finally in relation to the benefits of evidence based practice to the organisation it could perhaps be claimed that evidence based practice may lead to a change in practice; as a result of said change, indeed cost saving may occur.
For an example of this the author would again like to refer to the afore mentioned study on anticoagulants, if the use of the anticoagulant preoperatively is to reduce the risk of developing thrombosis, this in turn will lead to a reduction in hospital length of stay, when no thrombosis occurs, thus in the long term introducing a cost saving to the organisation. However, even with all the benefits of evidence based practiced as already discussed, throughout the literature review, it was difficult for the author not to discover the weaknesses, or indeed the pitfalls to the use of and the implementation of same.
Lack of understanding! Perhaps one of the main barriers to evidence based practice is indeed the very lack of understanding of what it is! ” Evidence based practice is a well known concept, yet practitioners appear to lack knowledge of the principles that underpin it” (Dale, 2006). It could be said that definitions of evidence in nursing are very broad, Is it literature review? Is it clinical expertise? Is it nursing knowledge? Is it nursing theory? Is it local?
Is it organisational? As evidence based practice is a relatively new phenomenon to the profession of nursing, only really being born in the 90’s, there are a lot of nurses trained before this time who do not understand the concept of evidence based practice. This in turn perhaps leads to another pitfall of evidence based practice! Conflict between professionals: There may indeed be a lack of team effort in implementing evidence based practice in the work place.
As previously mentioned the “old fashioned trained nurses” may not understand what evidence based practice is and may feel that ” I have always done it this way” or ” you’re only qualified what would you know” Resistance to change is very common in all areas of life. ” The extent to which different healthcare professionals work well together can affect the quality of the health care that they provide. If there are problems in how healthcare professionals communicate and interact with each other, then problems in patient care can occur. (Zwarenstein, et al. , 2009).
In addition there may interdisciplinary conflict as a result of nurses carrying out evidence based practice. As already mentioned above in the research carried out by Salazar, et al. in 2011, it is of more benefit to administer anticoagulant therapy pre total hip or total knee replacement; however the nurse does not prescribe these medications and perhaps he or she may not feel they have the autonomy or authority to propose this or indeed even show the consultant or the anaesethist these findings.
There could be a perceived lack of authority to change practice on reflection of research findings ” Medical disinterest is a significant barrier to evidence-based standards” (Sams, et al. , 2004) Unfortunately it would appear from the authors own experience that some surgeons still see the nurses as ” only nurses”. Therefore the nurse may feel this is a waste of time. Speaking of time this leads onto another pitfall in the use of evidence based practice.
Time Constraints: In these times of cost savings, high staff turn over, emmigration and staff shortages, there may be a perceived lack of time to carry out any research or data. It can be said that staff work hard and perhaps they feel as if research is not part of their job, as it is not spelt out in the their job description. However as discussed earlier it is the responsibility of every registered nurse is accountible for his or her own practice.
In addition it could be said that in this nday and age nurses feel that they do too much writing and have less time for hands on care therefore they feel that they really do not have the time for researching data. “Because we are so busy doing the “real” work of caring for patients in the operating room, it is hard to even contemplate activities that would result in more work! We often believe we don’t have the time, that our energies are better directed toward patient care, and that research is something to be conducted by academics;” (Knoll & Leifso, 2009).
If however the time was made available, another question to be asked is; Is there the library facilities available? Lack of study facilities or library facilities: Yes if perhaps the nurse works in a teaching hospital then it could perhaps be presumed that there would be very good library and research facilities to hand to aid in research. However in some organisations there may be a “lack of resources to support changing practice to reflect research findings” (Hewitt-Taylor, et al. , 2012).
However not all hospitals are teaching hospitals, so where does the information come from. In an ideal world the organisation would provide such facilities, however what if there is a: Lack of Organisational Support: Is there managerial support provided? Do management understand the process and the importance of the process for the organisation? Is there a cost involved to the organisation? If there is going to be a change in practice will it be cost effective. Is there organisational readiness to change?
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