In this globalization world, the nursing career had become more challenges and competence. IOM Report (2003) title “Health Professions Education; A Bridge to Quality” have recommended evidence based practice (EBP) as one of the integration of core set competencies into health professions education. Now days, EBP is the most popular topic to be talk and written about in nursing, nationally and internationally. Hitherto, nurses at times don’t understand what is EBP and some nurses are even called it buzzword. The latter couldn’t be further from truth. EBP is here to stay and nurses must understand it.
Sacket et al (2000) described EBP as the integration of the best research evidence with clinical expertise and patients values. Evidence base practice is the application of the best available empirical evidence, including recent research findings, to clinical practice in order to aid clinical decision making evidence based practice is based on the notion of rational decision making. Higgs and Jones (2000) have purposed that evidence in evidence-based practice should be considered to be knowledge derived from a variety of source that has been subjected to testing and has found to be credible. Here the nurse selects all research that has been done in area. These research results are analyzed together, synthesized, coming up with a through integrate review. Then, the research put into the context of clinical expertise and the value system of the patient, and particular protocols or best practices are developed.
In this paper, the important of EBP will be explored in relation to antenatal clinic. The objective of the study is to assess the effect on obstetric practice and pregnancy outcome of routine late pregnancy ultrasound define as greater than 24 weeks gestation, in women with either unselected or low risk pregnancy .The Australasian Genetics Resource Book (2007) highlighted ultrasound is the use of high frequency sound waves to make an image. In pregnancy, an ultrasound gives a picture of the developing baby in the uterus (womb). It is regularly considered part of the routine care for all pregnant women.
The ultrasound is used as both a screening and a diagnostic test either give an indication that the baby is at an increased risk of a problem (a screening test), or it can detect a definite problem in the baby’s physical development for example, in the heart or the kidneys (a diagnostic test). Mostly, a mother will question the nursing staffs working at the antenatal clinic regarding the ultrasound screening whether the process is safety of their unborn baby and themselves.
In the rural area of Malaysia, most of the antenatal clinics have no facility such as ultrasound machine. As a result, the pregnant women with medically indicated and get referral letter from medical officer or midwife have to go to government hospital in the city to have an ultrasound. In difference, the private hospital performed routine ultrasound screening for pregnant women in their late pregnancy.
The selected evidence are cited by Bricker L and Neilson J (2000) ; Routine ultrasound in late pregnancy ( after 24 weeks gestation) track down from Cochrane Library. Cochrane Database of Systemic Review , 2007, issues 1,published by John Wiley and Sons,Ltd. This research is done by qualified person because one of two reviewers was Dr Leanne Bricker who was the consultant in fetal and maternal medicine of Liverpool Women’s NHS Foundation Trust. It could be argue that the reviewer is eligible to do this research and this made the research the more reliable.
WHO Statistic (1999) mentioned that annually 585 000 women die of pregnancy related complications. It is 99% in developing countries and 1% in developed countries. So, we can summarize that every minute one women dies from a pregnancy related complication. In Malaysia, high rate of prenatal and maternal morbidity and mortality continue to be a major problem in the country. A crucial factor of good obstetrics is the provision of adequate care during the antenatal period. Antenatal care was first introduced to medicine in the first decade of this century. Hence, there no qualm that it has a brought gigantic benefit to women and their children. The main purpose of antenatal care is to ensure an uncomplicated for the mother and the safe delivery of a life and healthy infant. At present, modern technology and information technology have beyond more complicated. The equipment such as the ultrasound machine also was greatly up to date. The users of ultrasound as one of the obstetrician armamentarium have been part of the cause to improved antenatal and intra partum care. An ultrasound scan uses high frequency sound waves in very short pulses.
These travel from a transducer, which rests on your skin, and are reflected off different tissues inside you and then received back at the transducer. The transducer passes the signal into a computer that displays an image of your insides on a screen. Usually this image represents a thin 2 dimensional slice of your anatomy. The operator moves the transducer around to get the best views to help diagnosis, whilst watching on the screen for anything abnormal. They will record several images or short video clips to illustrate the scan and these are kept in a computer database that is part of your patient record. The operator will use a small amount of gel on your skin to ensure the transducer contacts your skin effectively. Routine ultrasound can be used in late pregnancy to detect problems which may not otherwise be apparent, such as abnormalities in the placenta in the fluid surrounding the baby, or in the baby’s growth.
The process of evidence base practice involved critical appraisal as one of the step. Hill & Spittlehouse (2001) defined critical appraisal as the process of systematically examining research evidence to access its validity, results and relevance before using it to inform a decision. Ahead of implementation of critical appraisal it is essential to understand research process principal and being able to recognize a well conceived designed of conducted study. The Critical Appraisal Skills provide us what is the best evidence in order to understand the methods and result of research besides to access the quality of the research. Oxman et al 1994, mentioned that the piece of evidence will be critically appraise for it validity and quality using and appraisal tool named, Critical Appraisal Skills Programme (CASP).
The word research means to search again and examine carefully, more specifically, research is a diligent, systematic inquiry or study that validate and refines existing knowledge and develop new knowledge. In fact, research is determined, hand on, received, understand and accepted by nurse practitioner only, (Brown 1999). Furthermore, the ultimate goal of research is the development of a research body of knowledge for a discipline or profession like nursing. Joppe (2000) highlighted that the reliability of result is the key questions in a research.
Brown ,1999;Melnyk & Fineout- Overholt;2005 stated that evidence based practice is the conscientious integration of best research evidence with clinical expertise and patient values and need in the delivery of high quality , cost – effective health care. In this research, the reviewer has made the research more reliable by provided data of all research finding plus a clear precise description of the research methodology.
This title of the research clearly indicates the focus of the study. Above and beyond, the abstract includes the study problem, objectives, search strategy, selected criteria, data collection and analysis, significant result and implications of the findings for nursing practice. This research is significance to read because all relevant information is presented in a way that captures the attention of the reader. Crosby (1990) point out that a well-written abstract gives readers a good idea of what the study is about, how it was conducted and the findings or recommendations by the author.
It is being stated clearly that, the reviewers drew on the search strategy developed for the pregnancy and childbirth as a whole. Relevant of trial were identified in the groups specialized registered of control test. The pilot reviewer assessed trial quality and abstract data under supervision of co-reviewer. Moreover, the trial were not assess blinded as the reviewer have the information about the author identification, source of publication and result when making inclusion criteria. In fact, regarding the disagreement and insufficient data, the reviewer contacted the author personally above and beyond search in all relevant studies in published and unpublished studies.
The publication prejudice is less because all of the studies were in English. The neonatal upshot measures of the research also seek advice from professor of perinatal medicine. By the way, any debarred trial was undoubtedly given a reasonable accused and all the information of follow up was stated in the references. The participants included all women in late pregnancy (after 24 weeks gestation) in both unselected population and the sample size of the trial wide-ranging. The type of intervention used was routine ultrasound examine in late pregnancy (after 24 weeks gestation) to assess one/some/all of the conclusion measure on fetal size; amniotic fluid volumes; placental grading; fetal structural anatomy; fetal presentation. In relation to Crombie (1996), when choosing a study design, many factors must be taken into account because different types of studies are subject to different types of bias.
It claimed that in this study there is no mention about consent and participants were kept in murkiness about the study. Almost certainly, it is great to mull over in the ethical aspect. It could be quarrel that the participants have been treated purely as a source of data. Theoretically, the ethical considerations in all research are the same; the safety and protection of human rights. These rights are mainly could be achieved by informed consent. While no inform consent was taken even so confidentially has maintained. On no account mention any involvement of ethical committee it is a poor steps as explaining the study design is the core of understanding the methodology. Olsen (2003) put in plain words that they are three elements of ethical research to firmly practice.
In this review, all results were presented clearly and were similar from study to study. The reviewers have assessed the quality of each study and include all RCTs of routine ultrasound in late pregnancy after (24 weeks) in the research. Quasi-randomized trials were regard as for inclusion due to scarcity of RCTs. The study was good in view of the fact that the limitations of the research and the reason for any variation in the result were discussed in particular by reviewers. The ultrasound selection were differed among trials; some offering routine scans to all participant earlier in the pregnancy (before 24 weeks gestation), some offering no routine scan at anytime in pregnancy to the control group and some offering scan at all stages of the trial, but only revealing results of late pregnancy ultrasound (after 24 weeks gestation) for the study group.
Furthermore, the rationale for routine ultrasound scan after 24 weeks gestation differed among trials as it is difficult to assess the effect of scan before 24 weeks gestation on the outcome measures. Although the reviewers has point out that the most effective approach to assess the cause of routine late pregnancy ultrasound would be trials where the intervention in late pregnancy ultrasound alone, but this is not such trials exist.
However, the reviewers also have reported on the predictable finding in this study. In the Perth 1993, they were significantly higher intrauterine growth restriction on the Serial ultrasound and Droppler examination group. Even, the author states that it may have a chance finding, it is possible that frequent exposure to ultrasound may have influence fetal growth. On the other hand, none of the addressed long term neurodevelopment results. Exposure of the expectant mother to uncertainty and possible anxiety about the health of her baby has implication of which may be far reaching. The reviewers also have identified the future research on the maternal psychological outcome and long term neurodevelopment outcome.
From the time when, it is not mention what type of ultrasound machine was used and which group of personal is performing the procedure. Sometimes this could probably introduce preconceived notion to the results. In some situation, the ending measured effect the result because the quality of ultrasound imaging is not reach the standard regarding the technical capabilities of the ultrasound equipment and also on the skills or expertise of operators.
There are two type of research method; quantitative research method and qualitative research method. The quantitative research method defined by Burn and Grove (2005), is conducted to test theory by describing variables, examining relationship among variables and determining cause – and – effect interactions between variable. It is a formal, objective, systematic process using numerical data to obtain information about the world. In addition, quantitative method is research method dealing with number and anything that is measurable agreed by (Smith, 1988) that quantitative research involves counting and measuring of events and performing the statistical analysis of a body of numerical data. Counting and measuring are ordinary structure of the method.
More often than not, the outcome or result of the study is presented in tables, graphs or other form of statistic because it is a kind of number or a series of numbers. If truth be told, the quantitative analysis endow with result that is more reliable for statistical approaches. The main concerns of the quantitative paradigm are that measurement is reliable, valid, and generalize in its clear prediction of cause and effect (Cassell & Symon, 1994).
The strengths of the quantitative method are it stating the research problem in very specific and set terms as stated by (Frankfort-Nachmias & Nachmias, 1992). It also clearly and precisely specifies both the independent and the dependent variables under investigation. As well, quantitative method include following firmly the original set of research goals, arriving at more objective conclusions, testing hypothesis, determining the issues of causality. In view of (Balsley, 1970) it’s help achieving high levels of reliability of gathered data due to controlled observations, laboratory experiments, mass surveys, or other form of research manipulations. To boot, this method are also allowing for longitudinal measures of subsequent performance of research subjects. Kealey & Protheroe (1996) indicated that quantitative method rally round eliminating or minimizing subjectivity of judgment.
Despite the fact, the weaknesses of the quantitative method are failure to provide the researcher with information on the context of the situation where the studied phenomenon occurs and inability to control the environment where the respondents provide the answers to the questions in the survey. Limited outcomes to only those outlined in the original research proposal due to closed type questions and the structured format. More to the point, not encouraging the evolving and continuous investigation of a research phenomenon are the disadvantages of using quantitative approach.
According to Munhall (2001) the qualitative research method is a systematic, subjective approach used to described life experiences and situation and to give them meaning. The knowledge generated the qualitative research will provide meaning and understand of specific emotions, values and life experiences. As said by Morgan (1980), the qualitative research shares the theoretical assumptions of the interpretative paradigm, which is based on the notion that social reality is created and sustained through the subjective experience of people involved in communication.
Some researcher using qualitative method are concerned in their research with attempting to accurately describe, decode, and interpret the meanings of phenomena occurring in their normal social contexts as declared by Fryer (1991). In view of that, qualitative approach in general is more likely to take place in a natural setting acknowledged by Denzin, 1971; Lincoln & Guba, 1985; Marshall & Rossman, 1989.
The strengths of the qualitative method as declared by Bogdan & Taylor, 1975; Patton, 1980, it provide a holistic view of the phenomena under investigation. Furthermore, qualitative method is the process of obtaining a more realistic feel of the world that cannot be experienced in the numerical data and statistical analysis used in quantitative research. It also provides the flexible ways to perform data collection, subsequent analysis, and interpretation of collected information. Kirk & Miller, 1986 writes that it gives the ability to interact with the research subjects in their own language and on their own terms. Summarizing, the qualitative approach present descriptive capability based on primary and unstructured data
However, the qualitative method coming up with some weaknesses of as point out by Cassell & Symon (1994) that it departing from the original objectives of the research in response to the changing nature of the context. In that case it also arriving to different conclusions based on the same information depending on the personal characteristics of the researcher. The inability to investigate causality between different research phenomena and difficulty in explaining the difference in the quality and quantity of information obtained from different respondents and arriving at different, non-consistent conclusions appeared as the disadvantage of qualitative method.
It follows requiring a high level of experience from the researcher to obtain the targeted information from the respondent. Lastly, it also contributes lacking consistency and reliability because the researcher can employ different probing techniques and the respondent can choose to tell some particular stories and ignore others.
In spite of that, the quantitative research method is used in this research. Seven eligible Randomized Controlled Trials (RCTs) were participated in this survey. The methodology mostly could be summarized as quality and the reporting of reports were good. Yet, the Glasgow 1984 (UK) study was ‘quasi randomized’ with allocation according to the hospitals number and this had probable to engender bias. On the other hand, RCTs for evaluating the effect of intervention in this study, is used even though it is less in effect in answering questions about patient’s personal experience, attitude or psychological outcome. Sequentially, to explore psychological aspect of the pregnant women during the routine ultrasound screening, it could be squabble that it will be more apt to include qualitative research in this study. Review Manager (Revman) software was used to act upon statistical analysis.
Meta – analysis was used to analyze and combine the result of the studies and it is an appropriate technique of data analysis. The plus of using this type of analysis is that it increases the sample size so that if the significant differences exist they are more likely to be demonstrated. Sacket (1996) mentioned that evidences from systematic review and Meta – analysis has taken the top place of the hierarchy because it provides misleading about the effect of intervention.
In this research, quantitative and qualitative approaches were bringing into being be a foil for each other while the scantiness of each were essentially counterbalance. Conversely, it also point out the time and cost implications, from the time when the volume of data produced was enormous and an tremendously extensive knowledge foot was vital to analyze it.
Seeing as the “method” section is a strength of the study. In this study, the sample size was large (25 036 women) and included variety of subjects. This heterogeneity of the subject has increases the generalizability of the findings as agreed by Burns & Groove (2005). The sampling method, sampling criteria, and sample characteristics are clearly presented. The study could be considered as ethical because it was approval for conduct by an institutional review board but in state of affairs unethical because no informed consent was obtained from the object or sampling.
In this research seven trial comprising 25,036 women were included ( Alesund 1999 ); Glasgow 1984; Perth 1993; new Zealand 1993;Trondheim 1984;Peterborough 1987 ; Radius 1993) . The attribute of the incorporated test on the whole was acceptable as assess by reviewers. There was no difference in antenatal, obstetric and neonatal intervention or morbidity in screened versus control group. From the result of the studies, routine ultrasound in late pregnancy was not associated with improvement in overall perinatal mortality. However, placental grading as an adjunct to third trimester examination scan was associated with a significant reduction in the stillbirth rate in the one trial that assessed it. There was no data on maternal psychological effect. Data with regard to long term substantive outcome in fetal neurodevelopment is lacking.
The study originated that there is thus far no evidence that routine ultrasound improves outcome or increase interventions. The fact, ultrasound could be used in late pregnancy to find the cause of compilation such as bleeding. In some situation, ultrasound screening in late pregnancy appears to be useful in placental grading. In some country, screening all pregnant women for possible problem late in pregnancy is controversial. The ultrasound is seen not demonstrated fetal harm if we use properly followed proper procedure. For the long term side effect, the users of repeated ultrasound are still not fully known regarding the exposure of the fetus. Some problems occur with such screening are increasing major intervention without benefit like caesarian section. Till now, there is no specific epidemiological evidence that ultrasound screening during pregnancy is harmful but no fact conclusion has been reached from available data, for that reason continue awareness is necessary. In spite of that, the policy practice in the antenatal care needs a changeable. So, it is highly recommended that routine ultrasound in late pregnancy only be done for high risk mother such as mother with placental previa.
In fact, further studies on maternal physiological outcomes and long term neurodevelopment outcome for the fetus is essential to be carried out. In addition, the level of performance of technical operator and equipment should be sporadically audited and governed by a dogmatic body to prevent the mother and unborn child. In our day, nursing care is grant access to be root on the modern best evidence, interventions will be more useful and will effect in superior patient outcomes. So, nurses are motivated to learn how to group and interpret data to implement in their practice on the best evidence available.
Evidence based practiced (EBP) has grows to be a critical concept for ethical liable in professionals nursing practice. As said by Mckenna et al (2004), negative beliefs, Krishbaum et al (2004), attitudes and value (Pravikoff et al 2005) have been shown to be powerful barrier to EBP. In order to overcome barriers in EBP, strategies are needed to recover such as awareness, knowledge and skills in evaluating evidences. It is also importance to have administrative support by providing access to EBP or research mentor in practice arena.
As indicated by Avis (2006), the Randomized Control Trials (RCTs) are remains one of the best means to make your mind up whether one form of care is better than another. Since RCTs is purely and evaluation technique, the consequence of knowledge cannot be condense to the application of procedure to fabricate evidence. Besides, understand the result as well as the limitation of relevant research study, it also need an awareness of the background theories which influenced particular research studies.
In my view, this research is simply good because it provide complete information include literature review, sampling method, sampling size and etc. Basically the methodology was performed clearly and the result was presented well. All the statistical tools used were shown and the barrier exist were explained particularly. It is the most swollen with pride that the study had achieved the objectives and was helpful in development of nursing practice.