Evidence Based Practice in Nursing Essay

Evidence Based Practice in Nursing Essay Introduction Evidence based practice is a complex experience that requires synthesizing study findings to establish the best research evidence and correlate ideas to form a body of empirical knowledge (Burns Grove 2007). There are many definitions but the most commonly used is Sackett et al (1996). Sackett et al (1996) as cited in Pearson, Field, Jordon, (2007) describes evidence based practice: â€Å"the conscientious, explicit and judicious use of current best available evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical experience with the best available external evidence from systematic research†. (Sackett et al 1996 page 5). The author will discuss the importance of evidence for practice, different types and levels of evidence. The research process, dissemination of evidence, barriers and will conduct a critique of two research articles. The importance of evidence based practice is to enable nurses to provide high quality care, improve outcomes for patient and families and to run a more efficient health service. Therefore other agencies within the health service will benefit when interventions and care is based on research (Burns Grove 2007). According to the Nursing and Midwifery Council (NMC) code nurses are accountable to society to provide a high quality of care so therefore it is important that nurses reflect, evaluate the care and keep abreast of new knowledge and evidence that is available (Burns Grove 2007). Providing a streamlined service, which is cost effective and based on current evidence based practice has shown to reduce cost but also to enhances the quality of care the patient receives (Melnyk et al2010). Working in partnership with the nurse the patient is able to participate in decisions about their care. This is not only beneficial for the patient but also increases the satisfaction of the nurse treating the patient (Craig Smyth 2007). Furthermore Craig Smyth (2007) suggests evidence based practice is a problem-solving approach to the delivery of health care. In using a problem solving approach the nurse is able to integrate clinician expertise and patient preferences to provide individualized care suitable for the patient. To acquire knowledge in the past, nurses have relied on decisions based on trail or error, personal experience, tradition and ritual. Parahoo (2006) suggests learning by tradition and ritual are important means of transferring knowledge, for example learning the ward routine. According to Brooker and Waugh (2007) Students learn from effective colleagues who practice safety and on the basis of best evidence. However, a disadvantage of this method of learning may lead to transmission of invalid information and may put the patient and nurse at risk (Brooker Waugh 2007). According to Burns and Grove (2007) to generate knowledge a variety of research methods are needed. The two different research methods are quantitative and qualitative. According to Burns and Grove (2007) quantitative research is an objective formal systematic process and demonstrates its findings in numerical data. According Munhall (2001) qualitative research is gathering information to describe life experiences throu gh a systematic and subjective approach and does not use figures or statistics to produce findings. In nursing practice the quantitative approach has been considered to provide stronger evidence than qualitative (Pearson, Field, Jordon, 2007). Pearson, Field, Jordon (2007) suggest health professionals and servicer users require a variety of information to facilitate change and to include evidence not only of effectiveness but feasibility, appropriateness and meaningfulness to achieve evidence based health care practice. Evidence based practice promotes the application of research evidence as a basis on which to make health care decisions so it is important to search for the truth and knowledge logically. Robust research which may draw on expertise and experience represent a higher level of evidence because of the discipline involved (Burns Grove 2007). There are thirteen steps in the quantitative research process and one step gradually builds on another (Burns Grove2007). The beginning of the research process starts with a problem which usually highlights a gap in knowledge (Melnyk Fine-Overholt 2005). The next step is the purpose of the research. This is produced from the problem and identifies the aim of the study (Burns Grove2007). To build a picture up of what is known or not known about the problem a literature review is conducted. This will provide current theoretical and scientific knowledge about the problem and highlight gaps in the knowledge base (Burns Grove 2007). This is followed by the study framework and research objectives, questions and hypotheses. This continues to the end till all the steps are covered. The final step is the research outcome. Hierarchy of evidence is generated from the quality of information from different evidence. Practitioners are able to use the hierarchy of evidence to inform them on which information is most likely to have the maximum impact on clinical decisions (Leach 2006). Leach (2006) suggests hierarchy of evidence may be used to discover research findings that supersede and invalidate earlier accepted treatments and change them with interventions that are safer, efficient and cost-effective. If findings from a controlled trial are inadequate, choices should be guided by the next best available evidence (Leach 2006). According to Scottish Intercollegiate Guidelines Network (SIGN 2009) the revised grading system is planned to place greater weight on the quality of the evidence supporting each recommendation, and to highlight that the body of evidence should be considered as a whole, and not rely on a single study to support each recommendation. The grading system currently in use with the SIGN guidelines starts with 1++ and ends in 4. For the evidence to be rated at 1++ it must include a high quality meta-analyses, systematic reviews of random controlled trails (RCT) or RCT with a low risk of bias. Level 4 is based on expert opinion (SIGN 2009). There are many barriers to implementing evidence based practice. One of the common barriers is staff information and skill deficit. Health professionals lack of knowledge in regarding results of clinical research or current recommendations may not have the sufficient technical training skill or expertise to implement change (Pearson, Field, Jordon 2007). Nurses have also highlighted lack of time as a barrier in applying research to practice. As the number of patients increases nurses face the challenge of providing safe, high-quality care within a short time frame. Nurse educators and researchers have developed a â€Å"toolkit† to ease the implementation of evidence based practice into nursing (Smith, Donez Maghiaro 2007). According to Gerrish and Lacey (2006) dissemination is a process of informing people about the results of a particular research. There are many ways to present results, video, seminars and the most accepted is through professional journals. However with the internet being more assessable the researcher is able to post details on the website hosted by NHS trust or university. One disadvantage in using the internet is that it provides no guarantee of quality (Gerrish Lacey 2006). SIGN guidelines are circulated free of charge throughout Nation Health Service (NHS) Scotland. For this to happen they must be made widely available as soon as possible to facilitate implementation. Furthermore guidelines on their own have proved ineffective and more likely if they are disseminated by active educational intervention and implemented by patient-specific reminders relating directly to professional activity (SIGN 2009). Critique 1 Rydstrom I, Dalheim-Englund A, Holritz-Rasmussen B, Moller C, Sandman P-O (2005). Asthma quality of life for Swedish children.Journal of Clinical Nursing 14, 739-749. Blackwell Publishing Ltd. As the title suggests this was a research to find out how Swedish children with asthma experience their quality of life and to look for potential links between their experience of quality of life and some determinants. This study was accomplished by using a quantitative research approach which adhered to the aims and objectives. Quantitative research is formal, objective, systematic inquiry that involves numerical data (Burns Grove 2007). The two stages used in the quantitative research were correlation and quasi-experimental (Burns Grove 2007). This is an acceptable method to use as the study was trying to explore the relationship between two variables and the findings were produced in a numerical format. In previous literature it was noted investigations in children with asthma around the world all had similar experiences (Rydstrom et al2005).It also highlighted that girls and boys perceived asthma in a different way and girls were more likely to include asthma in their social and personal identities where boys would exclude the condition (Williams 2000). The researchers wanted to ask the children how they experience their life living with asthma. Also to look at possible links between childrens quality of life and determinants such as age, sex, pets, siblings, location and social status (Rydstrom et.al. 2005). Some common types of sampling used in quantitative research are random and non-random samples (Burns and Grove 2007). In the article for the purpose of this study all hospitals and clinics were used and fifteen were chosen randomly for the study (Rydstrom et al2005). Both children and parents were asked to participate in the study but children had to meet the inclusion criteria before being selected (Rydstrom et al2005). By using a random sample the general population becomes representative of the larger whole (Parahoo 2006). Validity was established by cross-matching Paediatric Asthma Quality of life Questionnaire (PAQLQ) with About my Asthma (AMA), by Mishoe et.al.(1998). Warschburger (1998) recommended that PAQLQ was a reliable instrument and Reichenberg Brogerg (2000) found that there was no difference concerning reliability between the Swedish and the original PAQLQ. The study was approved by The Ethics Committee at the Medical Faculty of Umea University in Sweden and consent was received from parents and children. Burns and Grove (2007) define sampling as a process of selecting groups of people who are representative of the population. Data was collected through self administration questionnaires. There advantages and disadvantages in using questionnaires. Advantage firstly, the data is gathered is standardised and therefore easy to analyse. Secondly, respondents can answer anonymously which may produce more honest answers. A disadvantage is the responses may be inaccurate especially through misinterpretation of questions in self completing questionnaires. (Gerrish Lacey 2006). Children age seven to seventeen were required to fill in Paediatric Asthma Quality of life Questionnaire (PAQLQ) which was used to measure the childrens quality of life in different domains. Parents were required to fill in Paediatric Asthma Caregivers Quality of life Questionnaire (PACQLQ) (Rydstrom et al2005). Children and parents filled in questionnaires separately and a nurse was on hand to help children who could not manage on their own. The researchers clearly identify what statistical tests were undertaken. However the results are presented in a complex manner. The results showed the majority of children estimated their quality of life at the positive end of the scale. Children reported impairment in the domain of activities than emotions and symptoms for example not being able to run around. Living in the south of Sweden and being a boy were reported to have a better quality of life. Furthermore children living with a Mum over forty or with cohabiting parents had a better quality of life (Rydstrom et al2005). The researchers brought to the attention of the reader the laminations within the study. Children view friends and their social environment being important to them however there were no questions relating to this and also it did not take into consideration the childs stage of development (Rydstrom et al2005). Also the research was done within a week, therefore would the results be different if it was done over a longer period. This was not a controlled research so there is a possibility that some data may be missing as nobody was checking to see if the children had filled in all the questions. The findings highlight it is important for the nurse to look at all aspects of the child development. Furthermore caring tends to focus on the patients limitations, another important issue for nurses is to try to discover those aspects in a childs daily life that contribute to a high QoL in order to improve and maintain the childs wellbeing. Critique 2 Lyte, Milnes, Keating Finke 2007. Review management for children with asthma in primary care: a qualitative case study.Journal of Nursing and Healthcare of Chronic Illness in association with Journal of Clinical Nursing 16, 7b, pp123-132 As the title suggests this research article will focus on review management for children with asthma within a primary care setting. This study was accomplished by using a qualitative case study design. In using a qualitative case study design it can provide much more comprehensive information than what is available through other methods, such as surveys (Neale, Thapa Boyce 2006). Neale, Thapa Boyce (2006) suggest case studies also allow one to present data collected from multiple methods (i.e., surveys, interviews, document review, and observation) to provide the complete story. Qualitative research is systematic, subjective approach (Burns Grove 2007) which describes life experiences, meanings, practices and views of those involved (Craig Smyth 2007). In the UK one in eight children suffers from the effects of asthma and the majority of cases are now being managed in the primary care setting (National Asthma Campaign 2001). With improvement in management of asthma over the years there is still a high level of morbidity and mortality (Lyte et al2005). Out of Sight, Out of Mind (Asthma UK 2005) agrees with Lyte et al(2005) that death rates are high. In Scotland the death rates due to asthma vary each year. Furthermore inquires have shown at least 90% of those deaths could have been avoided. However child admissions to hospital due to asthma have fallen slightly (Out of Sight, Out of Mind Asthma UK 2005). Furthermore it was highlighted through a systematic review of literature published at the time of research that it was unknown whether primary care based asthma clinics were effective. Additionally it concluded that patients views on asthma clinics were also unknown (Fay et al2003). One cannot ignore the fact that there are evident gaps in generic knowledge of primary care asthma services for children in the UK (Lyte et al2005). Therefore the aim of the study is to investigate current review management of childrens asthma in one primary care trust and to consider the views of children, their parents/carers and the role of the practice nurse in asthma care in one primary care trust (Lyte et al2005). For the purpose of this research Lyte et al(2005) used purposive sampling to gather information. Craig Smyth (2007) suggests there are various methods can be applied to data collection. Lyte et al(2005) used interviews, observations and reviews of available documentation regarding asthma (Artefactual). In using this type of sampling the researchers can be specific on the groups they wanted to target. However they may be an element of bias as the practice nurse selected the parents and children for this research. To strengthen the research the researchers used triangulated methods for data collection. According to Craig Smyth (2007) the theory behind triangulation if multiple sources, methods, investigators or theories provide similar findings their creditability is strengthened. The study was approved by the Local Research Ethics Committee and the Universitys Senate Ethics Committee. Throughout the research during the data collection consent was treated as an ongoing process. However there was difficulty in communicating with children. To solve this problem, when meeting with the children the researchers would go through the informed consent and voluntary participation again. Confidentially of all participants were protected and guaranteed by the Data Protection Act. Children expressed a wish to participate and share information in the research (Lyte et al 2005). However some children felt through the research of not being involved. Lyte et al (2005) suggested it is the childs personality that determines how much response the practice nurse receives. It is often said good communication in nursing is crucial and is the foundation of building trust and encourages children to seek advice. It is important to communicate with children appropriately to match the stage of development (The Common Core of Skills Knowledge 2010). Ultimately effective communication allows for the exchange of information, needs and preferences of the patient between herself and the patient (The Common Core of Skills Knowledge 2010). However Hobbs (1995) suggests that some practice nurses may not have the training in regarding complexities of caring for children and their families. One cannot deny that it is important for practitioners to have the appropriate training (Alde rson 2000) because children have equal rights to contribute to their care as well as adults (Save the Children 1997). It was noted that children did not have sufficient knowledge about asthma. Furthermore parents and children highlighted that there was insufficient information on asthma in the primary care setting. For children and adults to make informed choices regarding their asthma they require having up to date information to help them in making decisions. Equally in one practice it was identify that the practice nurse lack confidence in caring for children with asthma and Hobbs (1995) confirms this lack of confidence and points out that practice nurses deal with arrange of illnesses. Parents and children in the study both agreed that one area for improvement was the waiting room (Lyte 2005). Some children may find going to the doctor a very frightening experience. The first expression needs to be reassuring and non-threatening. (Making Your Waiting Room Kid-Friendly 2006). The waiting room should be child friendly and also have books, television/video for older children. With todays technology many children use computers in the classroom. Some computer programs are touch-screen driven, making them friendly to all levels. Providing a computer in the waiting room may be ideal opportunity to encourage children to show off their technical skills by accessing the computer for health-related information (Making Your Waiting Room Kid-Friendly 2006). It might be concluded from this research the strengths outweigh the weaknesses, despite the research being conducted in one primary care trust. The most satisfactory conclusion that can come from this, to facilitate children and parents a comprehensive package of care needs to be put in place in order to manage their asthma effectively. References Burns N, Grove S, (2007). Understand Nursing Research, Building an Evidence-BasedPractice. Fourth Ed Craig J V, Smyth R L (eds). (2007). The Evidence-Based Practice Manual for Nurses. China: Churchhill Livingstone Elsevier. Leach M J (2006). Evidence -based practice: A framework for clinical practice and research design. International Journal of Nursing Practice. 12, pp 248-251 Lyte, Milnes, Keating Finke 2007. Review management for children with asthma in primary care: a qualitative case study.Journal of Nursing and Healthcare of Chronic Illness in association with Journal of Clinical Nursing 16, 7b, pp123-132 Melnyk, Mazurek , Fineout-Overholt, Ellen, Stillwell, Susan, Williamson, (2010). Evidence-Based Practice: Step by Step: The Seven Steps of Evidence-Based Practice. AJN, American Journal of Nursing: January 2010 Volume 110 Issue 1 pp 51-53 Mishoe SC, Baker RR, Poole S, Harrell LM, Arrant CB Rupp NT (1998). Development of an instrument to assess stress levels and quality of life in children with asthma.Journal of Asthma 35, 553-563. Munhal (2001) cited in Burns N, Grove S, (2007). Understand Nursing Research, Building an Evidence-BasedPractice. Fourth Ed Questionnaires a brief introduction [online]. (2006) [Accessed 15th March]. Available from: . Reichenberg K Broberg AG (2000) Quality of life in childhood asthma: use of the paediatric Asthma Quality of Life Questionnaire in a Swedish sample of children 7-9 yearsold. Acta Paediatrica 89, 989-995. Roberts P et al(2006). Reliability and Validity in research. Nursing Standard. 20,44, 41-45 Rydstrom I, Dalheim-Englund A, Holritz-Rasmussen B, Moller C, Sandman P, (2004). Asthma quality of life for Swedish children. Journal of Clinical Nursing, 14, pp739-749. Sackett et al (1996) pp 5 cited in Pearson A, Field J, Jordan Z (eds). (2007). Evidence-Based Clinical Practice in Nursing and Health Care. Singapore: Blackwell Publishing. Williams (2000) cited in Rydstrom I, Dalheim-Englund A, Holritz-Rasmussen B, Moller C, Sandman P, (2004). Asthma quality of life for Swedish children. Journal of Clinical Nursing, 14, pp739-749. Warschburger P (1998) Measuring the quality of life of children and adolescents with asthma The pediatric asthma quality of life questionnaire.Rehabilitation 37, XVII-XXIII.

Response Journal for “The Charmer” by Budge Wilson Essay

Budge Wilson’s â€Å"The Charmer† is a remarkable tale of loss, morality, and love. It is the story of how a young girl comes to realize that her devilishly handsome brother is nothing more than a charmer. It is set in a 1950’s Halifax home where Zachary, the narrator’s brother, repeatedly abuses his privileges and takes advantage of his family. Zack seems to believe that his looks will help him escape any situation he may find himself in. He uses his sense of humour and charm to manipulate his family and friends. Zack has a way of making those around him feel special, and uses this quality to his advantage. His sister, Winnifred, washes his bike and fetches his baseball glove just to see his â€Å"flashing Colgate smile† and to be called Posie, the nickname he has chosen for her to let her know that she has measured up. He is aware that the cake his mother has baked is not meant for him, yet he eats it anyway. He offers an insincere but convincing apology, and she starts to bake another cake. His family are his willing slaves, and it is only after the tragedy of Lizzie’s death that they finally begin to see who Zachary really is. Zack is the imperfect model son, but his family is too blinded by love to see his flaws. His fake apologies somehow manage to touch their hearts, and allow them to forgive all of his mistakes. Zachary steals money and alcohol from his parents, but manages to get away with it. He gambles and crashes the family car, but goes unpunished. He is â€Å"the only son, the only brother, the oldest child,† but even more than that, he is as the title implies, the charmer. Despite his good looks and charming personality, Zachary does not accomplish anything in life. At twenty-four, he still lives at home, still wolfs down chocolate cakes, and still borrows the family car. He spends his money on his girlfriends and his alcohol, and gambles away what is left of it. He loses job after job, and is becoming, if he is not yet, an alcoholic. Zack has so much offered to him, but fails to apply himself to improve his situation. However, he cannot be held entirely responsible for his failures, as his family holds some of the blame. If they had only shown less sympathy, and had seen past his false facade, he would have learned early on that he  could not charm his way through life. The conclusion of the story is quite ironic, as the narrator’s daughter displays the very same deceiving qualities that her brother was famous for. Winnifred describes her daughter, Lizzie, as â€Å"pretty and mischievous† and is aware that Zachary was the same way. She is reminded of the manner in which her parents treated Zachary, and learns from their mistakes. She refuses to allow her daughter to become what Zack has, and punishes her accordingly. To portray the themes of this story, the author used a number of literary devices such as, allusion, characterization, flashback and paradox. Allusion is clear as the author refers to Zachary’s â€Å"Colgate† smile, and to the famous people that Winnifred often sees on television. These stars include Clark Gable, John Wayne, Kirk Douglas, Steve McQueen, Mick Jagger, John Lennon, Burt Reynolds, and Tyrone Power. Characterization is used to create Zachary’s character. The narrator says that her brother is charming, intelligent, and fun, but nevertheless a devil. Others say that he is sensitive, while he thinks he can escape any situation. He interacts with other characters, and uses them to further his own cause. The entire story is based on flashback, since the narrator is recounting the events of her childhood, and finishes the story by speaking of an incident that takes place when she is an adult. The paradox of this story is evident when the mother refers to Zack and says, â€Å"This is his way of coping. He’s probably suffering more than the rest of us.† The truth of this statement is highly improbable, since Zack seems to care for no one but himself, and does not even bother to visit his younger sister though he knows she is deathly ill. However, the character may be suffering emotional pain that his actions do not let on. â€Å"The Charmer† presents a timeless, captivating situation, which every reader can in one way or another, relate to. It is the tale of a sister, who sees her brother for who he is, and not who he pretends to be. It is a tale of a mother who cannot accept that her son is imperfect, and of a father who struggles to see past his own love for his son. Primarily, however, it is the story of one boy who ages into adulthood, yet does not mature, and who  hurts his family, yet feels no remorse beyond that which he pretends to.

Wuthering Heights by Emily Brontë A Perfect...

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A Look at Kinesthetic Learners and Methods

A Look at Kinesthetic Learners: Kinesthetic learners typically learn best by doing. They are naturally good at physical activities like sports and dance. They enjoy learning through hands-on methods. They typically like how-to guides and action-adventure stories. They might pace while on the phone or take breaks from studying to get up and move around. Some may seem fidgety, having a hard time sitting still in class. Key Learning Methods: Kinesthetic learners learn best through doing including manipulating items, simulations and role plays, and other methods for presenting subject matter that physically involve them in the learning process. They enjoy and learn well from experimenting and first hand experience. Further, they learn best when activities are varied during a class period. Ways to Adapt Lessons: Vary instruction not only from day-to-day but also within a single class period. Provide students with as many opportunities as your curriculum warrants to complete hands-on work. Allow students to role-play to gain further understanding of key concepts. Provide students with the opportunity to work in small discussion groups as they study materials. If possible, plan a field trip that can help reinforce key concepts. Allow students to stretch partially through the class if they seem to become restless. Other Learning Styles: Visual Learners Auditory Learners