Evidence-based practice (EBP) is a phrase that has become more familiar to practicing nurses. Sackett, Richardson, Rosenbery, and Haynes (2000), who are credited with the initial work related to emphasizing the incorporation into practice, describe EBP as an integration of the best evidence (from systematic research studies) with clinical expertise and patient values. (1) Quality patient care outcomes are dependent on decreased variation in care and interventions based on evidence from practice. Patient care guidelines based solely on traditional knowledge lack the solid foundation to improve quality of care and patient safety. However, many barriers exist to nurses' implementation of EBP. Busy work schedules, short staffing, inability to access resources, such as a library, how to interpret the statistical analyses of a report and even the lack of interest and support from nurse managers or administrators have been identified as barriers to the use and implementation of EBP. (2) Quality care is an objective of all nursing care, but the competitive need to attract customers is focusing more attention on outcomes based on safe patient care. At our 27th Annual Congress, EBP and its use was a topic frequently discussed in multiple sessions. Since our practice must have a foundation of evidence and not just the "way we do things around here", this column will deal with the topic of bringing evidence to the clinical nurse, site a couple of articles that describe and use EBP and then critique an article that demonstrates the need to carefully assess the evidence found before applying it directly to practice.
Wells, N., Free, M., & Adams, R. (2007). Nursing research internship: Enhancing evidence-based practice among staff nurses. Journal of Nursing Administration, 37, 135-143.
How can we bring evidence-based practice (EBP) to the clinical nurse at the bedside? The question is often hard to answer because of resistance to anything associated with nursing research or EBP. The mystique of research or evidence causes fear in many nurses, and advancing beyond the fear is often problematic. If nursing is to move forward as a profession, then basing our practice on evidence is crucial. We must raise the bar with ourselves as practitioners, which will give us more satisfaction in our nursing careers. One way to do this could be in the model Dr. Nancy Wells and her colleagues described regarding a nursing research internship designed to overcome barriers to understanding EBP and that would serve as a professional development opportunity. This article describes how Vanderbilt University Medical Center developed a nursing research internship program that spans 2 years, with monthly attendance. The first year of the program introduces the nurse to continuing quality improvement concepts, how to search the literature, and critical analysis of a research study. The second year focuses on a clinical problem that can be investigated with a desired practice change in mind. At the conclusion of the first and second years, the intern writes a report about the progress and the outcomes of the project. An abstract and poster presentation are required during the National Nurses Week celebration. The number of participants in the program is small, as management buy-in must be attained in order to provide "leave time" for courses related to the program. Selection for the program is based on manager and administrator nomination.
Although smaller hospitals or work settings may not have the ability to develop such an internship program, the tenets of this program or curriculum could be used to promote research through such means as the shared governance structure. Unit-based shared governance meetings could begin to ask questions about practice issues on a unit, such as pin care methods for skeletal traction, and then could solicit the assistance of advanced practice nurses to assist with investigation of the clinical question. Asking the question is the first step in bringing evidence to the clinical setting. For example: What is the relationship between the removal of a Hemovac 24-hr postoperatively and the rate of infection for total joint patients? Dr. Wells's internship model had numerous positive outcomes. Some of these were increased questioning about why things are done in certain ways in practice, a positive attitude change about research, and a better way to solve clinical problems. In addition, positive attitudes developed about the professional commitment to nursing. Managers felt this program was a positive way to reward nurses for their contributions.
Todd, B. (2006). Beyond MRSA-VISA and VRSA: What will ward off these pathogens in health care facilities? American Journal of Nursing, 106, 28-30.
The use of EBP is the responsibility of all practicing nurses. An example of how evidence from practice can be used in the clinical area is represented in this article. Orthopaedic nurses are seeing changes in practice in the increase in infections caused by Methicillin-resistant Staphylococcus aureus. At the present time, most patients can be treated with Vancomycin, even though the treatment may be long and surveillance must continue with each hospitalization. However, another threat, as described by Todd (2006), is that since 1995, Vancomycin-intermediate Staphylococcus aureus or Staphylococcus aureus with partial resistance to Vancomycin (VISA) and Vancomycin-resistant Staphylococcus aureus (VRSA) have been reported in the United States. She noted eight cases in her article. These organisms were a common cause of death before antibiotics and could be again. Particular concerns for the orthopaedic nurse are Staphylococcus aureus infections, which are difficult to treat when the patient has a joint space infection, as there is often poor antibiotic penetration into these spaces. Patients with a known history of prolonged Vancomycin use are at risk for VISA and VRSA development (Todd, 2006, p. 29). Todd defined resistance to a drug (Vancomycin, in this case) by what is termed minimum inhibitory concentration (MIC). To put this in understandable terms, Vancomycin-sensitive Staphylococcus aureus requires a concentration of no more than 4 mcg/mL of blood to inhibit growth. VISA requires 8-16 mcg/mL, and VRSA requires 32 mcg/mL to inhibit growth. At present, all of the VISA and VRSA strains have been sensitive to a Federal Drug Administration-approved antibiotic. Will that be the case in the future?
The evidence from practice in this situation is that orthopaedic nurses must be attuned to the prudent use of Vancomycin, must adhere to prescribing guidelines, and must closely monitor the use of Vancomycin in one's institution. Evidence from practice demonstrates that thorough hand washing and strict gowning and gloving are effective measures in the prevention of infection. Nurses must be vigilant in the control of infection by preventing transmission of and proliferation of resistant organisms through consistent use of universal precautions and the adherence to policies by all staff members and visitors. At times when we have high acuity situations or low staffing ratios, we cannot relax standards of quality care. Reminding our colleagues and coworkers to use good universal precautions will demonstrate our ability to transfer evidence from practice into good quality clinical care.
Cuellar, N.G., Rogers, A.E., & Hisghman, V. (2007). Evidence-based research of complementary and alternative medicine (CAM) for sleep in the community-dwelling older adult. Geriatric Nursing, 28, 46-51.
Older adults often have difficulty sleeping and resort to a variety of interventions to treat the problem. Care givers may ignore the importance of sleep disturbances in the elderly and ascribe such as a part of normal aging. Not investigating what methods are used for sleep that fall outside of the normal Western-medicine-approved treatment regime, such as alternative medicine or complementary medicines (CAM), may result in adverse events for the older adult. When nurses complete an assessment of an older adult in the hospital or in the home, it is important to understand that CAM may be part of his or her medication plan because of a fear of overmedication from prescribed pharmacologic agents or reliance on methods that have "worked" in the past. Unfortunately, patients who use CAM remedies may not view these as part of a treatment plan and may fail to disclose use during an assessment with a healthcare provider. For example, the older woman who has just come home from the hospital after a hip fracture may return to her use of herbal treatment for sleep, unaware of the interaction of such herbs with her prescribed medications, as many forms of CAM have not been tested for interactions and safety with common medications (Cuellar, Rogers, & Hisghman, 2007, p. 49).
This article gives an excellent review of the many forms of CAM used by older adults for sleep aids. It discussed forms of sleep interventions, including Chinese medicine, acupuncture, herbs, aromatherapy, music therapy, and Tai Chi. The evidence-based research for these methods is also discussed, noting that the evidence is not clear as to the value, safety, or objective measures for the use of these therapies as there is little clinical research devoted to this area. It should be noted that 42.1% of all Americans use some form of CAM; 88% use is seen in the older adult, almost twice that of the national average (Cuellar et al., 2007, p. 46). This latter number is significant in our work with all orthopaedic clients. For those on the older end of the age spectrum, the use of healthcare agencies increases. It is critical that assessment for the use of CAM remedies is made, as the cost of these interventions may be seen as less expensive for the older adult. However, these authors stress the importance of specifically asking older adults about the use of natural and herbal products as there is virtually no evidence from practice to demonstrate the combined effects for either a positive or a negative outcome for patients. Sleep is an area of need for the older adult and part of a continued health pattern for the older adult. The disturbance of sleep in this age group may foretell disease and can impact health promotion. Therefore, understanding how older adults use CAM, where there is little evidence to support its use, is an important assessment in working with this group of patients.
Jeong, G.K., Gruson, K.I., Egol, K.A., Aharonoff, G.B., Karp, A.H., Zuckerman, J.D., & Koval, K.J. (2007). Thromboprophylaxis after hip fracture: Evaluation of 3 pharmacologic agents. American Journal of Orthopaedics, 36, 135-140.
This article is an example of how evidence from practice should be viewed with critical appraisal before quickly changing practice guidelines. The discussion of prophylaxis for deep vein thrombosis (DVT) after a hip fracture is a needed area in the literature, and most suggestions for treatment are usually an extrapolation from the care of the elective hip replacement patient. The patient who experiences a hip fracture is often very different from the patient requesting elective surgery, specifically related to the issues of comorbid conditions, age, and ability to quickly mobilize after surgery. Prevention of DVT, however, is essential. As orthopaedic nurses know, current initiatives have compelled hospitals to review their policies for DVT prophylaxis and to implement policies for assessment within 24 hr of the patient's admission to the hospital. Guidelines recommended by the American College of Chest Surgeons, which are supported with extensive practice evidence from the literature, recommend a combination of mechanical and pharmacological intervention for the patient who may be at risk for DVT. The recommendations for a variety of orthopaedic procedures outline specific interventions for hip fracture patients, total joint replacement, spinal surgery, and other common procedures.
The recommendations in this article do not coincide with the 1A (the strongest evidence) evidence supported by the American College of Chest Surgeons for DVT prophylaxis after a hip fracture repair. This article discusses three pharmacologic treatment modalities, namely aspirin, enoxaparin, and Dextran. Although just reported in the literature in 2007, this study was conducted between July 1987 and December 1999. In the 10-year period between the end of the study and the publication of the results, the evidence noted in these results for application to practice has changed markedly. Aspirin is not a recommended pharmacological agent for patients at risk for DVT, although low molecular weight heparin (enoxaparin and Dextran) does have approval. In addition, the number of patients included in this review was very small and cannot be considered statistically significant for changing practice guidelines. What is significant is that this investigation does compare the three types of medication, and all of the patients had aggressive ambulation programs, wore a mechanical device for DVT prevention, and could bear full weight after surgery. One has to ask whether any of these factors were the cause of the positive results rather than the use of a particular pharmacologic intervention.
As a critical thinking nurse reading an article, one needs to compare the suggestions one finds in an article with other relevant evidence and to discuss the results with colleagues and advanced practice nurses. Simply because an article has appeared in print does not mean it contains evidence worthy of application to practice without careful analysis and thought.
Wilson, J.F. (2007). Current clinical issue: Posttraumatic stress disorder needs to be recognized in primary care. Annals of Internal Medicine, 146, 617-620.
Because of recent events, this article jumped out as an area of practice that would be appropriate for orthopaedic nurses to review. Posttraumatic stress disorder (PTSD) is not a new concept, having been identified in 1980 as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders-III (American Psychiatric Association, p. 617). Since September 11, 2001, and the recent conflicts in Iraq and Afghanistan, nurses, and especially orthopaedic nurses, caring for military personnel must be sensitive to this syndrome and be prepared to evaluate symptoms that seem to cluster around other disease entities or may not even be identified by the patient. Because of the types of injuries seen in this war as opposed to others, head injuries and blast orthopaedic injuries are more common. The trauma from such severe events may not appear until months after the initial injury and the obvious wounds have been treated or rehabilitated. Such complications as heavy drinking, suicide ideation, panic disorder, hypertension, shortness of breath, tremors, and palpitations can comprise symptoms. This article encourages care givers to treat the patient holistically, considering the ramifications of the disease for the family as well.
Because many veterans do not report the symptoms until long after the war event, treatment can be delayed for many months and even years. The article points out that the limited number of clinical psychologists in the military has often jeopardized access to treatment, and the physician and nurse working with the patient in the local community should be aware of the need for treatment and appropriate diagnosis. Treatment is usually in the purview of psychiatry, with a combination of selective serotonin reuptake inhibitors (SSRIs) and psychotherapy being used to reduce symptoms and improve quality of life. Interrupted treatment, such as not continuing medications, tends to cause relapses with care. Patients hospitalized for extended repair of orthopaedic injuries when back at home should not have the SSRIs stopped. Benzodiazepine is not recommended as a principal therapy. There is scant evidence from practice to help these patients, as many do not want to be in clinical trials or because participants are those from a select group rather than from randomized treatment situations. These patients deserve the best care possible either in the Veterans Affairs setting or in their local community. Knowledge about this disease process will become essential as these patients re-enter the home environment.
Meade, C.M., Bursell, A.L., & Ketelsen, L. (2006). Effects of nursing rounds: On patients' call light use, satisfaction, and safety. American Journal of Nursing, 106, 58-70.
Many nursing departments are looking critically at the current and potentially more serious nursing shortage in the upcoming years. Various reasons are given for the shortage including the "graying nurse," who will soon retire from both service and academic positions. In addition, legislative policies and initiatives have mandated specific nurse-patient ratios (Meade, Bursell, & Ketelsen, 2006, pp. 1-5). The question that begs answering is how can fewer numbers of nurses deal with an increasingly smaller nurse-patient ratio without subjecting the patient to unsafe care, decreased satisfaction with care, and longer waits for the nurse to answer the call bell. New models of care are being developed that bring the nurse closer to the patient (decreased nurse-patient ratio) and that establish purposeful attending relationships with the patient, thereby closer attention being paid to what the patient says he or she needs. Is not that what nurses have always done? All of these changes seem to be contradictory with a decreased number of nurses in the work force and a change in the nurse-patient ratio.
These authors suggest that another change in the nurse's work flow, thereby enabling them to make more frequent rounds to the patient's room, will decrease the number of times the call bell is used. At first glance, this seems to impose even more demands on the nurse's time and to create stress that would not enhance job satisfaction. Therefore, where is the evidence that this is a practice change worthy of implementation? Is the evidence sufficient to answer the question or has the right question been asked? These authors report about the use of the following two methods to change practice: (a) making rounds every hour to see the patient, and (b) making rounds every 2 hours to see the patient. The key goals in this practice change were to increase patient satisfaction, to decrease call bell use, and to prevent falls.
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