Principles of Research & Evidence Based Practice, Research Paper Example

Section 1

Introduction

Researching in health care should focus on improving the quality of service and patient outcomes. Evidence based practices are developed through implementing the findings of related research, and making improvements based on evidence. According to Thyer (2004), evidence based practice is not a static intervention, but it should be constantly evolving, based on new research findings. Rosenberg and Haynes (2000, p. 1) defines evidence based practice as “the integration of best research evidence with clinical expertise and patient values”.

According to Nutley, Davies, and Walter (2002), however, research studies are only one source of evidence. Effective dissemination of evidence, according to the review created by the authors is crucial for developing effective interventions to improve the quality of health care. As the conclusion of the article confirms, “effective dissemination is “pushing’ evidence out is not enough, there is also a need to develop the ‘pull’ for evidence from potential end users” (Nutley, Davies, and Walter, 2002, p. 9).

Research for implementing evidence based practice, according to Thyer (2004) should follow the below five steps: converting the need for information for an answerable question identifying the best and most reliable research evidence that could answer the question appraisal of the evidence integration of the evidence with personal experiences and expertise within the health care unit evaluating effectiveness and efficiency following the implementation.

The Department of Public Health Services King’s College London (n.d.) defines three main levels of evidence in research related to evidence based practice: randomized controlled trials, good/poor studies of non-randomized control groups (case/control or cohort), and studies without control groups, such as case studies and testimonials.

Woods,  Fineout-Overholt and Kennedy (2012) also  emphasized the importance of using more than empirical research when developing evidence based practice. According to the review, clinicians’  expertise and patient preferences should also be taken into consideration.

The below essay will focus on evaluating the different types of evidence, while  assessing their applicability and adaptability to practice. Further, the author will focus on examining methods that are aimed at the classification of evidence, and rating the reliability of the sources, which is critical for creating a plan for improvement within health care organizations, ensuring that the best possible results are achieved. The author will review two research studies that can potentially contribute towards implementing evidence based practice in health care organizations. Using the above discussed model, the paper will focus on collecting evidence, validating results, reviewing potential integration methods, and proposing a method for evaluating effectiveness following the implementation.

Discussion

In order to ensure that the best possible evidence is used to create quality improvement projects within health care organizations, Researchers should build effective collaboration with practitioners and nursing managers to carry out studies and share evidence that can potentially improve patient outcomes. Doody & Doody (2011) presented the IOWA model for implementing evidence in nursing practice. The authors state that the implementation has seven steps: topic selection, forming a team, retrieving evidence, grading the collected evidence, developing a standard for evidence based practice, implementing evidence based practice frameworks, and evaluating the results. Unlike the above discussed 5-step model (Thyer, 2004), this implementation framework includes one crucial step: grading of the evidence. In order to ensure that the collected information through research of literature is relevant and reliable, a grading criteria needs to be developed. The below reviews of two different research publications will focus on the appraisal or grading of the evidence presented by the authors, in order to determine whether or not the findings can be applied for developing frameworks that improve patient outcomes and the quality of health care within the nursing unit.

Family Caregivers’ Experiences

Plank, Mazzoni, and Cavada (2012) examined the experienced of new family caregivers after patients were discharged from the hospital. The authors used a qualitative phenomenological approach, in order to understand the experiences of caregivers and provide recommendations for nursing staff to support individuals in this transition. When assessing personal experiences, the qualitative phenomenological approach was found to be effective, as it is able to highlight the main themes within the examined population and draw conclusions accordingly. The study was based on a non-randomized sample, and was aimed to reveal the main phenomenons related to the topic of the research. The selection criteria included restrictions of age, the condition that the individual had no previous experience in the role, and were acting as a primary caregiver for the patient released from the hospital. The collection of data was completed through in-depth interviews with new caregivers, and focus groups. A short demographic questionnaire was also conducted before the interviews and participation in the control groups. The analysis of the collected data followed a 10-step method: close reading of interviews highlighting statements that are extremely relevant to the study creating “meaning units” with meaningful statements pooling of the “meaning units” creating “cluster of meanings” descriptions grouping “cluster of meanings” into themes theme validation integration of the themes into the description of experiences validation of the findings (repeated visit) correcting findings based on the results of validation.

Based on the identified new themes, the authors were able to create a conceptual framework of new, informal (family member) carers’  transition. Based on the results of the research, the authors found that most of the respondents lacked professional support and ffelt unable to cope with all aspects of looking after their family member. The authors, therefore, recommend that health care facilities utilize multi-professional nursing teams to support new caregivers in this transition, by displaying empathy.

According to Sandelowski (2004), results of qualitative research indicate symbolic, conceptual, and instrumental utility. This means that no quantifiable data is available to validate the results, therefore, it is important to focus on a large, or targeted population. A further study by Sandelowski and Barroso (2002)  states that evaluating qualitative research studies is challenging, and in most cases is based on subjective judgment.

While the need for more support for new family member caregivers is identified and evidenced by the findings of the study, it is not providing an intervention framework for health care professionals, and does not provide the researcher with information how the experiences can be influenced. Further, there is no proof that interventions focusing on educating and supporting new caregivers would result in higher confidence level of family members looking after their loved ones.

Nursing staff levels and complications

The second article reviewed, created by Scheruders et al. (2014) examines the relationship between staffing levels and complications of hospital inpatients. The study uses a retrospective longitudinal hospitalization-level study design, which is appropriate for measuring correlation between two main variables: the number of complications and nursing staffing levels. The scale of the study was large, with more than 250.000 patient records included, and the authors used a quantitative analysis method. The main purpose of the study was to reveal whether or not higher staffing levels are potentially resulting in fewer complications among inpatients. The study was important, as the majority of clinical staff believes that improved staffing levels automatically result in better patient outcomes. The findings of the research showed that there is no direct relationship between the two variables, therefore, simply improving staffing levels would not benefit patients. The results are valuable for nursing managers and team leaders who are constantly seeking evidence for implementing changes within their unit to create more value for stakeholders and in particular patients. To represent the diversity of the sample, the authors collected basic demographic information about patients, and analyzed the number of complications in relation with the allocated nursing hours per patient. The study was carried out covering a period of 5 years. The authors of the study also used a T-test and chi-squared test to measure the impact of demographic characteristics on the likelihood of complications. The analysis was also stratified.

While the authors found no strong correlation between nursing staffing levels and the likeliness of complications, it is important to note that in randomized studies, the method of stratification is likely to exclude the influence of other contributing factors that might affect the variables (Abadie, Chingos, and West, 2014). Still, the study did not provide enough evidence for researchers to develop a program that might reduce the number of complications. While the authors confirmed that there was no positive correlation between nursing levels and the number of correlation, it simply suggested that “more sensitive patient outcome measures  should be investigated” (Scheruders et al., 2014, p. 809). Therefore, while the large scale empirical quantitative study found that staffing levels themselves do not improve patient outcomes on their own, they did not answer the question that nursing team leaders usually ask when planning to implement evidence based practice: which factors can reduce the number of complications among inpatients?

Conclusion

The above review of the two studies has revealed that selecting evidence for implementing evidence based practice should involve the evaluation of sources and the reliability of the information presented. While the study created by Plank et al. (2012) presented findings that can lead to developing frameworks for improving caregiver-nursing staff collaboration and increasing the support provided for family members, it lacked evidence related to the potential benefits of implementing such a framework. The study lacked a quantitative element, therefore, it did not provide professionals with measures on how to monitor the effectiveness of programs designed.

The second study, created by Scheruders et al. (2014) showed that there was no relationship between nursing staffing levels and the number of complications. As the trial was not controlled, the influence of other factors, such as training levels of staff, the severity of the condition, socio-economic status, and many more could not have been eliminated. Therefore, while the study was carried out throughout a timeframe of five years, and provided a large sample, it provided little or no information for researchers and nursing managers to reduce inpatient complication rates.

As a conclusion, when focusing on implementing evidence based practice, clarifying the research questions helps nursing managers identify relevant and valuable research. This step of evidence based practice implementation was proven to be extremely important.

Section 2

Critique of Articles

Evaluating evidence and findings of research studies is a challenging task for nursing leaders. The The Joanna Briggs Institute (2014) created a comprehensive manual for health care professionals that provides them with appraisal tools and methods of systematic review. The grading method recommended by the authors categorizes sources into two groups: Grade A and Grade B. Grade A sources provide a strong recommendation for developing a health management strategy, while Grade B sources have a weak recommendation. Based on the above overview of the two sources, it is clear that both of the studies belong to Group B: the link between the evidence presented and the application of the results is weak. The detailed validation of the results and research appraisal will be carried out in the next two parts of Section 2, focusing on the synthesis of data, validity, value, and correlation with clinicians’ experience, as well as patient preferences, in order to create an implementation plan for evidence based practice.

Paper and Evidence Evaluation of the First Research Study

Design and Limitations

The qualitative research of the study created by Plank et al. (2011) was utilized to identify themes and common issues related to becoming a non-professional caregiver for a family member. Further, the study’s main aim was to evaluate individual experiences and help nursing managers and staff fully understand the issues the population faces. In this sense, the study’s design was effective. The main limitation of the study design is that it relies solely on interviews and subjective reflections, and does not take into consideration whether or not the participants’ confidence about caring for their relative is reflected on the quality of care provided. That stated, it is possible that all new carers have a low confidence in their skill, however, they overcome initial hurdles, and deliver the best possible care for patients.

Data Collection Methods

The data collection methods used by the authors was based on interviews and focus groups, and the research publication states that “Both the individual interviews and focus groups were  conducted in a room free from distractions at the rehabilitation unit” (Plank et al. 2011 p.2074). This increases the validity of data, and reduces the risk of bias during the research.

Evaluation of the Sample

 The authors used a “purposive sample”. According to Oppong (2013 p. 203), the size of the sample  using purposive sampling “is determined in line with theoretical saturation”. Therefore, purposive sampling should have a process attached to it based on the research focus. The selected sample had to match certain identified characteristics. In this case, the sample was limited to individuals aged 18 or older, being new to caring, talking on the role of a primary carer on an unpaid basis, and willing to participate in the study. This restriction of the sample created both limitations for the survey and an enhanced focus.

Method Evaluation

The methods used by the researchers were appropriate, as they included in-depth interviews with new caregivers before the person they were going to care for was discharged from the hospital. The authors did not use the retrospective manner of data gathering. The main reason for this was to avoid inaccurate memories hindering the accuracy of personal accounts (Blane 1996). However, the interview questions used by the authors could have influenced the answers, creating a high level of limitation to the reliability of the study. When conducting the interviews, the authors state that “Caregivers were asked to comment on their concerns about the imminent patient discharge and how they prepared themselves for it” (Plank et al. 2011. p. 2074). The wording of the above statement indicates that the interviews could have been biased. It would have been more appropriate to simply ask participants whether or not they were ready to care for their  loved ones. The use of the word “concerns” suggests the existence of doubt and lack of confidence. Regarding the focus group data collection method and analysis, aimed at validating the results of the initial interviews and to facilitate the flow of new ideas through communication among new caregivers. In this research, open ended questions were utilized, which ensure that the answers remain unbiased. However, the influence of other caregivers on one’s opinion could not be excluded as a hindering effect.

The data analysis method used by the researchers was appropriate to the research focus and aims. Identifying themes (using a process previously described within this paper) was relevant to the focus areas of the research: the condition of the care recipient, support required, and the new role. The sample’s demographics were disclosed without names and personal information, apart from gender, age, and the information about the recipient. The core concept that arose during the data analysis was that most of the new family member caregivers felt that they were responsible for everything.

The main limitation of the study was based on the selected sampling method. Using a purposive, small sample would provide data that is not relevant to the entire population. The sample was not representative, therefore, a different research approach could have delivered different methods. Further, as the authors (Plank et al. 2011 p. 2079) confirm: “Ideally, this research should have been continued over a longer period providing a better understanding of how carers’ experiences  change over an extended time”.

Paper and Evidence Evaluation of the First Research Study

Design and Limitations

The selected study design (Schreuders et al., 2014) was longitudinal retrospective research, in order to find a correlation between nurse staffing levels and patient outcomes. The research design was appropriate for the aims of the study. As Twigg et al. (2011) confirm, however, it is hard to estimate the individual patient’s exposure to nursing hours, therefore, this design might have been more appropriate for indicating the overall effectiveness of the unit, instead of trying to find correlations between staffing levels and the number of complications. Further, the authors were looking to examine “nursing sensitive complications”.

Provided that the appropriate framework is used to identify these types of complications, the design is appropriate. Any discrepancies in identifying these complications, however, could hinder the results. Further, some authors (Carryer and Budge 2010; Rotter 2010) state that most complications are dependent on nursing interventions, therefore, it might not be appropriate to differentiate between nursing sensitive and non nursing sensitive complications.

Data Collection Methods

The authors collected and sourced digital data from three databases: A Department of Health (WADOH): the Health Corporate Network (HCN); the WA Data Linkage Branch (WADLB); and the Health Information Network (HIN). All the above networks are updated regularly and provide reliable information. However, nursing data was sourced from the hospitals’ payroll records, and the reliability, accuracy, and relevance of this data is questionable. Based on the above data, according to the authors (Schreuders et al., 2014 p. 802) “Exposure to nurse staffing was estimated by measuring nursing hours per patient day”. This  estimation’s accuracy is not guaranteed, and this might hinder the validity of the data. It is hard to estimate how many nursing hours a patient is exposed to, as it is dependent on the individual hospital’s policies, the priority areas, and other factors. The authors also estimated nurse skills, using a nurse skill mix. The problem with this approach is that it makes assumptions based standardized measures, and might not reflect individual nurses’ real skills and competency levels. Jackson et al. (2015) mentions another tool to assess competency and skills of nurses, as well as the relevance of their skill mixes to their work. The Cassandra matrix, described by the above study could have provided more appropriate data on nursing skills.

Evaluation of the Sample

The sample was retrieved from the database of three teaching community hospitals in a metropolitan area. The selection of the hospitals was based on a criteria of “clean” nursing data recorded on the system. This  provided a good quality of information for the researchers. Further, the authors of the study excluded 7598 fortnights worth of data, which had inadequate nursing staff level records. The authors also used the Inpatient unit movement data to identify patient location during their stay. Again, the accuracy of the data can not be guaranteed. The authors also excluded patients who were aged under 18 or were admitted to one of the below departments: “paediatric, maternity, rehabilitation, or psychiatric care” (Schreuders et al., 2014 p. 802).

Method Evaluation

The method of data collection was based on retrieving large scale information from metropolitan area hospitals, and ensure that only “clean” data is used. However, estimates were used to determine important variables, such as allocated nursing hours and skill sets, and this reduces the validity of the results. The main limitation of the methodology presented in the research is that it used generalized estimating equation methodology, to identify the correlations.

Conclusion

The above review and critique of the two articles has provided the author of the current study with an insight into research methodologies, and validating data. None of the studies were Grade A, and both included weak recommendations for implementation. Therefore, for nursing managers looking to integrate the results of the studies into evidence based care, it is recommended that professional experiences and patient preferences are also taken into consideration  (Woods, Fineout-Overholt and Kennedy 2012).

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