Nursing Case Studies Example
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Evidence Based Nursing Practice
Nursing has a strong tradition that focuses on different ways of knowing how to provide excellent care. According to Carper’s theory, there are four significant patterns that define nursing which include personal, ethics, empiric and aesthetic patterns. Evidence-based practice (EBP) is a standard procedure that provides nurses with a method that they can use to critically appraise and scientifically prove evidence for the delivery of quality health care to a particular population (Barry, 2014).
Evidence-based practice has an empiric way of knowing and focusing on the methods of critically applying and appraising available research and data to help in understanding and informing nurses towards better decision making. Although evidence based practice is not the only way of knowing, it provides a way of addressing and framing questions on how best patient care can be provided. For the purpose of this article therefore the definition of evidence based practice that will be used is “Application of Skills and Knowledge: Principles of Nursing Practice F” (Gordon & Chris, 2011). It highlights on the significance of combining clinical judgment with the best available evidence and with an emphasis on the crucial role for patient-centered care.
The objective of this study was to explore the awareness and knowledge of nurses' towards EBP on patient care and to explore some of the factors that are likely to encourage or create barriers towards its adoption. The study also includes information sources that were used by nurses as well as their literature searching skills which were also investigated.
Application of Skills and Knowledge for Evidence-based Patient Care
According to The Sixth Principle of Nursing Practice, Principle F, Nursing staff and nurses have to be updated on their skills and knowledge and should use them with understanding, intelligence and insight in line with the specific needs of each patient care. A large number of all the relevant stakeholders was consulted during the development of the Principle of Nursing Practice. As part of the change process, respondents indicated that of all the Principles, only one should address the concept of evidence-based practice and that nurses should also have the capability of implementing the evidence (Gordon & Chris, 2011). This could for instance be achieved through updated training on the skills of using clinical reasoning which is the ability of the nurses to apply evidence in accordance with the context and particular needs of individual patients. Changes in the wording of the principle involved the replacement of clinical reasoning with insight, intelligence and understanding (Belowska, Panczyk & Gotlib, 2014). .
Use of information for Best Practice
Nurses’ knowledge and skills in the delivery of quality healthcare that is based on the constant practice of information that emerges from the best evidence that is available is a very significant component. Evidence based practice has had numerous definitions but one of the most effective, enduring and helpful description was done by (Jeffs et al., 2013) who described it as the explicit, conscientious and judicious use of the best current evidence to make decisions that concern the care of individual patients.
According to Jeffs et al., (2013) definition, there is a strong emphasis on clinical reasoning and expertise together with the integration of expertise with the best evidence available. It is important to note that possessing the latest research in the field is not enough to constitute evidence-based practice. What really marks the transformation and transition of evidence being simply information to best practice is in essence, the appropriate use of information of individual patients within their individual context.
There is extreme danger when evidence is inappropriately placed into practice without prior clinical skills knowledge and reasoning that is needed for the consideration of the applicability and appropriateness of treatments to certain patients (Jeffs et al., 2013). This point is well illustrated by the discussion of the aseptic technique whereby an effective aseptic technique process should be able to prevent direct and indirect contamination of an individual, area or object by microorganisms. It is a technique that can be applied to all clinical procedures with nurses being taught the principles of asepsis together with their underpinning evidence much earlier in their careers. However, although the principles of asepsis may be the same, there are however a wide variety of different techniques that can be used in the making of these principles and hence resulting in different procedures for different healthcare settings.
Although protocols and procedures are used for asepsis, not all of them are evidence based and standard and hence a leeway for poor practice and confusion. There are further problems which may also arise when the practice becomes ritualistic, which may include the fact that clinical reasoning skills may be lost and the balance between practice and evidence may also be distorted (Jeffs et al., 2013). A good example of asepsis can be the case of the use of gloves which is a substitute for good hygiene. Nurses consequently, just like all other healthcare professionals have a key threefold responsibility for ensuring that they are knowledgeable of the latest evidence, to ensure the applicability of the evidence to specific health care settings and practice on procedure and to finally work with other colleagues in the appropriate implementation of evidence.
Nurses can develop their understanding, knowledge and skills as well as application of the latest evidence from research by taking part in the development of national clinical guidelines. Their involvement can be through direct participation as a guideline of a development group in a specified topic area or through the revision of draft consultation documents. It is through their involment in these activities that nurses are able to play the significant role of ensuring that all the guidelines have a nursing perspective within them (Barry, 2014).
Additionally, their involvement in guideline development gives them an invaluable insight and experience in the process of identification, appraisal and analysis of the latest available research evidence and development of recommendations (Gordon & Chris, 2011).
Nurses therefore ought to take advantage the local as well as national data providers to ensure that they continue to improve their practice based process. For example, they can utilize the support of specialist librarians and trust based and hospital libraries. There are also nursing colleges that offer assistance and library services in the identification and acquisition of the latest evidence. These usually have published information on literacy competence framework that help nurses in the development of their skills and in retrieving important information, applying it and putting it to practice (Gordon & Chris, 2011).
Practice Change for Evidence-based Procedures
Nurses can use a wide variety of resources to help them identify the latest evidence. They can for instance use publications for clinical guidelines like the ones by the National Institute for Health and Clinical Excellence as well as the Guidelines and Audit Implementation Network. Nursing Colleges support the development and implementation of various clinical guidelines that have specific relevance to nursing in accordance with clinical effectiveness necessities within its work range (Gordon & Chris, 2011).
The development of measures for nursing principles is an important component that helps to demonstrate and indicate that quality nursing practice is being achieved. It is therefore important to have a set of well-defined measures developed for the Principles of Nursing Practice. According to Palinkas & Soydan, (2012) there is need for considerable work in the development of practical, robust, useful and valid measures of nursing practice. These help to demonstrate the effectiveness of the implementation of evidence to managers, health care professionals as well as the public in recognizing quality nursing care (Palinkas, L. A., & Soydan, H. (2012). Translation and implementation of evidence-based practice. New York: Oxford University Press).
As part of the development of a range of projects that support the implementation of the Principles of Nursing Practice, nursing colleges have conducted scope studies that identify the existent and evolving measures for each of the principles. These studies often involve nursing experts to help ascertain important available measurements that are linked to different principles. Such colleges also have endorsement processes that sanction and ensure there are good quality measurements. The National Patient Safety Agency is an example of how measurements that are based on the latest evidence can be developed. A good example includes campaigns meant to advocate for the importance of regular cleaning of hands that uses several methods aimed at encouraging the awareness of hand hygiene and compliance among staff. This kind of approach prompts and educates health care workers on the significance of cleaning their hands during patient care and is usually accompanied by posters that constantly remind members of staff of this and to also highlight on hand hygiene champions (Lamont, T., & Scarpello, J. (2009). National patient safety agency: Combining stories with statistics to minimize harm. British Medical Journal, 339(7731), 1194. Retrieved from http://search.proquest.com/docview/204031974?accountid=32521)
Hand washing facilities and hand rubs are therefore always readily available as users and patients of the campaign are engaged and involved in the production of user-friendly audit tools and resources that measure compliance. Compliance can for instance be measured through the use of simple, reliable and consistent observation audits. Some of the tools that are available for the auditing of hand hygiene include the Feedback Intervention Trial and the Lewisham Tool. Nurses however, ought to realize that observation alone is not sufficient and may be inappropriate in all of the health care settings. It is therefore important to choose the most appropriate measure for particular settings using clinical reasoning and evidence (Tan, Amil Kusain, Jr., & Olivo, Jeffrey., (2015). Assessing healthcare associated infections and hand hygiene perceptions amongst healthcare professionals. International Journal of Caring Sciences, 8(1), 108-114. Retrieved from http://search.proquest.com/docview/1648623569?accountid=32521)
A case study example of a nurse-led service in the East Midlands will offer a better understanding of the use of best available evidence in patient care services. This particular care service involved surgeries for carpal tunnel syndrome that consequently helped to improve patient outcomes (Macfarlane, G. J. (2001). Identification and prevention of work-related carpal-tunnel syndrome. The Lancet, 357(9263), 1146-7. Retrieved from http://search.proquest.com/docview/198946244?accountid=32521). The service was developed to assist the high numbers of patients who had a presumptive diagnosis of carpal tunnel syndrome and were considered a low priority group and consequently subject to a considerable amount of waiting times between referral and discharge. A rapid access carpal tunnel service was as a result developed. This was based on evidence that supported cost, efficacy, improves patient outcomes and savings (Shaw Wilgis, ,E.F. (2002). Treatment options for carpal tunnel syndrome. JAMA, 288(10), 1281-2. Retrieved from http://search.proquest.com/docview/211355577?accountid=32521).
This service is nurse-led it has been able to provide fast and effective treatment pathways for patients with the carpal tunnel syndrome who undertake surgery in GP practices, this therefore makes them closer to the patients’ homes. Because of the service, the previous16-20 week referral-to-discharge rate was therefore reduced to 12 weeks. Evaluation of the service is also performed by the service providers to enable them measure ongoing efficacy (Newey et al 2006).
It is therefore conclusive to note that nurses do have a pivotal role in ensuring that their patients receive effective person centered care that is safe and based on the best available evidence. This ability of nurses to apply a special combination of clinical reasoning, technical expertise and evidence care to an appropriate range of healthcare settings often develops over time and is a product of experiential learning, formal teaching, reflective practice and effective mentorship.
Challenges in the Implementation of EBP
Nurses face real challenges in their attempts to translate best evidence to clinical practice. To begin with all the relevant research-based databases are usually not comprehensive in most areas posing a threat to coherent data sources. There is also an ongoing explosion of the total amount and type of information that is available. Time constraints are additionally an inherent phenomenon in clinical practice which is also exacerbated by the increasing demands for nursing care. There is furthermore a need for the systematic and accurate ways for making inferences from research that is applied to specific patient populations. A need also exists for accurate and systematic ways to make inferences from the research as applied to particular patient populations (Taxman., & Belenko, 2012)
Bridging this gap between clinical practice and research is able to be accomplished through multiple means. One of the most common methods often used has always involved the incorporation of evidence-based research into organizational procedure and policies (Taxman & Belenko, 2012)
There are however, a number of other operational issues that may arise. To begin with, there are numerous small studies that have been published within the nursing literature, as result, evaluating all of these studies to ascertain scientific merit can prove to be a daunting task. There are therefore certain cases whereby published guidelines can assist to reflect the national standards and hence minimize tasks. Secondly, although it is possible for policies that are changed to reflect the current guidelines that have been developed through evidence, the most important issue is the actual change of the nursing practice such that it is able to reflect evidence based research. For instance, traditionally, the method that was used for the verification of placement of a nasogastric tube was by air insufflation. According to the current nursing research, the radiologic examination is the accurate method that is used for verification (Taxman., & Belenko, 2012)
There are a number of different studies that have been carried out to investigate the perceptions of nurses towards EBP. These generally indicate that nurses view EBP positively and consider it as significant for the improvement of patient care. It is nevertheless a fact that the pace of implementing and accepting EBP is always rather slow. Several preceding studies have attempted to investigate all the possible barriers that can affect the adoption of EBP. One barrier that was included in the study that also has a potential of affecting this evidence based nursing practice is the huge amount of literature on health care that is usually published in a wide variety of different sources. All these make it impossible for individual medical professionals to maintain the readership updated. According to studies, it has been estimated that almost 8,000 articles that are relevant to the family are usually published every month. It is also worthy to note that the average family medicine practitioner is unable to completely dedicate approximately 20 hours the day just to stay abreast with new information (Taxman., & Belenko, 2012).
There are several other barriers that limit the adoption, acceptance and implementation of EBP. Funk et al. designed a questionnaire that is called “Barriers” that investigates the views of nurses towards the problems within research findings. Some of the other potential barriers therefore include the fact that some of the nurses felt that they did not have enough authority needed to change the patient care procedures as well as not having the sufficient time needed while on the job to implement all the new ideas. Yet another significant barrier is the lack of time and resources as well as a difficulty in fully understanding the statistical analysis that are carried out which were all some of the top most barriers towards the adoption of EBP by community nurses (Taxman., & Belenko, 2012).
There is also a significant barrier in the lack of time needed to understand, search for and interpret the research findings. Nurses can find it hard to adopt the EBP due to the inadequate access to information technology (IT), lack of information searching skills as well as limited IT skills. Because of the wider adoption of EBP in the medical fields of today, the barriers in the implementation of have therefore received more attention in all the recent studies (Marshall, Morgan, Klem, Thompson., & Wells, 2014).
Through a keen comparison of the experiences of participants with EBP across three specific health professions, it is worth noting that both the workplace structure and the individual factors work together to enhance the barriers to EBP. Lack of knowledge that pertains to the implementation of EBP also has the capability of placing a huge demand on nurses for them to apply valid evidence to individual patient situations by searching related evidence through the use of clinical judgments as well as giving due consideration to system resources and client values (Taxman., & Belenko, 2012).
Therefore, to effectively apply the EBP process, there is need for training on the basic skills that are required to undertake work. Nurses as a result have to be able to identify all the knowledge gaps, form relevant questions, conduct effective literature search, apply the rules of evidence to help determine the coherence of studies. Nurses also have to apply their literature findings in accordance to the patient problem, they also have to appropriately involve their patient in the all the clinical decision making.
Although nurses a positive attitude toward EBP and consider it significant to their practice, there are several personal and institutional barriers that obstruct its smooth implementation. The purpose of this study was to investigate the role that registered nurses have towards EBP including their beliefs, understanding and attitudes. The challenges towards the implementation of EBP has also been covered with a highlight on the relevant measures that can be taken that include their training needs, provision of relevant information needed and updating their literature searching skills. Findings in the study will be instrumental in the development of standard strategy that promotes EBP among nurses and how well the challenges encountered can be overcome. Since EBP is information-intensive, the findings will similarly be useful in medical libraries for the development of comprehensive training programs aimed at improving the literature utilization and searching skills of nurses as well as other medical professionals.
Barry, M. (2014). Better, safer patient care through evidence-based practice and teamwork.
American Nurse, 46(4), 12.
Belowska, J., Panczyk, M., & Gotlib, J. (2014). Comparison of Knowledge and Attitudes
Towards the Use of Scientific Research in Clinical Practice Among Departmental and Charge Nurses. Polish Journal of Public Health, 124(3), 138-144. doi:10.2478/pjph-2014-0031
Jeffs, L., Sidani, S., Rose, D., Espin, S., Smith, O., Martin, K., & Ferris, E. (2013). Using
theory and evidence to drive measurement of patient, nurse and organizational outcomes of professional nursing practice. International Journal of Nursing Practice, 19(2), 141-148. doi:10.1111/ijn.12048
Gordon, J., & Watts C (2011) Applying skills and knowledge: Principle of Nursing Practice F.
Nursing Standard. 25 (33), 35-37.
Marshall, J. G., Morgan, J. C., Klem, M. L., Thompson, C. A., & Wells, A. L. (2014). The Value
of Library and Information Services in Nursing and Patient Care. Online Journal Of Issues In Nursing, 19(3), 1. doi:10.3912/OJIN.Vol198No03PPT02
Taxman, F. S., & Belenko, S. R. (2012). Implementing evidence-based practices in community
corrections and addiction treatment. New York, NY: Springer.
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