Essay which explores the concept of evidence based practice and evaluates its relevance and contribution to practice.
Evidence-based practice is a fairly recent development in healthcare. This involves the healthcare professional judging and making an informed choice from data in their particular field of expertise, combining this with his/her own practical knowledge and then make an independent, informed, opinion based on the strengths and weaknesses of the two.
“Historically, nursing, and specifically clinical procedures, have been very ritualistic” (Walsh & Ford 1989; Ford & Walsh 1994) Dougherty p.2).
Nurses were traditionally taught to ‘do procedures by the book or by rote’ and it was not until the 1970s that it became accepted practice for nurses to be given an amount of leeway, in that they gradually started to be trusted to use evidence based procedures.
Research points to the right thing to do in a particular situation – this can be influenced by recommendations from professionals and experts, as well as feedback from clients and users. Put succinctly, evidence-based procedures enable research to be put into practice. A clinical audit is a way of finding out by means of evaluation and interventions if practice has been improved and, importantly, if the practice is cost effective. It is important to set clear standards of practice to ensure this outcome. It is also important to ensure that all fundamentals of practice are met – this is achieved by a consideration of risk management.
“Risk can be defined as the possibility of incurring misfortune or loss resulting:
· harm to patients
· resources being diverted to provide extra treatment to correct the initial injury
· resources being diverted to the investigation of complains, adverse incidents and medical negligence
· harm to the reputation of the provider because of poor performance
· reduction in confidence of the public (adapted from Swage 2000)”
When a healthcare professional has the ability to adapt a skill in practice, it means that there is an underlying understanding of why a procedure is being carried out and knowledge of what is required at each stage, and why. Knowledge gained from practice is complex and can arguably be more valued than what is learned purely from theory. All nurses are accountable for their actions, and they need to be able to rationale their actions based on knowledge. This knowledge can also be derived from their experience. A good nurse will be able to recognise subtle changes in a patient’s condition and should act accordingly.
Almost 140 years ago Carl Wunderlich established that there was a significance of changes in body temperature when it came to identifying illnesses. He established that there was a ‘normal’ range of body temperature and if it deviates out of this range then there is a probability of disease. It therefore became important to establish a reliable method of measuring body temperature.
Until relatively recently, mercury thermometers were mainly used by medical professionals. Electronic thermometers take the reading by means of an electronic probe rather than the mercury column; digital thermometers take many forms. Some are in the form of a probe which, when covered by a plastic sleeve, can be used between patients with the sleeve being changed for each patient. Sometimes it is put under the tongue (sub lingual), in the armpit (per acilia) or put gently into the anus (per rectum). It is usual to use the sub lingual or per acilia as these are less intrusive for the patient and cause less distress. However, a rectal reading can be more accurate in the case of extremes of temperature. The sub lingual and per acilia methods can be affected by environmental factors which lead to an inaccurate reading. If the patient has just had a hot or cold drink or recently taken off clothes, this can affect the reading. Consequently, this makes the rectal method more accurate in cases where the patient is very ill and an accurate reading is absolutely essential.
Tympanic thermometers use a reading of the tympanic membrane in the ear and show this as a reading on a small digital display: this method is commonly used in hospitals today for quick temperature readings of newly admitted patients or those in A and E. The tympanic membrane is a thin structure in the patient’s ear canal and it is well perfused with blood. The sensor at the end of the probe records infra-red radiation (IRR) that comes from the warmth issued by the membrane. It then translates this into a digital reading on a screen. The probe is covered by a disposable cover and between patients it is changed in order to eliminate cross infection.
“It has been suggested that tympanic thermometers give a more accurate representation of actual body temperature because the tympanic membrane lies close to the temperature regulation centre in the hypothalamus and shares the same artery” (Van Staaij et al, 2003).
The aspect of professional practice that I have chosen is that of paediatric care. This deals with medical care of infants, children and young adults so there is a wide span of expertise needed within this field. Paediatric nursing deals with different, smaller body sizes from adult nursing and there are many maturational changes. It is not enough to treat a child as a ‘miniature adult’ because children are not simply that. Children and minors cannot give informed consent and make their own decisions. It is essential for care in a paediatric setting to involve the parents or guardians and explanations of every procedure may be required by them.
Companies promote the purchase and use of tympanic thermometers in households. These types have therefore become very common in the home and they are seen as being fast, non-intrusive and effective. This may be true in the home where strict accuracy is not as essential as in a professional environment. There are other factors, however, which need to be considered in the paediatric situation. The accuracy of the reading may be influenced by variations in ear wax and this might cause a false low reading.
Tympanic thermometers are not recommended if a child has an ear infection. There is a need to be very gentle with the child and not push the thermometer too far into the ear canal. Both of these factors can cause increased stress to a child. If a child is fidgety , a children often are, then this can affect the reading too. It is difficult in these circumstances to get a young child to sit quietly and keep his/her head at the correct angle to get an accurate gauge. The thermometer must be pointed directly at the ear drum to work properly. It is essential to keep the lens very clean and free from fingerprints, wax, or scratches, and these thermometers should not be used on very small babies. Medical staff are trained not to rely on readings made by parents due to the accuracy of the procedure being called into question.
Tympanic thermometers are often used when the patient is under anaesthesia during surgery, as well as in the intensive care of young people. Children and young people with learning difficulties benefit from the fast method of this procedure.
Evidence-based practice has established the following practice for use of tympanic membrane thermometers:
After explaining and discussing the procedure with the parents and child, hands should be washed and it should be ensured that the same ear is used on consecutive readings (there can be a difference of up to 1degree C between ears), make sure that the thermometer is taken from the base unit and is clean and ready for use.
· place disposable probe cover on the probe tip, ensuring the manufacturer’s instructions are followed
· gently place the probe tip in the ear canal to seal the opening, ensuring a snug fit
· press and release SCAN button
· remove probe tip from the ear as soon as the thermometer reads DONE, usually indicated by bleeps
· Press RELEASE/EJECT button to discard probe cover
· replace thermometer in base unit” (Doughty, p470)
A lot of what is taken for granted with nursing practice is because of routine procedures rather than research findings. Usually, nurses’ practice does not go exactly ‘hand in hand’ with research. Nurses generally do appreciate the importance of research, but they do tend to be institutionalised into keeping to the norm.
“ Some major barriers to evidence-based practice have been identified:
· nurses do not know about it. Access to resources such as the internet or the appropriate journals where the relevant research can be located can be problematic.
· Nurses do not know how to do it. Nurses often feel they lack the necessary expertise required to both find the literature through systematic searching and appraise the scientific merit and relevance of available research literature.
· Nurses do not have time for it. The high workloads and acuity levels within current and clinical practice mean that nurses often do not have the time to access, appraise and implement relevant research findings
· Nurses do not have adequate access to computers or quiet space for reading and reflection.”
(Lynch et al, p32)
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Lynch, L & Hancox, K & Happell, B & Parker, J – Clinical Supervision for Nurses. Wiley, Oxford (2008)
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