Implementing Evidence-Based Practice in Nursing

Need for Evidence-Based Practice

Research evidence (e.g. NICE, 2015, Watson et al 2008, Polit & Bridges 2010, Polit & Beck 2006, Harvey 2015, Harber 2013, Griffiths & Bridges 2010) has proven that nurses are more likely to achieve better patient outcomes, in minimum costs, when they implement evidence-based practice (EBP). First, EBP can be defined as the transformation of new knowledge and its implementation across the healthcare system to create better patient outcomes (NICE, 2015). According to Brownson et al (2012), Watson et al (2008) it is the use of the latest research evidence in clinical decision-making to deliver the best care quality to patients. Its main intention is to standardize the practice of healthcare that is anchored on best evidence, thereby making practitioners more accountable to their decisions while eliminating an illogical variation in care practice (Improvement Science Research Network, 2010, Keele 2011, Fitzpatrick & Kazer 2012, urns & Grove 2010, Munhall, 2007, Hymel, 2006, Boswell & Cannon 2010). There are several advantages of EBP and possession of EBP skills by nurses. For instance, according to Mitchell et al (2010), Parahoo (2014), De Chesnay (2015), Cutcliffe & Ward (2006) EBP skills enable nurses to provide care based on scientific knowledge and research rather than myths, advice from other practitioners, or traditions. According to Schneider et al (2012), Munhall (2011), and Hicks (2009) the implementation of EBP requires nurses to undertake four major steps of identifying patient problems and developing a clear clinical question from it, conducting a literature search from relevant clinical literary materials, examining the evidence and their application to the underlying question, and implementing the findings into practice. Therefore, nurses are more likely to deliver care based on scientific reasoning rather than assumptions. Nonetheless, EBP helps nurses to maintain relevant and current practice approaches and enhances their confidence in decision-making.

The purpose of critiquing tools

Upon discovering the critical importance of EBP in the practice of nursing, practitioners have held, with high regard, different tools for critiquing research, as they give a roadmap as to the specific items they need to consider when critiquing research. According to Brownson et al (2012), Brink & Van Der Walt (2006), Merwin (2008), and De Chesay (2014) nurses use critical appraisal tools to systematically analyze clinical research especially when they want to identify whether the research has a clearly defined research question, whether the researchers used a clear method of addressing the underlying research question, whether the results are valid and whether the results are applicable to local practice. This implies that if the study does not cover all these elements it is not worth using as a source of evidence for practice.

There are different types of critical appraisal tools such as the Critical Appraisal Skills Program, Cochran ROB for Randomized Control Trials, the Wallace for qualitative studies and the AMSTAR for systematic reviews. However, before evaluating each type and their respective advantages/limitations, it is important to understand that all the tools are meant for relatively similar purposes. For instance, AHRQ (2008) observes that critical appraisal tools enable an evaluation of study purpose and whether it is stated clearly. Ideally, a clearly stated study purpose helps in determining the importance of the topic, its focus, and whether it may be of interest to the practitioner. This means that by using the appraisal tools to evaluate the study purpose, nurses can identify whether the study findings can be applied to their situation before they can continue to read the whole research report.

Critical appraisal tools also guide nurses in identifying whether the study author has reviewed the relevant literature that makes up the background of the study (Improvement Science Research Network, 2010; De Chesnay 2014, De Chesnay 2015). Nurses are interested in the literature review because they need to understand any knowledge gap in the field of interest thereby having a clear justification for reading and using the research evidence presented therein. Lastly, Critical appraisal tools are useful in evaluating the study design and approach used to achieve the respective research objectives (Gerrish & Lathlean, 2015). Ideally, researchers use different terms that can be confusing to the readers. However, with the help of appraisal tools, it is easier to understand the terms because the tools use alternative terms that assist in clear understanding and application of the research evidence into practice. Most critical appraisal tools (e.g. CASP and Cochran ROB) have specific critique templates for different types of studies such as systematic reviews, qualitative studies, quantitative studies, cohort studies, and single case study designs.

The questions asked by critical appraisal tools are mostly sensible because they are good considerations to make before applying a piece of evidence into practice. For instance, it is useful to ask whether a particular research finding applies to the local practice. Similarly, according to Brownson et al (2012) & Moule & Goodman (2009), most critical appraisal tools are well-structured and can effectively guide a practitioner towards effective use of evidence. However, a significant limitation across the tools is that they fail to evaluate whether there was a public involvement in the respective studies, therefore it is difficult to identify the impact and quality of public involvement in the study results (Given, 2008, Burnard et al 2011).

Paper 1- Critical appraisal

In this section, we review a peer-reviewed qualitative study that focuses on finding and using research evidence by students in academic assignments. Herein, we use the CASP framework to evaluate the quality of evidence and highlight specific methodological advantages and limitations in the study.

Chandler

Study Focus

The main topic of concern was to explore the younger adolescents’ accounts of self-harm. This topic is of great importance because young people face various challenges and barriers to help-seeking, a phenomenon that has led to an increased rate of self-harm among them (Townsend, 2014). By evaluating young people’s secrecy of self-harm, effective remedies can be formulated to ensure they receive adequate social services to help with solving the problems they face. Therefore, this study not only contributes to the advancement of young people’s quality of life but also provides an opportunity for the identification of life journeys and the challenges they face in it.

Study Background

To justify their study, authors also claim that the relationship between self-harm and later suicidal behavior is a complex one, because for example, a qualitative study by Curtis (2016) and Chandler (2013) found that in some cases, the victims of self-harm perceive suicide as life preserving as opposed to life-ending. As part of their justification to the study, the authors also claim that there is a paucity of evidence on the relationship between self-harm and suicide among young people, and therefore their study will attempt to unearth and understand that relationship in an attempt to develop effective solutions for the epidemic. The qualitative study will provide an opportunity for the researchers to gather data from the participants at community level rather than at the hospital, where most cases of self-harm are not treated. This gives a convincing background and a valid reason to conduct the study. Nonetheless, the researchers only use a few references to support their background instead of using multiple references that would easily convince readers that the topic is worthwhile.

Study Aim

Researchers need to clearly state their study aim to help in identifying whether it is of interest or relevant to the reader. Moreover, according to Leavy (2014), a clear statement of the aim of the study helps in identifying whether the research methodology suites the intended objectives. In Chandler (2017), the researcher has clearly stated that his main aim is to explore younger adolescents’ accounts of self-harm. Thus, a reader who is interested in exploring younger adolescents’ accounts of self-harm can easily identify the relevance of the study. However, the fact that the study uses one research design (i.e. qualitative research design) means that the findings may apply to specific contexts of practice.

Study Methodology

Researchers can take many different research designs to fulfill their objectives. However, the validity of the study findings depends on how suitable the research design is to the intended objectives (Maxwell, 2013). Therefore, a critique of the study design entails identification of whether the selected research method or design will help in achieving the underlying objectives. Chandler (2017) main aim was to younger adolescents’ accounts of self-harm. Their preferred research design was a qualitative research design with data collected through focus groups, in-depth interviews, and online surveys. According to qualitative research experts such as Maxwell (2013), the qualitative research design is the best approach for understanding experiences and perceptions of the target population about a specific phenomenon because it provides an opportunity to understand the phenomenon from the opinions of those experiencing it. Qualitative research design is mostly based on interpretive research philosophy/paradigm which holds that the experiences and perceptions of are best described by those having the experiences. Therefore, this analysis concludes that the selected research design was the most appropriate for achieving the research aim in Chandler (2017).

As part of the research methodology, the researcher uses narrative and interpretive theories as the fundamental basis for study. While I do not intend to comment on how the theories are used within the study, it is imperative to acknowledge the role of theories in explaining concepts for an easier understanding. Furthermore, Leavy (2014) asserts that theories enhance the understandability and comprehension of complex concept, thereby enhancing the study validity.

The Tool of Data Collection

Data collection tools are important determinants of study outcomes because valid studies must use the most suitable data collection tools to achieve their objectives. In the study by Chandler (2017), the researcher used focus groups, in-depth interviews, and online surveys. The methodologies were explorative and offered an opportunity for the researcher to explore the respondents’ accounts of self-harm. From the study results, the tools seemed to work well in answering the underlying research question, and there could never be a better alternative. However, the use of questionnaires, surveys, in-depth interviews and focus groups provided a leeway for researcher bias because there are chances that the researcher might have interpreted the data in their own way rather than what the respondents meant. However, the tools were of great advantage to the researcher in gathering more in-depth responses from the respondents (Given, 2008).

Methods of Data Analysis

In any qualitative study, the most important bit is the method of data analysis because it is within this aspect that the researcher’s conceptualization of the research question, as well as their understanding of what is going on with the participants, is understood. In the study by Chandler (2017), the researchers used thematic analysis techniques to analyze and interpret their data. According to Maxwell (2013), thematic analysis approach entails the grouping the data into similar themes and presenting an analysis based on those themes. Therefore, by using thematic analysis method of data analysis, the researchers selected one of the most appropriate methods of analysis the qualitative data meant to achieve the underlying research objectives. However, an alternative to the descriptive observation method could have been descriptive observation method, which entails reviewing and synthesizing the data based on the observations and words used by the respondents thereby allowing for the development of insights into the respondents’ perceptions and experiences (Gisselle & Lotte, 2018). Descriptive observation method could have also worked better in this particular study because the researcher was interested in the perceptions of the respondents. Ideally, the perceptions could have been organized in observations and words used by the respondents and analyzed collectively.

Sample

In qualitative research, the researcher may not be able to include the whole target population into the study. Instead, researchers prefer to choose a representative subset of the whole population and gather data from them (Gisselle & Lotte, 2018). But, according to Maxwell (2013), researchers must be careful when choosing the sample to avoid the risk of bias and other issues that may affect the validity of study outcomes. Thus, when critically appraising such studies, appraisers are interested in the sampling methods and how they affect the study validity. Chandler (2017) selected a sample of 122 young people within the age range of 13-26; 108 of them ranging within 13 – 16 years. While one would argue that the sample population should have been larger, the decision to include only 122 young people seems to be a wise one because it would not be convenient including a larger number of participants. Chandler (2017) made several ethical considerations that enhance the reliability of his study results. For instance, the research designs received an approval from the university ethics committee. The approval process entailed a careful risk assessment to ensure no participant would put at risk of harm by the study. Besides, the researcher discussed with all the interviewees the plan of action in case they no longer found the interview process interesting.

Chandler (2017) has provided a clear account of how each type of data was collected and handled. However there are scanty details on how the qualitative data were coded and categorized into various themes for further analysis, a phenomenon that affects the replicability of the study. Furthermore, despite using surveys and questionnaires for data collection, Chandler (2017) fails to mention whether they were tested for reliability, validity and understandability. However, despite several methodological omissions Chandler’s (2017) can still be considered to have valid results. Chandler (2017) has conducted a balanced discussion of the study findings with minimum bias. For instance, the researcher has used extracts of the interview transcripts to discuss the results, meaning that the discussions are purely based on the research findings rather than the author’s own makings. Nonetheless, while Chandler (2017) did not develop a clear research question, the researcher finding seems to have satisfied the study’s main aim. For instance, it was found that perceiving self-harm among adolescents as a secretive and private affair may not be productive. Ultimately, the author concludes that it is beneficial for adolescents to talk to each other about self-harm, and this corroborates with the research findings that youth who talked to each other about self-harm are less likely to perform the actual self-harm that those who do not talk about it.

Paper- 2

Background

Given (2008) argues that researchers must give a background of the study to justify why they think the study is important. In the current study, the researcher’s main aim is to evaluate the effectiveness of nutrition and exercise rehabilitation as an intervention for obesity in hypoventilation syndrome (NERO). To justify the study, the researchers have clearly stated that whereas the use of respiratory management of obesity hypoventilation syndrome has been a popular intervention for NERO, it only focuses on sleep-disordered breathing instead of treating obesity. Therefore, as the researcher claims, there is a paucity of research, especially randomised control trials (RCTs) on weight loss interventions for patients with OHS, thereby justifying the need for their RCT.

Literature Review

Leavy (2014) argues that developing a robust study requires a review of most current literature for purpose of identifying what is already known about the subject, what is yet to be known and what the current study should try to find. In the study by Mandal et al (2018), the researchers have attempted to review some latest literature as well as other earlier studies. In fact, through the literature review, the researchers have identified the paucity of RCTs on weight loss as an intervention for OHS, thereby forming the basis of their study. However, it is important to note that the researchers have missed out on the latest research of 2018 and 2017. This implies that whereas there is sufficient literature review to support the study, the study misses out on the most current data. Furthermore, the researchers fail to apply theories in explaining their concept despite being a common practice in research. Failure to give a theoretical perspective to concepts implies that the study may lack the fundamental background of the phenomenon under investigation, this affecting the study validity (Given, 2008).

Study Aim

The research aim defines the focus of the study, and therefore it must clearly be stated (Maxwell, 2013). Mandal et al (2018), the researchers have made an effort of clearly defining the study aim, which is to identify the effectiveness of weight loss as an intervention for OHS. This is a clear and appropriate study aim because like other health conditions, OHS requires more RCTs to support evidence-based practice. More importantly, Mandal et al (2018) clearly defined their variable sand respective variable measures. For instance, to measure the intervention’s effectiveness, the researcher relied on health-related quality of life (HRQOL), weight loss and exercise capacity. According to Leavy (2014), HRQOL is an effective measure of exercise-related interventions because it is easier to tell whether the quality of life has improved or worsened.

Study Design

Gisselle & Lotte (2018) argues that researchers must choose the most appropriate study designs for the aims and objectives they want to achieve. Mandal et al (2018), the researchers selected RCT study design as their preferred study design. Intending to measure the effectiveness of intervention the RCT study design is the most appropriate for achieving this objective because according to Leavy (2014), RCTs provide an opportunity for researchers to directly measure whether the treatment effect is directly related to the intervention. Furthermore, Mandal et al (2018) mention that RCT was the best option because it would allow them to randomly assign the treatment intervention to participants thereby eliminating the influence of other confounding factors that may lead to an inaccurate conclusion of the findings. This was a good reason for choosing the RCT study design.

Study Sample

While the researchers provide some details about their sample population, they fail to indicate their inclusion/exclusion criteria. According to Leavy (2014), this makes it difficult to establish the kind of participants included in (or what makes up) the study, thereby affecting the study replicability. Nonetheless, Mandal et al (2018) mentioned that a total of 178 patients were recruited but only 37 were included in the study. Yet they fail to specifically mention the sampling methodology they used in selecting the samples. According to Leavy (2014), this makes it difficult to follow and replicate the study if one would want to. Failure to mention the sampling method also makes it difficult to establish the implications of selecting the sample, the appropriateness of the sample size, and the generalizability of the study findings. Therefore, study reliability and validity is much affected by this limitation.

Data Collection

Mandal et al (2018) have demonstrated how they implemented the intervention and gathered data in the form of primary and secondary outcome measurements. With regards to the former, Mandal et al (2018) measured the weight outcomes using bariatric scales and seated scales for patients with up to 150kg and above 150kg respectively. With regards to the latter, Mandal et al (2018) measured the patients’ anthropometric and body composition based on WHO guidance (WHO, 2008). Moreover, the researchers used bio-electrical impendence to measure each patient’s fat-free mass. The respective outcome measurements seem to be the most effective ones. Leavy (2014) argues that bariatric scales are effective and safe for measuring weights due to the accuracy and precision with which they work. Similarly, Leavy (2014) writes that sometimes when the patient is above 150kgs, it may be unsafe to use bariatric scales thus the use of seated scales can be of help. Therefore, the researchers’ choice of primary and secondary outcome measurement tools seemed to take into great consideration patient safety while ensuring an accurate measurement.

Ethical Considerations

RCTs are studies involving human subjects, and therefore it would be important to make certain ethical considerations so that the participant’s safety is assured (Leavy, 2014). A particular ethical consideration made by Mandal et al (2018) is seeking ethical approval from the Westminister National Research Ethics Committee. Seeking such ethical approval in RCT research not only contributes to participant safety but also enhances the study reliability (Gisselle & Lotte, 2018). However, Mandal et al (2018) did not take account of informed consent nor did they mention about the confidentiality and privacy of study participants.

Results

A clear presentation of study results is one of the essential elements of a valid RCT. Mandal et al (2018) have presented their study results in tables, making them easier to interpret and evaluate their accuracy. For instance, in one of the tables, Mandal et al (2018) have indicated the baseline data for both the control and interventional group; while other tables have been used to indicate a change in baseline measures three months after the intervention. This makes it easier to compare and interpret the data at a glance (Gisselle & Lotte, 2018). More importantly, though, the data presented by Mandal et al (2018) seems to be comprehensive as they provide and compare both primary and secondary outcomes with the baseline data.

Data Analysis

Mandal et al (2018) have used statistical methods to analyze data. For instance, the researchers used the prior hypothesis to establish the absolute difference in the weight loss among participants 12 months after the intervention. Besides, Mandal et al (2018) used an analysis of covariance to identify the difference between the two treatment groups. However, to identify the within-group difference, the researchers used a paired t-test or Wilcoxon signed-rank test. The measurement of inter-group and within-group difference was an important part of determining the treatment effects and isolating any confounding factors that may have affected the study outcome validity (Gisselle & Lotte, 2018).

Barriers for Implementing Research into Practice

Several barriers might be encountered in implementing both the qualitative and RCT that have been analyzed in this paper. For instance, with regards to the RCT, the researchers have found that implementing a 3-month comprehensive rehabilitation intervention can contribute to an improved weight loss, improve quality of life among obese patients despite similar results not being eminent 12 months after the trial. But, regardless of indicating the feasibility of using physical exercise and nutrition as an intervention for OHS, the study has not provided adequate information that might be needed when practically implementing the intervention. For instance, the study has only shown the effectiveness of the intervention for OHS patients but has not shown which patients might benefit most from the intervention. Furthermore, while implementing the intervention, it might be difficult to account for the heterogeneity among the participants because RCTs must have large population samples to yield statistically significant outcomes. Hence, the study results may not be adequately generalizable because it only ended up with measures of central tendency as opposed to a complete representation of the target population (Leavy, 2014).

There are several limitations in the study by Chandler et al (2017) that may affect the implementation of the study recommendations. For instance, some of the qualitative data in the study were collected through an online survey. Yet, online data collection limited the richness and depth of the data because the researcher could not probe the respondent for further information. Moreover, the data were collected from a smaller population, limiting the generalizability of the study findings.

To convince readers, researchers must present an argument that their study topic is worthwhile. Given (2008) and Thyer (2009) assert that this argument can be presented by identifying how big the problem is, as well as the level of seriousness with which it must be handled. This implies that in every study, researchers must present a thorough review of background literature indicating how the seriousness of the study has been highlighted by previous studies. In the study by Chandler (2017), the researchers have demonstrated their intent to provide a clear background and justification of the study by highlighting some literature self-harm among the adolescents. The authors claim that self-harm is a vital health concern that is increasingly being prevalent among adolescents. The authors also explain that self-harm contributes to various negative outcomes in adolescence including suicidality, depression, anxiety and drug abuse. However, it may be challenging to implement the current study because they fail to give a clear integration between concepts highlighted on the background of the study and the concepts that are actually highlighted in the results and discussion section. For instance, the discussion at the background section highlight concepts such as anxiety, depression, and drug abuse, yet the study’s findings and discussions are predominantly focused on the relationship between attention seeking and self-harm. This mismatch between the introduction and the background of the study my make it difficult to practically implement the study because readers may fail to triangulate the existing literature with the actual data findings of the study.

Chandler (2017) misses out on one significant issue of research implementation, which is the sampling method. By failing to explicitly mention the sampling methodology he has applied in the study, it may be close to impossible to implement the study recommendations because the sampling method acts as a determinant to the generalizability of the study (Burnard et al, 2011).

The study by Mandal et al (2018) seems to be justified as it seals the gap of a lack of RCT on nutrition and exercises as an intervention for OHS. Unfortunately, though, the researchers have failed to identify their educational credentials, therefore it is difficult to establish whether they had the necessary qualification to conduct the randomized control trial. According to Given (2008), RCTs involve human subjects and therefore they should be conducted by individuals with adequate experience. Failure to declare their educational credentials, therefore, affects the reliability of the study findings (Maxwell, 2013). Consequently, it would be difficult to implement a study with compromised reliability.

Conclusion

In conclusion, this critical appraisal of qualitative and quantitative research was an enlightening experience that made me realize just how much information is contained in a single study, and the importance of each part of the study to evidence-based practice. I realize that a critical analysis of the study may reveal significant details that might be of help when applying the evidence into practice. Therefore, I resolve to enhance my evidence-based practice skills owing to its importance to my future practice as a medical practitioner.

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