NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

This is a reflective essay to demonstrate the nursing process and how it was applied in

The clinical area in which I was placed. Atkinson et al (1983, p2) describes “The

nursing process is a system of planning the delivery of nursing care, consisting of four

steps: Assessment, Planning, Implementation and Evaluation”. This is a client

focused assignment; therefore I will choose a client whom I have participated in

providing nursing care for. I will discuss the nursing process, how it was applied and

the context in which it was done. I will use reflection to compare my findings to how

literature states it should be done. I plan to show an understanding of holistic care and

how it is used in each stage of the nursing process. Holistic care is an

approach to healthcare which treats the individual as a whole person in relation to

their needs (Hinchliff et al, 1998). NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

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In order to maintain confidentiality I have provided my client with a pseudonym

(Nursing and Midwifery Council, 2002).

I based this assignment on Mary, who is a 72 year old lady and suffers with

osteoarthritis which is a degenerative disorder in bone and cartilage (Hinchliff et al,

1996). She had fallen at home and was presented at the Accident and Emergency

department by emergency services. After a short stay on Medical Assessment she

was transferred to the unit for rehabilitation following her fall. I spent seven weeks

on a large intermediate care ward. The ward is nurse led with very little medical

intervention. The NSF for Older People (2001 p.3) defines intermediate care “to

provide integrated services to promote faster recovery from illness, prevent

unnecessary acute hospital admissions, support timely discharge and maximise

independent living”. There is a great deal of input from a large team including

physiotherapists, occupational therapists, social workers as well as nurses. Initially an

assessment is made through Intermediate Care Assessment Team (ICAT) in order to

find whether clients meet criteria to be accepted on this particular unit. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay. Its aim is to

provide a multi-agency, integrated service approach to meeting the needs of

vulnerable older people who have complex health and social care needs. ICAT

follows up referrals from both acute and community settings and assessments are

made relating to clients physical, social and mental health. Clients on the unit will be

over 65 years and live within the trust area. They will be medically fit for discharge

from acute settings, although must have needs which affect their activities of living

(AL’s). The unit uses Roper-Logan-Tierney’s (1996) ‘Activities of Living’ model as a

basis for assessing and identifying needs.

ASSESSMENT

Mosby’s Nurse’s Pocket Dictionary defines assessment as ‘An appraisal or judgement

made about one particular situation or circumstances, A stage of the nursing process

involving the collection of information and data relating to patients and their

healthcare needs’ (Mosby 2002, p.31). Why do we assess? The purpose of

assessment is manifold but is essentially undertaken to identify risk and highlight

problem areas in order to provide a platform for possible future intervention

(Hinchcliffe et al, 1998). After the decision was made by ICAT and Mary came to the

ward, I participated in her admission process. As per trust policy I collected the

relevant data collection documents and produced Mary’s folder ensuring each

document was in the correct order. My mentor and I referred to the client’s case notes

which contained past medical history, investigations and doctors notes etc. We

transferred information from recent documents, such as full name, date of birth,

address and next of kin. Under supervision of my mentor I was instructed to gather

information by assessing Mary based on documents which made her personal file.

Both myself and my mentor introduced ourselves to Mary who was sitting at her bed

side in a cubicle. In an attempt to establish a therapeutic relationship with my client I

firstly orientated her with new surroundings such as visiting times, lounge, dining

areas. Involvement and relationship with another is both necessary for the enactment

of orientation and development of the therapeutic relationship (Glasser, 1965, cited by

Perry et al, 1991). Using an informal manner I went through each part of the

assessment. I used skills in observation, open ended questions and listening in an

attempt to retrieve as much information possible, particularly in Activities of Living.

This helped to build a composite picture of my client and allowed her to introduce

new facts that might be pertinent. The questions posed by assessing in the

individuality component of the model (such as how, how often, why and when)

furnished information not only about the way in which the person carried out each

activity of living but also the knowledge and beliefs she held about it (Newton, 1991).

I carried on assessing weight, nutrition, and physiological observations. Due to the

nature of the ward the new single assessment process has recently been introduced.

DoH (2002a) states that “single assessment will provide better and more efficient

access to cares services. It will minimise duplication of assessments by agencies and

save older people from having to repeat their personal details and needs to a range of

professionals. On gathering individualised data, it then must be interpreted.NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay. The needs

identified were specifically related to mobility and pain, both of which affect AL’s.

Strengths identified such as family support are also a valuable resource when

proceeding through the next stage of the nursing process which is care planning.

CARE PLANNING

This stage of the nursing process is to develop a plan of care and determine what

approach should be used to help with identified problems. During the planning phase,

the nurse applies the skill of problem solving and decision making. Setting priorities,

writing goals and planning nursing actions also make up this phase (Atkinson et al,

1983). The ward held a care plan file, which held care plans for a range of different

problems. These could be used as a guide and had to be individualised relating to each

specific client and their needs. On reflection, I felt this was a good idea, particularly

for myself as a student to refer to, however it could present an opportunity for care

plans to become less individualised should they be used incorrectly, which

consequently, could have an adverse effect and defeat its objective. Archibald (2000)

explains that Nursing models have been used to provide systematic care delivery

stemming from a desire to organise care coherently, enabling the plan of care to be

used and continued by others. He goes on to suggest that since the introduction of

models, nursing practice has become more patient centred and holistic. Daws (1998)

agrees that the nursing care plans play a vital role in promoting a holistic and

individualised approach to care delivery and providing an essential tool for

documenting needs and preferences. With reference to Mary, goals were set to

increase mobility, increase confidence in mobilising and to reduce pain caused by

osteoarthritis. Due to the nature of this ward care plans usually determine discharge

outcomes. Targets are set for a maximum rehabilitation period of 28 days. Reasons for

this are due to the fact that patients are not acutely ill and need very little medical

attention. Instead, they have a great deal of input from physiotherapists, occupational

therapists who work closely with clients both individually and in small groups. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

Newton (1996 p.29) states “Goals of Nursing care must be realistic and achievable

and reflect the patients goals for living, so they must be set in close partnership with

the patient and based on assessment of the individuals AL’s and on the nursing

knowledge associated with them”. The care plan is initially implemented by nursing

staff who will also take into account client centred outcomes. The easy care (single

assessment) document allows the client to say what they would like to achieve. All

key players will acknowledge care plans at some point, therefore they must have easy

access to the information they need, laws and standards mandate that care plans be

specific, clear and legible (Alfaro-LeFevre, 1998). In order to keep Mary involved in

her care, goals were agreed with her. This is to ensure patient autonomy but also to

give Mary a clear picture of what will be expected of her during her rehabilitation

period. It was established that the goal set for pain was highly prioritised and so

analgesia was reviewed by a doctor. This ensured Mary could proceed concentrating

on client centred outcomes.

IMPLEMENTATION

The Oxford Dictionary for Nurses (1998, p.313) defines implementation as “the stage

of the nursing process in which the patients individual care plan is utilized and

executed, in collaboration with other members of the healthcare team” . Hand over

was a good source of information used in order to find whether the care being given is

right for the patient. The ward used pre written handover sheets which were kept

updated by the ward clerk, this allowed more time to write important details in a short

space of time. Sometimes nurses do not have enough time to read charts and look up

common problems during their shift. When you have time to prepare for the shift, you

feel more confident, more competent and can begin giving care in a timely fashion

(Alfero-LeFevre, 1998). With reference to Mary care was continued to be monitored

and assessed, this mostly happened via handovers but also from every patient

encounter. I would see this as an opportunity to assess both physical and mental

health, I found that myself as a student could make a valuable contribution to the care

being given. All care was documented and signed and Mary’s assessment/care plan

file was kept at the foot of the bed. All of the contents are legal documents and can be

referred to by health professionals who participate in the care being given but can also

be viewed by Mary and her family. DoH highlights this within the essence of care

document (benchmarks for record keeping) (2001, p.3) stating that “patients are able

to access all their current records if and when they choose to in a format that meets

their needs”. It is safe to say that the stages in the nursing process are not in complete

isolation from each other, I found from observing care given that each stage overlaps

the next. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay. It is at this stage that clear direction is given about what is to be done for the

client and by whom it should be done. Since the entire MDT was based in the same

unit, the communication was excellent. This ensured a timely advantage for patients

and for tasks to be delegated to the correct healthcare professional. Handovers were

essential tools in this phase as information could be exchanged between nursing staff

and the rest of the MDT, and further strengths and weaknesses could be highlighted.

Tasks were allocated to each member of the team on specific days at specific times.

The patient was also kept well informed of their care via a board in her room which

gave the days and times and activities to be held. All input from therapy staff was

documented by form of report and handed over to nurses on completion. Weekly

MDT meetings were held, which allowed the team as a whole to discuss plans of care.

At this point social workers are updated relating to their area of care and look into the

possibility of services post discharge. Mary was kept updated of this information

which can only be implemented on her consent. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

EVALUATION

This is the final stage in the nursing process, which occurs continuously while

providing care. Evaluation refers to goals which were set, any reassessment and

documentation relating to specific goals. In Mary’s case this was her care plans.

Therefore the questions would be asked: Is the client in pain? How well does the

client mobilise? Is the client confident in mobilising alone? This phase also involved

re-assessing Mary in relation to AL’s, and so by using the Roper, Logan and Tierney

(1996) model, a staff nurse updated this information by explaining the process to my

client and asking her views on each topic relating to AL’s. Tierney (1998) suggests

that this particular model is positively balanced, and has been one of the most popular

in the United Kingdom”. Wimpenny (2001) agrees stating “It is certainly the best

known and most widely used model in this country”. Generally the model had worked

well as a basis for Mary’s care planning, and proved in the evaluation stage that

progress was made and the model was excellent in relation to most physical and social

aspects of care. It was documented and handed over that my client had appeared to

have progressed in all that was set. Newton (1991, p.181) confirms this by stating

“Value is also placed on observablee behaviour as an indication of the need for

nursing and the basis of evaluation of the effects of nursing”. On reflection, I found

that the care plans were maintained well. The intervention of therapy staff and their

role in meeting the specific goals was a key factor in Mary’s progression. At this point

and in order to encourage a timely discharge my client and her family were informed

of a home visit. This would prove to the MDT whether her progression in hospital

reflected on her own living environment, therefore determining an expected discharge

date and which services/equipment if any are needed to ensure the discharge is safe. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

Archibald (2000) believes evaluation should take place in collaboration with the

patient and family. This happened on the unit via progress reports or case conference

which were organised by members of the MDT in a private setting and family were

welcomed to be involved on consent of the client. The evaluation of care was fully

documented by the nurse and the MDT agreed that goals had been met. Therefore the

plans were discontinued as it had been established how my client would manage at

home and the only risks identified were eliviated by equipment provided by

occupational therapy. After a discharge date was set the nurse made appropriate

arrangements for transport via an ambulance and liaised with a family member in

order ensure a safe arrival at home. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

CONCLUSION

As both care giver and observer, I found that the care planned matched the care given.

Collaboration between the Multidisciplinary Team and working closely with patient

and family enabled outcomes to be achieved. This experience has taught me the

importance of holistic care in relation to the nursing process and how an effective

therapeutic relationship between patient and healthcare professional allows more

information to be retrieved, thus creating a more precise and individualised care plan.

To care for a person holistically requires ongoing assessments – utilizing knowledge,

attitudes and skills. Improving assessments and patient involvement in care is

highlighted in the essence of care document (DoH, 2001b). The fact that the MDT

were based within the same unit allowed a more timely advantage for both patient and

staff , allowed maximum communication to all concerned and worked well in relation

to discharge planning. My client had commented how she enjoyed the 4 weeks on the

ward. I think that the social aspect of the ward helped a great deal. Mary was

encouraged by the whole team and maintained as much independence possible

throughout her stay. I have benefited as a result of this placement, as it has taught me

the importance of the nursing process. I have become more efficient in collecting

information from the client and utilising it appropriately in order to care for the client

in a holistic way. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

This report is aimed at looking at the challenges that Evidence-based medicine faces today in terms of its implementation. In order to achieve this, there was a need to first understand the origin and definition of EBM, the different arguments for its existence and finally deciding exactly what to focus on.

In this case, a number of different healthcare environments were taken into consideration. These include:

Healthcare policy makers

Clinical Education

Healthcare organisations- specifically hospitals

Primary care setting- specifically clinicians and patients

Innovation in healthcare

A literature review was then conducted targeting these specific environments while still focusing on the challenges EBM faces during implementation. Four main databases (Cochrane Library, Web of Knowledge, MEDLINE and EMBASE) were used to find and retrieve relevant studies. To find these studies, several keywords had to be used in different combinations. An inclusion criteria also had to be set in order to minimise the amount of results gotten at the end of the search and to maximise the investigative topic of the review. This resulted in 24 studies, which were then retrieved for further analysis and discussion.

Although the papers did not all have the same aim and objectives, they did have some aspects in common and these aspects brought about a number of recommendations that will help in the management of the challenges or even to an extent try to reduce it.

Finally, the report proved that the problem that is faced by many is not so much that the principles of EBM are inconsistent, but that applying and furthermore implementing EBM in policy or clinical practice is proving to be very challenging.

As a general conclusion, although EBM still has too many barriers in its way, its positive impacts are just starting to be validated and it will continue to be validated and consequently evolve in the future. NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

1.1 Background and definition of Evidence-based Medicine (EBM)
The philosophical origins of Evidence-based medicine (EBM) extend back to mid-19th century Paris and even some people say as early as the assessment of evidence in research during the reign of the Chinese Emperor Qianlong [1] . This has remained a hot topic for clinicians, public health practitioners, purchasers, planners, and the public (patients) (Sackett et al., 1996).

A Canadian doctor David Sackett in the 1990s created the term Evidence-based Medicine [2] (EBM) (McQueen, 2001) and gave it its most renowned and accepted definition to this date. He defined EBM as a

“Conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett et al., 1996).

In its simplest form, it means combining the best available external evidence with personal clinical expertise (Sackett et al., 1996). As stated by Haynes et al. (2002), EBM greatly relied on this; unfortunately, major investments in biomedical research, leading to new and better tests and treatments, has spurred the development of critical appraisal of the medical literature and evidence-based medicine (Haynes et al., 2002; Evidence-based Working Group, 1992). NURS 8510 – Evidence-Based Practice III: Implementation, Evaluation, and Dissemination Essay

Initially, EBM’s early focus de-emphasised traditional determinants of clinical decisions including physiological rationale and individual clinical experience (Haynes et al., 2002). Subsequent versions have emphasized that research evidence alone is not an adequate guide to action. Rather, clinicians must apply their expertise to assess the patient’s problem and must also incorporate the research evidence and the patient’s preferences or values before making a management recommendation (Figure 1) (Haynes et al., 2002).

Macintosh HD:Users:Sophie:Desktop:Screen Shot 2012-08-31 at 14.30.43.png

Figure 1: Early model of the key elements for evidence based clinical decisions (Haynes et al., 2002)

A more advanced model for evidence-based decisions (Figure 2), recently defined as “the integration of best research evidence with clinical expertise and patient values”. This model is prescriptive rather than descriptive (Haynes et al., 2002). In other words, it is a guide about how decisions should be made rather than how they are made. Finally, this model states that patients’ preferences should be considered first rather than clinicians’ preferences.

Macintosh HD:Users:Sophie:Desktop:Screen Shot 2012-08-31 at 14.41.58.pngFigure 2: An updated model for evidence based clinical decisions (Haynes et al., 2002)

EBM normally asks questions, finds and appraises relevant data, and harnesses that information for everyday clinical practice. With this, there are four steps in EBM:

Figure 3: Four key steps involved in EBM (Erhman Medical Library, 2006)