92440 Evidence For Nursing

Part 1: General content questions

One of the underlying concepts explored through this subject was conveying broad clinical scenarios and questions to searchable questions and using refined search terms to extract data.

1.Short terms find information relevant to the search because databases are indexed. Long sentences make the databases search for every word in the sentence which brings unexpected results.

2.Specific search terms only literature that has the term in the search and has few specific results. Broad search terms return many articles even including the less the relevant ones.

3.Tanner’s Model of Clinical judgment summarizes an approach to handling health situations. It explains how health concerns, patients’ needs problems and decision for care approach should be taken. This model highlights the importance of simulation in the enhancement of clinical judgment skills and capabilities. It emphasizes that clinical judgments require critical thinking creativity and decision making. This research-based model of highlights the main components as notice, interpretation, response, and reflection.

Evidence-Based Practice (EBP) is an approach that uses current nest evidence conscientiously, explicitly and judiciously in formulating clinical decisions. It is the integration of the clinical skills to the best possible external evidence. EBP integrates the clinical expertise, consumers’ values, and the reliable research evidence in the decision-making process. Clinicians bring their expertise, education, then integrates it with consumers’ encounter and lived experience, preferences, unique strengths, expectations, concerns, values, and beliefs.

4.A systematic review is centered towards a particular clinical topic aiming to provide a specific answer. The authors search extensively for studies underpinning the topic, review and assess their quality summarizing the findings in a predetermined manner as per the question. Randomized control trials are experimental, and they involve practical studies on real patients to identify the outcome

Part 2: Research methodology and results

Read the article carried out by Byrne et al. (2017). A copy of this article is in Assessment 2 folder.

5.Some of the advantages of using randomization method in this study was to eliminate any changes of bias.  The blinding during the data collection minimised the performance bias. The allocation concealment minimised the bias that could have occurred as assessment or performance bias. The prospective design helped to minimize recall errors and bias in the selection. Randomization also helped in eliminating confounding factors that could have been caused by unequal distribution of predictive factors, and it made comparison easier.

6.The first primary outcome was the discharge time which was not significant with or without adjustment of the surgery. The scores between the groups were (5.8 days) for the chewing group and (6.1 days) for non-chewing group.  Another outcome was the first flatus time. Again, there was no significant different between the two groups where both scored (P = 0.076): 42.0 (2.9) for chewing group and 58.0 (8.2) non-chewing group. The score was still not significant after adjusting the surgery type. The last primary outcome was first bowel motion (TBM).

The TBM of the chewing group was 50.0 hours (2.4) and that of non-chewing group 80.0 hours (6.5) which was significantly lower. There was also a significant decrease in TBM after surgery type adjustment.

Secondary outcomes were complication rates, pain and total morphine equivalent (TMEq) medication for seven days after the procedure.

One of the secondary outcomes were complication rates. Intraoperative complication from the CG was 7 (9%) and 7 (9%) from the NCG. Early postoperative complication was 36 (44%) for CG and 42 (55%) for NCG. The NCG has 13 patients (17%) with recurrent ileus compared to eight (10%) CG. Reoperation was 3 (4%) patients for NCG and (0) for CG. Another outcome was in medication where there was no variance in total morphine equivalent for 24 hours. However, CG had significant reduction of morphine equivalents between day 2-7 post procedure.  Another outcome was pain scores which were higher in patients who had no bowel event in NCG than CG.  

7.Pain was first recorded though a paper-based case report form (CRF). The patients reported pain scores were only recorded until the patient’s TBM. Pain was assessed through a scale of 0-10 with 0 being no pain and 10 the most extreme pain.

8.The study adequately used the sample size. For instance, the prospective design allowed the researchers to watch the outcome as the patient’s recovery progress. This design also helped the researchers to the profess with other factors.  With this design, they were able to sufficiently select, allocate and administer the chewing gums to the treatment group and monitor the development by comparing with the control group. The study was also able to eliminate bias, succeeded in the blinding, and the observations were consistent.

9.The important difference that in the baseline that could have affected the study was the considerable difference while allocating groups from the randomisation. The study had 43% patients in the CG group who had ileostomy closures while the NCG had 25% patients of ileostomy. An ileostomy closure is a minor surgery for closing the ileostomy temporary. This resection is less painful, needs less amount of analgesia and the patient gets quick gut recovery than other surgeries colectomy. Since there was variance in such procedures, this could have also affected the pain and recovery assessments.

10.The purpose of blinding is to reduce and where possible eliminate both the ascertainment and performance that may occur after randomization. The failure to blind patients can have great effects on the trial since they will have the knowledge of different group assignments. This awareness affects greatly affect the patient’s behaviour during the trial and their reactions can cause subjective outcomes. For example, if one patient knows that he or she is not receiving a treatment that could have improved the conditions, he/she may drop the trial reject to comply with the trial procedures. Besides, such a patient can sneak to find alternative treatment somewhere else outside the study protocols. Such a patient can also leave the study and her/his data would not be recorded.

11.Yes, but there was no significant efficacy. The difference between the two groups was LOS was 0.9 days. The LOS in chewing group was (5.8 days) while that of the non-chewing group was 6.1 days. This was a difference of only 0.9 days. There was still little merging of the difference even after adjusting the type of surgery.

12.In relation to data interpretation, median refers to the middle number after arranging all the numbers in a sequence in a ranked order. Therefore, the median sits between the lower half and the higher half. If line separating the higher half and the lower half is recording a by stating that the median time to TBM was 50 hours in CG, the authors imply that after arranging the TBM of the 82 patients in CG, they then took the TBM of the patient number 41 and 42. They then found the mean of their TBM which was 50 hours. Therefore, if the median was 50 hours, then more than a half of the patients’ TBM was counting less or equal to 50 hours.

13.If the authors found the median was 50 hours in CG 95% 45.2-54.8. first of all, the sample median of 50 hours should be taken as a point of estimate of the entire population of patients who had bowel surgery. This point of estimation cannot be taken to provide much relevant information since it is not true that if every patient chewed a gum would have taken 50 ours TBM. There is no good estimation of how far or lower the mean would have gone if data for all the patient would have been taken. For example, the authors could not be confident that all the patient’s median TBM was within the 5 hours of 50 hours TBM. However, with a confidence interval of 95% CI 45.2-54.8, there is more information. The authors mean that the median TBM of the patients who can chew the gum would lie between the two margins of 45.22 and 54.8 because 95% of the calculated time CI would have the 50 hours TBM. If the authors decided to take repeated samples and then compute a 95% confidence interval on each sample, they will end up have 95% of the intervals containing the medians, and 5% of the intervals would not contain the population median.

14.The starting point is a null hypothesis where we assume that the chewing the gum did not affect the morphine need for morphine equivalents. The null is 1, meaning no effects. The closer the value of morphine equivalent to 1, then the higher the level of the validity of the null hypothesis.

24 hours the P was 0.589 which was closer to 1, this means that the chewing gum did not work

Day 2, the P was 0.019, which was far from 1, this means the chewing gum works

Day 3, the P was 0.002, which was far from 1, this means the chewing gum worked, and improved from day 2

Day 4, the P was 0.025, which was far from 1, this means the chewing gum worked but for some reasons, there was a fall from the previous trend.

Day 5, the P was 0.033, which was far from 1, this means the chewing gum worked but for some reasons, it was rising towards one.

Day 6, the P was 0.013, which was far from 1, this means the chewing gum went back to the previous working trend, and indication that maybe there was an external factor that was causing the variation.

Day 7, the P was 0.002, which was far from 1, this the chewing gum worked, and the trend went back to day two, which also means the external factor that was causing the variation was controlled.

In general, a low P value is an indication that the sample was providing adequate evidence for rejecting the null hypothesis and accepting that the chewing gum was working for all the patients.

Part 3: Implementation of EBP

Thinking broadly about the way you engage with evidence in your clinical practice, please answer the following questions:

16.There are various barriers to the implementation of research findings in clinical practice. These barriers can be classified as those that result from patients, those that result from health professionals, and those that result from health organizations and government. The barriers from patients are much more individualized. Recognizing that each patient is different from the other, the patient’s beliefs about health care systems, their culture or other individualized factors can affect the implementation of the finding. Considering that patients should be involved in a shared decision-making process, some patients’ opinions might conflict with those of healthcare professionals. In such a situation, health officials must honour the decision of the patients as there is the belief that ‘patients are experts of their problems.’ In addition, financial capacity of the patient can affect a research implementation. Where patients are supposed to purchase or adhere to a particular health life style, lack of finances might hinder the patients from facilitating the implementation of the findings. Another factor is patient education, if patients are not well-informed of the purpose of the new approach, they would be unlikely to take it. Health care providers can also be barriers to clinical finding implementations. These barriers come through information constraints which is lack of relevant information for the implementation of the approach at the right time.  Other clinicians’ barriers include lack of support tools, limited guidelines, the providers altitude etc. Organization barriers include lack of financial support for the implementation of the finding, poor implementation policies, lack of government support, lack of insurance support, and few number of personnel.

17.This subject has enriched my skills in evidence-based practice. The subject has equipped me with more knowledge in making clinical decision that can help in supporting patients in their recovery. For instance, learning how to interpret clinical findings is an essential skill in nursing career. Apart from interpreting the results, the subject has also taught me how I can do my own research. One of the important knowledge from this subject is the development of a search strategy in databases. Considering that researching is one important area whereby nurses have to gather evidence to support their work, I will be having an easier time in my research by using short terms to get specific results. Also, by assessing different studies from that have been conducted by other researchers, I will be able to filter out what is relevant for my clinical question and what is irrelevant.