uebc essay

Student no.: 09018509 Utilising Evidence Based Care

In this essay, I am going to consider how evidence-based practice can be used to support,

justify, legitimate and/or improve clinical practice. I am also going to explore and discuss

primary and secondary research evidences about how nursing interventions can potentially

improve the quality of life of patients in the community suffering from heart failure. I will

gather these evidences using a literature search which I will include an account of. Using a

critiquing framework for support, I will appraise both primary and secondary evidences that I

have chosen. I will also look at potential non-evidential factors that can influence evidence

utilisation in practice. Finally, a conclusion will be drawn.

Evidence-based Practice (EBP) is about utilising the finest scientific evidence available,

incorporating it with clinical experience, patient value and preferences to change or improve

targeted healthcare practice (Houser & Oman, 2011). Consequently, it provides professionals

a way to address queries to provide best quality care (Fawcett et al, 2001). EBP is also one of

the professionals’ responsibilities under the Nursing and Midwifery Council (NMC) code of

conduct in which they stated that professionals must deliver care based on current and best

evidence attainable (NMC, 2008). However, problems may arise with this method that can

affect certain nursing interventions. For example, referencing the aspect of care that I have

chosen, there might be new evidences for or against specific nursing actions to help heart

failure patients. There may be new research to improve current practice in helping heart

failure patients more effectively and efficiently. This shows that professionals should always

be aware of new information within their area of care. There are a lot of evidences available

to professionals but it may be quite difficult for them to determine which ones provide good

quality information. Due to this, hierarchies of evidence have been developed. Hierarchy of

evidence is about grading primary sources on which one provides better evidence based on

their design (Evans, 2003). This reflects different types of research designs to distinguish

ones that are susceptible to bias to ones that have sound results [National Health Service

(NHS) Centre for Reviews and Dissemination, 1996].

Mulhall (2002) and Hanberg & Brown (2006) cite the gap between research and practice and

how it can be implemented. In order for EBP to work, adjustments to attitudes, values and

work behaviour have to be made (McCluskey & Cusick, 2002). These are factors that deter

EBP as some staff may be reluctant in changing their practice. This may be because they lack

trust to evidence (Spallek et al, 2010) or they cannot see the reason behind the changes being

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made. For example, a nurse that had been working in dealing with heart failure patients for a

long time might not want to change her way of carrying things out. EBP obviously can help

in assisting to try and provide best quality care but clearly there are still areas that need to be

considered and further explored to exploit the benefits of it.

In order to ensure I get all possible articles, I have used a variety of resources such as the

library to look for hard-copy of journals and books. As well as this, I used electronic

databases to search for the primary and secondary sources that I require.

Books and hard-copy journals provided me with possible articles to use. However, as I have

chosen a specific subject and a few more criteria to search for articles in this essay, those

articles were quickly disregarded. Afterwards, I decided to perform an electronic literature

search. Firstly, I went to the subject area of Health and Social Care as this perfectly fits my

criteria. Secondly, went onto Databases to see what available databases there are. I have

chosen the British Nursing Index (BNI) and the Cumulative Index to Nursing and Allied

Health Literature (CINAHL) Plus to look for my primary evidence. I have chosen the BNI

and CINAHL Plus as I want to focus on the nursing side of heart failure. I did not choose

PsychInfo or Social Care Online and several specialist databases as I did not want to get any

articles that focus on other perspective other than nursing.

I asked the search engine to look for heart failure in the title section of articles and also

lifestyle as secondary to it. I also used quotation marks to specifically search for heart failure

rather than search each word individually. To further refine my search, I went onto the

chronic heart failure filter. Using these search criteria, I was able to pick the primary

evidence that fits best to my aims.

I used the Cochraine Library to search for my secondary evidence as it is best to look for

systematic reviews which is a form of secondary evidences. I used the advance search feature

of the database. I performed the search using heart failure with quotation marks in the title

section of articles. I also used quality of life and exercise in the abstract of possible articles as

keywords. As well as this, I used the search engine’s function to only show results restricted

to systematic reviews. Using these search criteria, I successfully chosen my secondary

evidence.

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The primary evidence that I have chosen is a study conducted by Brodie et al (2008) about

how a physical activity ‘lifestyle’ intervention based on motivational interviewing, compared

to standard care, can improve quality of life for people with chronic heart failure. The authors

of this article included an account of its approval from the ethics committee to carry out the

research. I am going to be using, but not limited to, the Critical Appraisal Skills Programme

(CASP) tool (2011) to critique areas of this research. This is a randomised controlled trial

(RCT) which according to Guyatt et al’s (2000) approach to grading research, as having the

highest level of evidence based on the method’s effectiveness. However, Evans (2003)

argued that focusing solely on effectiveness of a piece of research, while this is clearly vital,

it is equally important to look at appropriateness and the feasibility of the research.

Appropriateness emphasises the psychosocial aspects of the research; while feasibility

underlines matter associated implementation, cost and practice change. Using these 3

measurements, Evans (2003) still placed RCTs in the higher platform of the evidence

hierarchy. This research’s method can determine the cause-effect relationship of the

intervention and its potential outcomes (Morrow, 2008) which fits to its aims. This proves

that this research is appropriate to its targeted sample. But, there is still the issue of costs and

problems concerning practice change. This regards to the provision of training and time for

nurses to carry out the interviews. If this research is able to provide quality results, then it can

be forwarded to managers to be implemented but there is no warranty to it.

The recruitment method of this research was quite vigorous in terms of the criteria for

eligibility. It is justified by the researchers’ precise aim and their focus to the trial

intervention and the 2 other comparators they have chosen. This research used quota

sampling which Parahoo (2006) defines as the recognition of need for each group to be

sufficiently represented. The researchers used power calculation to predict a quantified sum

that can provide adequate power to identify treatment differences. The calculation indicated a

sample size of 90 with 30 participants for each group to suffice. The researchers found 197

eligible patients. 60 out of 197 were consented and completed the follow-up. The researchers

used their previous method of randomisation on their earlier research (Brodie & Inoue, 2005)

to randomly assign patients to groups. However, no explanation of this method was present in

this current article. This research’s sampling method fits impeccably to its method as it

represents, although not adequate, the different groups (Polit & Beck, 2008). The results

presented no significant differences between interventions but patients that had the

motivational interview showed the most change out of all. The low subject number and

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specific exclusion criteria limited the research’s generalisability. It still, nevertheless,

provided introductory information on potential concepts in providing support for the

implementation of motivational interviewing to change behaviour. The implication of this

research to nurses is focused on the exchange of information during the motivational

interview. The way in which the nurse carries out the interview can have an impact on the

results that will be collected. For example, according to Davis (1980), even the manner in

which participants are greeted can cause unintentional differences in responses. Other factors

such as clothing, age, gender, etc. can still affect results (Cartwright, 1986). On the other

hand, if this is done correctly, it can boost patients’ motivation to amend their lifestyle to

improve quality of life (Rollnick, 1996). In spite of all the restraints mentioned, the results of

this study demonstrated that motivational interviews are effective in improving quality of life

compared to traditional interventions.

I have chosen a systematic review of RCTs done by Davies et al (2010) about exercise-based

rehabilitation for heart failure patients. I am going to be using different tools to critique areas

of this review. Glasziou et al (2001) defines systematic reviews as a piece of evidence with

critically assessed and appraised literature. It is usually ensured that only sound materials are

used in a systematic review which leaves the reader with a consistent and concise piece of

work. National Institute for Clinical Excellence (NICE) produced a guideline called NICE:

Guideline Development Methods (2005) in which they included hierarchies of evidence

adapted from the Scottish Intercollegiate Guidelines Network (SIGN) (2004). This guideline

suggests systematic reviews can provide the highest level of evidence. This is supported by

Thompson and Dowding (2002, p 113.) by stating that systematic reviews meet the “beyond

reasonable doubt standard”. The authors included a clear set of objectives in the paper.

O’Mathuna (2010) emphasises this by saying it is important that the title or the abstract of the

report can clearly reveal whether it fits the clinical question at hand. Although the objectives

of this paper are clear, its title however, is indistinct. Stillwell et al (2010) believes that a

systematic review should start with a detailed question. Due to this, they developed a format

called PICO that authors can use. This abbreviation stands for patient population,

intervention chosen, comparators, and outcomes. This format helps readers to judge whether

the report is clinically relevant or not.

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This review has an in-depth summary of how they searched for their literature. They used

major electronic databases to search for potential studies. They filtered their search to only

systematic reviews, RCTs and meta-analyses which provides the highest quality of evidence

(SIGN, 2004). Each study they have chosen had a full-text report about its quality – from its

abstract to its results. They have also assessed each study’s risk of bias. These measures

should all be considered when trying to produce a high-quality systematic review (Higgins &

Green, 2009). The authors also included a description regarding conflict of interests between

them. This is important as it can increase the risk of bias (Goodacre, 2009). They specified

how they resolved these conflicts. They could have, however, also said whether these

disagreements may have indeed increased the risk of bias. Overall, this systematic review

went through a rigorous process to only get high-quality literatures. This will have a great

impact on its generalisability and value. As a result, it is more likely to be implemented in

practice.

The implication of this systematic review to the aspect of practice I have chosen is quite

significant. This is because heart failure is a progressive disease which has a substantial effect

on the quality of life of patients (Nazarko, 2008). Therefore it is important that constant

researches are being conducted to be able to identify interventions that can potentially

increase quality of life. This review identified exercise programmes as an intervention that

can improve the quality of life and reduce hospitalisations of heart failure patients. No

evidence found as to whether it can increase mortality. There is, of course, the issue of costs.

In this case, funding the provision of training to staff; who is going to carry out the

intervention; and who is going to oversee the whole service. This shows that even evidences

that provide sound results will still have issues during its process to implementation.

This review will have an impact on my future practice as a qualified nurse. Not only did it

give me an insight on the importance of evidence-based practice, it also gave me specialist

knowledge on possible nursing actions that can improve the quality of life of heart failure

patients. If this review does not get implemented, I can use the information in it provide

health education that may improve their quality of life. Reading through this review gave me

an awareness of potential changes that may happen to nursing in the future.

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It is obvious that there is a significant amount of researches available for professionals, but it

appears that various nursing actions are based upon habits, tradition, preferences or influence

from other professionals (Hewitt-Taylor, 2006). These certain factors can inhibit evidence

utilisation in practice.

A major issue about this matter is attitude to change. Sellman and Snelling (2010) emphasises

this by saying that, exclusively in practical terms, changing current or conventional practice

is possibly the most difficult chapter of evidence utilisation. They believe that, in reality,

some people embrace change; some resist it; and in several cases, lack of motivation is

present (Polit & Beck, 2006). Sellman (2003) suggests open-mindedness from all

professionals can help with overcoming this issue. However, there is still a considerable

amount of professionals that finds it difficult to adapt to changes (Campbell et al, 2006).

Campbell et al (2006) identified levels of change focused on its significance to practice

whilst also considering who will have to address the change. This illustrates that the

complexity of implementation depends on the amount of people involved and/or the people

that will be affected by it. Undoubtedly, there is a need for professionals to recognise that

change is unavoidable. This means that there is a necessity for a well-thought plan when

trying to implement changes. In relation to the aspect of care that I have chosen, some heart

failure nurses might show a resistance to the changes that are being implemented. Even

though the current care is still effective, there is no clear assurance whether another

intervention is capable of providing better care to improve quality of life of heart failure

patients.

There are organisational-related barriers present in evidence utilisation. Some organisations

promote evidence utilisation to improve practice. Some organisations do not class it as

priority. Therefore, some staff is experiencing a lack of administrative support (Rycroft-

Malone & Bucknall, 2010). Payne (2000) looks at this issue by focusing on the concern of

power and status. For example, the concept of evidence utilisation might be shut down by

managers whenever staff tries to recommend it. Due to this, the Depart of Health (DoH)

implemented the National Research Governance Strategy (DoH, 2006). This strategy

acknowledged the idea of research application into practice. As well as this, it gave Trusts

and other organisations a responsibility to structure research strategies. This has resulted to

the integration of evidence-based practice education to the higher education system (Polit &

Beck, 2006; Sellman & Snelling, 2010). The published NMC code of conduct (2008) with

supports this strategy as well. This clearly shows that the government is trying its best to

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endorse the awareness of evidence utilisation. However, if organisational-related barriers still

exist, it can greatly hinder evidence utilisation especially when it is combined with individual

resistance to change implementation (Tordoff, 1998). As primary care policies are different to

secondary care, nurses from both sections will experience different levels of difficulty. For

example, a specialist heart failure nurse in the community would work differently to the nurse

with the same post in the hospital. It is, for this reason, important to address organisational

barriers from different areas to be able to provide higher quality care to patients.

Highlighted above are personal barriers and limitations organisations have created. There are

also barriers between professionals that exist. Polit and Beck (2006) characterised this into

two categories. The first category is between professionals and researchers. This is about

conflicts between priorities – researchers try to focus only on the problem they have chosen

while professionals look at problems in a holistic perspective. The other category is barriers

between professionals. This is about consideration of different research having implications

to different professionals. This portrays the importance of ensuring research that has been

chosen relates to their profession. This is also about having an awareness of the hierarchies of

evidence. With these in hand, heart failure nurses will be able to update their current practice

which consequently, can help them achieve their goal of improving the quality of life of their

patients.

Problems may also arise from patients themselves. For example, they may not consent to new

interventions on trial as they are quite used to and happy with the care they have been

receiving. Thus, making it vitally important to update patients with potential changes they

may experience with regards to their care. This aids the information flow between care

providers and care recipients.

It clearly seems that there are a lot of barriers that professionals need to consider to be able to

effectively utilise evidence. It may be more difficult to some or it may be the opposite to

others. But regardless of that, evidence utilisation is something that most, if not all

professionals, should carry out as it is also one of the NMC’s expectations. If done

successfully however, it can greatly improve the quality of the service being provided by

professionals and as a result, patients will be more satisfied with the care that they will

receive and all other benefits that come with it; for example, reducing costs.

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In conclusion, evidence-based practice is essential in providing care. But, it is equally

important to look at potential factors that can hinder its operation. As well as this, nurses

should be aware of the quality of evidence they are reading as this will affect their practice

and those in receipt of their care if it will be implemented. With these considered, nurses can

considerably help heart failure patients in improving their quality of life. There are obviously

substantial amount of barriers present in utilising evidence in practice. This may prove

measuring the benefits of implementing change may be difficult. This emphasises the

usefulness of constant evaluation of practice. As a whole, integration of evidence to practice

is a way to protect professionals from sliding towards poor practice and guaranteeing that

patients in their care are receiving the best possible care.

3,121 words

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References:

Brodie, D., Inoue, A. (2005). Motivational interviewing to promote physical activity for

people with chronic heart failure. Journal of Advanced Nursing. 50 (5), 518-527.

Brodie, D., Inoue, A., Shaw, D. (2008). Motivational interviewing to change quality of life

for people with chronic heart failure: A randomised controlled trial. International Journal of

Nursing Studies. 45 (1), 489-500.

Campbell, S., Hancock, H.C. & Lloyd, H. (2006). Implementing Evidence-Based Practice. In

The Research Process in Nursing. Gerrish, K. & Lacey, A. Oxford, UK.: Blackwell

Publishing.

Cartwright, A. (1986). Health Surveys in Practice and Potential. 2nd ed. London: King

Edward’s Hospital Fund for London.

CASP (Critical Appraisal Skills Programme). (2011). Appraising the Evidence. Available:

http://www.casp-uk.net/index.aspx?o=1203. Last accessed 16 Nov 2011.

Davies, E.J., Moxham, T., Rees, K., Singh, S., Coats, A.J.S., Ebrahim, S., Lough, F., Taylor,

R.S. (2010). Exercise based rehabilitation for heart failure (Review). The Cochrane

Collaboration. Issue 4.

Davis, A.J. (1980) Research as an inactional situation: objectivity in the interview.

International Journal Nursing Studies. (17) 215-220.

DoH (Department of Health). (2006). Best Research for Best Health: A new national health

research strategy. Available:

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/

digitalasset/dh_4127153.pdf. Last accessed 18 Nov 2011.

Evans, D. (2003). Hierarchy of evidence: a framework for ranking evidence evaluating

healthcare interventions. Journal of Clinical Nursing. 12 (1), 77-84.

Fawcett, J., Watson, J., Neuman, B., Walker, P.H., & Fitzpatrick, J.J. (2001). On nursing

theories and evidence. Journal of Nursing Scholarship, 33(2), 115-119.

Glasziou P., Irwig, L., Colditz, C.B.G. (2001). Systematic Reviews in Health Care: a

practical guide. Cambridge: Cambridge University Press.

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Goodacre, S. (2009). Critical appraisal for emergency medicine: 6 systematic reviews.

Emergency Medicine Journal. 26: 114–116

Guyatt G.H., Haynes R.B., Jaeschke R.Z., Cook D.J., Green L., Naylor C.D., Wilson M.C. &

Richardson W.S. (2000) Users guide to the medical literature XXV. Evidence-based

medicine: Principles for applying the users guides to patient care. Journal of the American

Medical Association. 284, 1290–1296.

Hanberg A. & Brown S.C. (2006). Bridging the theory— practice gap with evidence-based

practice. Journal of Continuing Education in Nursing, 37(6), 248–249.

Hewitt-Taylor, J. (2006). Clinical Guidelines and Care Protocols. Chichester: Wiley.

Higgins, J.P.T., Green S. (2009). Cochrane Handbook for Systematic Review of

Interventions. Chichester, UK: Wiley.

Houser, J., Oman, K. (2011). Evidence Based Practice: An Implementation Guide for

Healthcare Organizations. MA: Jones & Bartlett Publishers.

McCluskey, A., Cusick, A. (2002). Strategies for introducing evidence-based practice and

changing clinician behaviour: A manager’s toolbox. Australian Occupational Therapy

Journal. 49 (1), 63-70.

Morrow, B.M. (2008). Randomised controlled trials: fundamental concepts. International

Journal of Therapy and Rehabilitation. 15 (7). 290-297.

Mulhall A. (2002). Nursing research and nursing practice: An exploration of two different

cultures. Intensive & Critical Care Nursing, 18(1), 48–55.

Nazarko, L. (2008). Cardiovascular problems: heart failure. Nursing and Residential Care.

10(5). 233-236.

NHS Centre for Reviews and Dissemination. (1996). Undertaking Systematic Reviews of

Research on Effectiveness. CRD Guidelines for Those Carrying Out or Commissioning

Reviews. University of York, York.

NICE. (2005). NICE: Guideline Development Methods. Available:

http://www.nice.org.uk/niceMedia/pdf/GDM_Chapter7_0305.pdf. Last accessed 17 Nov

2011.

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NMC. (2008). The code in full. Available:

http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/. Last accessed 10

Nov 2011.

O' Mathuna, D. (2010). Critical appraisal of systematic reviews. International Journal of

Nursing Practice. 16, 414-418.

Parahoo K. (2006) Nursing Research: Principles, Process and Issues. 2nd ed. Hampshire:

Palgrave Macmillan.

Payne, M. (2000). Teamwork in multiprofessional care. Basingstoke: Palgrave.

Polit D., Beck C. (2006). Essentials of Nursing Research: Methods, appraisal and utilisation.

6th ed. Philadelphia: Lippincott, Williams & Williams.

Polit D., Beck C. (2008). Nursing Research: Generating and Assessing Evidence for Nursing

Practice. 9th ed. Philadelphia: Lippincott Williams &Wilkins.

Rollnick, S., 1996. Behaviour change in practice: targeting individuals. International Journal

of Obesity. 20(1), 22–26.

Rycroft-Malone, J., Bucknall, T (2011). Models and Frameworks for Implementing

Evidence-Based Practice: Linking Evidence to Action. Oxford: Blackwell Publishing.

Sellman, D. (2003). Open-mindedness: a virtue for professional practice. Nursing

Philosophy. 4(1). 17-24

SIGN (Scottish Intercollegiate Guidelines Network). (2004). SIGN 50. A guideline

developer’s handbook. Edinburg: SIGN.

Spallek, H., Song, M., Polk, DE, et al. (2010) Barriers to implementing evidence-based

clinical guidelines: A survey of early adopters. Journal of Evidence Based Dental Practice

10:195-206.

Stillwell, S.B., Fineout-Overholt, E., Melnyk, B.M., Williamson, K.M. Evidence-based

practice, step by step: Asking the clinical question: A key step in evidence-based practice.

The American Journal of Nursing. 2010; 110: 58–61.

Thompson, C., Dowding D. (2002). Clinical Decision Making and Judgement in Nursing.

Edinburg: Churchill Livingstone. P. 109-129.

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Tordoff, C. (1998). From research to practice: Nursing Standard. 12(25). 34-37.

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Appendix

Primary Evidence

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Secondary Evidence

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uebc essay

Documents

guideline development methods

randomised controlled trial

chronic heart failure

heart failure patients

heart failure nurses

heart failure

clinical question

systematic reviews