Clinical Decision Making Using Evidence-Based Practice Essay

Evidence based practice has gained momentum in nursing since the development of Evidenced based practice medicine. Evidence based practice offers opportunities for nursing care to be more individualized, more effective, efficient, and dynamic, and to maximize effects of nursing clinical judgment. When evidence is used to describe best practices rather than to support existing practices, nursing care keeps pace with the latest technological advances and takes advantage of new knowledge developments. However, Quality and nature of the research, attitude of clinicians, and organizational factors are well known barriers to evidenced based practice. The need for studies that directly address wide range of pressing clinical issues and for replicating studies in a more diversified settings remains a challenge. This paper will evaluate the meticulous integration of evidenced practice components of diabetic therapy and outcome in middle age Latina. Clinical Decision Making Using Evidence-Based Practice Essay

Question

In Latina patients with Obesity and a Family History of Cardiovascular Diseases, are complementary medicines more effective than Metformin in treating Type 2 Diabetes?

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Evidence

The case study indicates that Martha is a 48 year old Latina woman with a 3-year history of Type 2 Diabetes. She also has a family history of cardiovascular diseases. Martha has been taking 800 mg of metformin once a day as a first-line treatment for Type 2 Diabetes. She also maintains diabetic diet along with daily exercise. However, her recent lab report indicates no significant improvement in her condition. Clinical Decision Making Using Evidence-Based Practice Essay. First, the test indicates that her hemoglobin A1c has reduced to 8.5 which is still above the target. A normal level of hemoglobin should fall below 5.7 percent. Secondly, Martha’s fasting blood glucose levels range from 160-190 mg/dL. A normal fasting blood sugar level is below 100 mg/dL. Furthermore, the patient also complains of weight gain and heart disease. Coffman et al illustrates that it may be especially difficult for people who do not speak English well and have low health literacy to understand information related to their diabetes such as diet, weight management, and other self-management strategies.

Critical Appraisal of the Evidence

The evidence indicates that metformin is not treating the patient effectively. The only change that has been noticed is a slight decrease in the hemoglobin A1c which has fallen to 8.5 percent. The new level indicates a decrease but leaves the patient far above the normal level which is below 5.7 percent. However, the evidence does not tell other factors apart from metformin which could also be working against the treatment. For instance, the patient has been gaining weight despite the fact that weight gain is not one of the side effects associated with metformin. The main side effects associated with metformin include nausea, abdominal cramps, diarrhea, vomiting, loss of appetite, metallic taste, and flatus. Side effects such as diarrhea, vomiting and loss of appetite may affect eating patterns and cause loss of body weight among patients with Type 2 Diabetes. However, previous research does not tell any case where metformin has been associated with body weight. Therefore, despite the fact that metformin is not working effectively, there could also be other underlying factors affecting the treatment process. Clinical Decision Making Using Evidence-Based Practice Essay.

Integrating Evidence with Clinical Practice

In a circumstance where one drug fails to achieve its purpose, it is always recommended to try other alternative treatment methods. For instance, evidence in this case indicates that the patient’s condition is not improving despite regular application of metformin and other measures including body exercise and diabetic diet. Trying another method may assist the patient to improve her condition. Besides, nurses and clinicians will have an opportunity to determine the effectiveness of metformin in comparison to other treatment methods.Intervention. Research shows that metformin can be replaced or used along with other alternative treatments known as complementary medicine. The role of a complementary medicine is to assist the primary or the conventional medicine to achieving its purpose. An example of a complementary medicine that this paper recommends is Sulfonylureas. The medicine can be taken along with metformin in cases where the patient is not responding effectively. Sulfonylureas is a second-line drug that has shown effective results in treating type 2 diabetes along with administration of metformin.

Another study suggests that a healthy diet and adequate exercise are important for diabetes self-management. Health education programs can promote the development of health literacy skills and disease-specific knowledge, enabling individuals to have greater control over their health. Clinical Decision Making Using Evidence-Based Practice Essay. Besides the complementary medicine, the patient should maintain diabetic diet and regular exercise to minimize weight gain. Moreover, the patient should also avoid depressing situations to minimize negative conditions associated with weight gain.

The results will be used to compare the effectiveness of metformin alone as well as metformin along with complementary medicine. The current case study presents the first evidence indicating that metformin has not been effective towards treating type 2 diabetes among patients with obesity and a family history of cardiovascular diseases. The use of metformin along with sulfonylureas will provide a second evidence needed to a complete comparison and draw effective conclusions. The patient should also maintain regular body exercise and diabetic diet to make the comparison more effective.

Outcomes

The aim of this clinical decision is to facilitate the treatment of the patient. So far, the evidence indicates that metformin alone has not been effective towards improving the condition of the patient. Therefore, the use of metformin and sulfonylureas will provide more information needed to determine the most effective treatment for type 2 diabetes in female patients with obesity and a family history of heart diseases.

Evaluating Effectiveness of the Clinical Decision

The evidence indicates that metformin has not been effective towards treating type 2 diabetes in this case. Instead, there are indications that the patient is developing more complications. For instance, weight gain and heart disease are signs that the patient is developing further complications. However, using metformin along with complementary medicine such as sulfonylureas may assist the patient to overcome her current condition. The patient has also been advised to maintain regular body exercise as well as the recommended diabetic diet. The outcomes of this clinical decision will be evaluated using the following tools: Glycated hemoglobin (A1c) test. This blood test will indicate the average blood sugar level for the last three months. According to the case study, the current hemoglobin A1c is 8.5 percent. Although any figure below 8.5 percent will indicate success of the clinical decision, the aim is to reduce the average blood sugar level to a figure below 5.7 percent. The main aim of the treatment is to ensure the patient reaches a normal blood sugar level which falls below 5.7 percent. Any figure above 8.5 percent will indicate that the new clinical decision is not successful. Fasting blood sugar test. The purpose of this test is to determine blood sugar level after a body is deprived of food. The test is based on the fact that most of the blood sugar comes from foods that people eat.  Clinical Decision Making Using Evidence-Based Practice Essay.After an overnight of fasting, a sample of blood will be taken and tested to determine the blood sugar level. Any figure below 100 mg/dl indicates a normal fasting blood sugar level. However, a figure within a range of 100 mg – 125 mg/dl indicates a prediabetes level. Any figure above 126 mg/dl is an indication that one is suffering from diabetes. The current level is within the range of 160 – 200 mg/dl.

The aim of the treatment is to lower the fasting blood sugar level to any figure below 100 mg/dl. The success of the treatment will provide evidence that can be used by practicing advanced nurses to develop appropriate treatment plan for patients with type 2 diabetes.

Clinical decision making in nursing involves applying critical thinking skills to select the best available evidence based option to control risks and address patients’ needs in the provision of high quality care that nurses are accountable for. – Standing, M. (2011)

Nurses are accountable for the quality, safety and effectiveness of their clinical decision making. We are accountable to the patients, clients and service users to whom we owe a duty of care. According to Standing, M. (2011), accountability in decision making is being answerable to patients, the public, employers, NMC and the law for the consequences of our actions and having to explain, justify, and defend our decisions.

The Nursing and Midwifery Council (NMC, 2008) states that nurses are personally accountable for their actions during practice and therefore they must be able to justify their decisions at all time. Nurses have to balance a number of elements before they make a decision, however the patient’s best interest is their main priority.

Decision making involves assessing available options and their effectiveness. It applies judgement regarding our reasons for doing or not doing things. As nurses, we use different information sources to support our judgement and decision making.

Nursing is the use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life whatever their disease or disability, until death. (Royal College of Nursing, 2003) Clinical Decision Making Using Evidence-Based Practice Essay.

Decision making requires thinking skills to exercise judgement in assessing the benefits of available options and choosing a preferred option that is then acted upon. Judgement is not decision making but is closely related. Decision making links judgement to practice by acting on it in choosing from the options available. There are different models of decision making in nursing developed to help nurses make their decision on all aspects of nursing care and I decided to focus on risk analysis and management and evidence based decision making.

Clinical practice is often concerned with risk reduction and with the developing trend in healthcare litigation, there is a big emphasis on risk management for both the patients and health care staffs. Clinical risk management will fundamentally happen through the interpretation and application of agreed individual care plans. The development of a comprehensive and individualised care plan will relate to the broad range of effective treatment, rehabilitation and support services provided at the current level of clinical knowledge (Morgan, S., 1998).

Risk assessment is a process of identifying and investigating factors associated with the increased probability of specified risk occurring. It is an examination of the context and details of past risk incidents in the light of current circumstances. It is also concerned with the patterns of circumstances in which these factors may arise.

A nurse may assess a patient as at risk of developing pressure sores, and then implement measures to try and reduced the likelihood of this event occurring by providing equipment such as specialist mattress.

Risk assessment is a continuous process in which nurses gather information from multiple sources and other health care professionals with the focus of identifying the factors that is associated with the increased probability of risk happening. It is the foundation on which decisions are made and risks plans are then formulated through available national and local policies and procedures (Morgan, S.,1998). According to Lipsedge (1995), good practice in risk assessment requires nurses to translate their knowledge into a clearly distinct formulation of the risks. The formulation should ideally reflect aspects of each individual, context and systems that may influence the potential for risks.

The primary aim of pressure ulcer risk assessment tool is to help nurses identify individuals at risk of pressure ulcers and determine the degree of risk (Shakespeare 1994).Formal pressure ulcer risk assessment involves the use of a tool that assists in identifying those patients likely to develop a pressure ulcer.

According to Guy, H. (2007), risk assessment on pressure ulcer requires multifactorial consideration.  Clinical Decision Making Using Evidence-Based Practice Essay.Risk-assessment tools are a useful signpost to risk factors but must not be used in isolation to identify risk. It is important to carry out a care plan once the patient is identified to be at risk of developing a pressure sore so that occurrence of pressure damage can be prevented.

Most nurses are familiar with the use of pressure sore risk assessment tools such as the Braden or Waterlow scales. These tools collect data regarding various factors thought to be associated with the development of pressure sores. There is normally some form of scoring system which shows the probability of the pressure sore occurring. For example, if a patient scores 15 or over on the Waterlow scale, the individual may be considered at risk of developing pressure sores and therefore the nurses will have to maintain a pressure ulcer prevention (PUP) bundle in order to keep track of the patient’s condition. According to Waterlow (1985), recommended care interventions are available with each recommendation corresponding to the risk score parameters of the Waterlow scale.

The Waterlow scale is mostly used in adult field of nursing. It can also be used with hospitalised mental health and learning disability patients. However, the Waterlow scale is specifically designed for adults and therefore it is not appropriate to be use on children. Paediatrics use a different pressure ulcer risk assessment tool called the Glamorgan scale (Willock, J. et al, 2007).

No risk assessment tool can be 100% accurate. The key issue in examining risk assessment tools is how good they are at distinguishing those at risk from those who are not and if they are better or more accurate than simply relying on professional judgement (Thompson, C. & Dowding, D., 2002). When considering risk assessment and risk reduction, it is important that the initial assessment of risk is accurate.

Evidence refers to information that is used to support particular beliefs, decisions and actions. Evidence-based decision making is a prescriptive approach to making choices based on ideas of how research and theory can be used to improve decision making in regards to delivery and quality of patient care. According to Nursing and Midwifery Council (2008a, p.7), nurses are now required to use evidence based practice. For example, nurses must deliver care based on the best available evidence or practice and must ensure any advice given to patients are evidence based. Clinical Decision Making Using Evidence-Based Practice Essay.

Sackett el al (1996) defines evidence base practice as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient by incorporating individual clinical expertise with the best available external clinical evidence from a systematic research.” This means that one solution will not be the same for all clinical scenarios and it is the nurse’s role to identify the research that best fits the clinical situation.

According to McKibbon (1998):

“Evidence based practice is an approach to health care wherein health professionals use the best evidence possible, i.e. the most appropriate information available to make clinical decisions for individual patients. Evidence based practice values, enhances and builds on clinical expertise, knowledge of disease mechanisms, and pathophysiology. It involves complex and conscientious decision making based not only on the available evidence but also on patient characteristics, situations and preferences. It recognises that health care is individualised and ever changing and involves uncertainties and probabilities. Ultimately, Evidence base practice is the formalisation of the care process that the best clinicians have practiced for generations.” Clinical Decision Making Using Evidence-Based Practice Essay.

McKibbon (1998) recognises the importance of the patient when making decisions about their own care. According to Reigle, Steven, Belcher et al (2008) and Talsma, Grady, Feetham, et al (2008), the reason why evidence based practice is consistently implemented is because it leads to the highest quality of care and best patient outcomes. It involves combining the knowledge of an expert, patient preferences and research evidence within the context of available resources. Also, studies by McGuinty and Anderson (2008) and Williams (2004) showed that evidence based practice has reduced healthcare costs and geographic variation in delivery of care.

“Integrating research evidence into decision making involves forming a focused clinical question in response to a recognised information need, searching for the most appropriate evidence to meet that need, critically appraising the retrieved evidence, incorporating the evidence into a strategy for action, and evaluating the effects of any decisions and actions taken.” – Thompson et al (2004)

One of the tools used in evidence based practice is the use of the early warning score system (EWS). EWS were developed to assist health care professionals detect if patients are deteriorating. It is based on physiological parameters taken when recording patient observation e.g. the patient’s heart rate, respiratory rate, temperature, oxygen saturations and systolic blood pressure. The EWS is designed for adults and can also be use with mental health and learning disability patients. However, due to children and adults different physiological responses, EWS is inappropriate to use on children.Clinical Decision Making Using Evidence-Based Practice Essay.  Alternatively, Paediatric Early Warning Scores (PEWS) is use for children, to record observations and is use to assess the child’s condition i.e. If the child’s score is high then this means he/she is at risk of deteriorating, this gives nurses an early indication that an action has to be done.

The use of early warning score (EWS) is the best practice for clinical observations (Department of Health, 2000), and this is backed up by NCEPOD (2005) who emphasised that every in-patient should have a EWS recorded. Accurate and timely observations and adherence to EWS is essential in order to recognise patients who are at risk of deterioration.

According to NICE (2007), nurses caring for patients in acute hospital settings should be skilled in monitoring, measuring, and interpreting data and have prompt response to the acutely ill patient and they should be assessed in order to demonstrate their competency. Early intervention can help prevent patient’s condition from deteriorating which then helps avoid the need to transfer the patient to a higher level of care.

However, despite the good outcome of using evidence based practice in decision making with regards to patient care, there are issues such as nurses do not always make their decision based on available evidence due to lack of skills i.e. poor IT skills, lack of research skills and literature. There are also misconceptions that traditional ways is the best way, or that gathering evidence is too difficult and time consuming. Becoming skilled in clinical decision making requires the application of a range of evidence regarding patient concern, physical and human resources within healthcare contexts, understanding health and illnesses, developing expertise in applying therapeutic approaches, a commitment to enhance the wellbeing of those in your care and fulfilling the requirements of the relevant professional body. Clinical Decision Making Using Evidence-Based Practice Essay.

Overall, as nurses, it is important to have a basis when we make a decision regarding patient care. Risk is integral to nursing and the assessment of risk is one of the most common judgements nurses make. Each decision making model requires certain set of skills in order to be put on proper use and get the right results. Nurses are expected to use valid evidence to support their decisions when deciding what care to provide each patient. It is also important that nurses use their resources cost effectively by ensuring that resources and equipment are used correctly by the patient. Sometimes it is difficult for the nurse to come to a decision that will satisfy clients and co-workers and they also may be challenged at any time, however the important thing is that the nurse takes full responsibility and is able to justify his/her decision. Making the wrong clinical decision is not only harmful to patients but can also damage a nurse’s career. Learning about developing and applying effective clinical decision making skills is vital for the wellbeing of patients and nurses’ capacity to demonstrate that decisions are justified.

Each representative of the medical profession certainly at least once in life thought about the essence of healing art. The traditional answer to this question is something like this: “healing art consists of the knowledge needed to understand the causes and pathophysiological mechanisms of diseases, from clinical experience, intuition and a set of qualities that together constitute the so-called “clinical thinking”.

Cultivated in the traditional medical education concept “clinical thinking” does not have clear meaning and holistic vision of healing and is based on analogies. At the turn of 80-90-ies the new fild of knowledge was formed in medicine – clinical epidemiology. The most popular became the works of the group of Canadian scientists – D. Sackett, B. Haynes, G. Guyatt and P. Tugwell from the McMaster University, Ontario. They were the first who tried to study the medical skill in terms of rigorous scientific principles. These scientific principles have a great impact on the style of medical practice and ideology of doctors.

Clinical epidemiology is developing the scientific basis of medical practice – a set of rules for clinical decision-making. The central tenet of clinical epidemiology is that: every clinical decision should be based strictly on proven scientific facts. This postulate is called “evidence-based medicine”.

Evidence-based medicine is an approach to medical practice in which decisions on the use of preventive, diagnostic and therapeutic measures are taken based on the available evidence of their efficacy and safety, and such evidence undergoes search, comparison, compilation, and wide dissemination to be used in the interest of patients (Evidence Based Medicine Working Group, 1993).

Evidence-Based Medicine is a conscientious, explicit and judicious use of current best evidence for making decisions about care of individual patients. The practice of evidence-based medicine involves the union of individual expertise with the best available external evidence obtained from systematic research. By individual clinical expertise experts mean the professionalism and clinical thinking, acquired through the accumulation of clinical experience in clinical practice. Increasing professionalism is manifested in many ways, but most pronounced it is in the more efficient and effective diagnosis, the more thoughtful identification and compassionate attitude to the difficulties of patients, their rights and preferences in making clinical decisions regarding the provision of medical care. Under the best available external proof, specialists mean clinically relevant research. Clinical Decision Making Using Evidence-Based Practice Essay. External clinical justified evidence not only invalidates the previous diagnostic tests and treatments, but also replaces them with new, more powerful, precise, effective and safe. (Sackett, DL et al. (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312 (7023), 13 January, 71-72).

Principles of evidence-based medicine include the testing of the efficacy and safety methods of diagnosis, prevention and treatment in clinical trials. The practice of evidence-based medicine is the use of data from clinical trials in daily clinical work of a doctor or a nurse.

In most countries there were recognized some of the rules for conducting clinical studies outlined in the standard GCP (Good Clinical Practice) as well as the rules of production of drugs (standard GMP) and perform laboratory tests (standard GLP).

The International System of evidence-based medicine evolves exponentially: since its establishment in the early 90’s to the present time the number of centers, books, publications and forums on the problem is huge. The U.S. Agency of Health Policy and Research subsidized in 1997 12 such centers established at leading universities and research institutions of different states, a growing number of centers on individual issues (child health, primary care, general practice, mental health, etc.). The common thing for all directions is the use of the principle of evidence at any level of decision-making – from the state program till the appointment of individual therapy.

Nowadays evidence-based practice is widely implemented in professional nursing practice. The idea of evidence-based practice for nursing was developed from the evidence based medicine movement.

Currently, nursing is an integral part of the health system. It is a multifaceted health discipline that has a social health importance, as it is meant to maintain and protect public health. Nursing is a science and art, aimed at solving existing problems related to human health in a changing environment.

Thus, evidence-based nursing is the kind of evidence based medicine. It involves identifying the necessary research and implementation of them into practice care in order to improve the quality of patient care. The aim of EBN is to provide high quality and most cost-effective care ever possible. EBN is a process based on the collection, interpretation and integration of important research results.Clinical Decision Making Using Evidence-Based Practice Essay.  Some experts define the EBN narrowly, considering only the use of randomized clinical trials, while others also include the use of case reports and expert opinions. In order to apply the practice in the right way, a nurse must understand the concept of research and know how to properly evaluate the study. These skills are taught in modern institutions of nursing education, as well as at training.

Nurses serve instrumental roles in ensuring and providing evidence-based practice. They must continually ask the questions, “What is the evidence for this intervention?” Or “How do we provide best practice?” And “Are these the highest achievable outcomes for the patient, family, and nurse?” Nurses are also well positioned to work with other members of the healthcare team to identify clinical problems and use existing evidence to improve practice. Numerous opportunities exist for nurses to question current nursing practices and use evidence to make care more effective.

For example, a recently published evidence-based project describes the potential benefits of discontinuing the routine practice of listening to the bowel sounds of patients who have undergone elective abdominal surgery. The authors reviewed the literature and conducted an assessment of current practice, and they subsequently developed and evaluated a new practice guideline. These authors reported that clinical parameters such as the return of flatus and first postoperative bowel movement were more helpful than bowel sounds in determining the return of gastrointestinal mobility after abdominal surgery. The authors found that this evidence-based project resulted in saving nursing time without having negative patient outcomes (Madsen et al., 2005). Clinical Decision Making Using Evidence-Based Practice Essay.

To understand what Evidence-based practice in nursing is better while defining the process it describes. In every day activity of clinical nursing, EBP provides nurses with a tool with the help of which they can provide the best and safest health care ever possible. The new emphasis of the EBP nursing comes from the problems that have emerged in recent years regarding the safety of the health system.

Formulating Questions

As it is written on the Yale University Nursing Library website and the website of University of Minnesota, the first step in EPP is to formulate right, necessary questions. Such questions consist of background questions such as “what causes some particular disease?” Such kind of questions has a practical application – the need to solve an exact clinical problem. The clinical questions should include foreground questions also. These pertain to how the disease or condition in question is usually treated.

Finding the Answers

As soon the right questions have been formulated, the nurse can then look for possible solutions to the problem by making some necessary research. The aim of the research is to find sources that tall about the possible treatments and outcomes of the disease. Nurses in clinics often use databases such as CINAHL and MEDLINE for performing their searches. Clinical Decision Making Using Evidence-Based Practice Essay.

Evaluation

The next step is to evaluate the evidence as soon as it is found. Not all clinical treatments are the same, and not all sources that pretend to provide evidence of a possible clinical treatment are the same. Implementing the evidence-based practice in nursing process there is a need to understand that there not only various levels of possible treatment, but also various levels of quality in terms of research sources. The research quality is based on the quality of the research design and its applicability to the exact clinical case.

Application

Having evaluated the evidence, the nurse can start its application in her practice. One of the main questions that appear at this stage is how the evidence can be applied in order to meet nurse’s specific need or situation. Concerns of nurses include the validity of the diagnosis, how possible therapeutic techniques can affect the patient, whether there is any adverse risk to the patient and the prognosis of the treatment. As soon as the decision is made about the provision of a certain treatment, application of the treatment is usually made.

Re-evaluation of the result

As soon as the treatment has been made, the clinical nurse should reevaluate if the implemented evidence was adequate and useful for the particular patient and situation. Clinical nurse should assess whether or not the intervention was successful. Nurses ought to know whether their findings might contribute new knowledge to the nursing field. Clinical Decision Making Using Evidence-Based Practice Essay. They also should know how they will apply these findings throughout their future nursing practice. (Http://www.ehow.com/about_6728914_define-evidence_based-practice-nursing.html)

Conclusion

“Evidence based clinical practice is an approach to decision making in which the clinician uses the best available evidence, in consultation with the patient, to decide upon the option which suits that patient best”. (Muir Gray JA. (1997) Evidence-based healthcare: how to make health policy and management decisions. London: Churchill Livingstone).

So evidence-based practice helps nurses to provide high-quality patient care based on research and knowledge rather than because “this is the way we have always done it,” or based on traditions, myths, hunches, advice of colleagues, or outdated textbooks.

For example, when clinical questions arise, should one look to a nursing textbook for the answers? Remember that books are not published every year, and new information may not be included in the edition you have. Also, when using textbooks, consider whether you have the most current edition.

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There are also issues to consider when asking colleagues for advice-specifically, be mindful that their responses may be based on their personal experiences, their observations, what they learned in school, what was reviewed during nursing orientation, or myths and traditions learned in clinical practice.

A recent study provided evidence that most nurses provide care in accordance with what they learned in nursing school and rarely used journal articles, research reports, and hospital libraries for reference (Pravikoff, Tanner, & Pierce, 2005). That finding, combined with the fact that the average nurse is more than 40 years of age, makes it apparent that many nurses’ knowledge is probably outdated. Practice based on such knowledge does not translate into quality patient care or health outcomes. Evidence-based practice provides a critical strategy to ensure that care is up to date and that it reflects the latest research evidence.

So, EBP important to nursing practice because it results in better patient outcomes; it contributes to the science of nursing; it keeps practice current and relevant; it increases confidence in decision-making; policies and procedures are current and include the latest research; integration of EBP into nursing practice is essential for high-quality patient care. Thus, evidence-based practice is very important for modern professional nursing practice. Clinical Decision Making Using Evidence-Based Practice Essay.