Introduction
Evidence-based practice in nursing is gaining momentum in many hospitals due to its usefulness in achieving maximum benefits for the patients and nurses. Evidence-based practice is the process whereby nursing practitioners locate, appraise, and to a larger extent, apply the best and latest medical literature and nursing evidence in order to add quality to the clinical practice (DiCenso, Guyatt & Ciliska, 2004, p. 1-15). The practice is mainly concerned with the formulation of questions relevant to a certain clinical problem through the utilization of the best evidence from the available medical literature. Considerations on the strengths in terms of the generalisability and validity of each literature source must be observed in this process. The evidence produces maximum benefits when it is implemented together with clinical expertise while incorporating the patient’s perspective. More importantly, evidence-based practice is dependent on self-reflection coupled with and peer assessment. This essay will delve into the critical appraisal of a research-based evidence paper and discuss its applicability to the nursing practice.
Critical appraisal of the evidence-based nursing practice
Research has become necessary to be integrated into the practice due to the dynamic nature evident in the patients and nurses. Patient care has become one of the major areas that the practice has found usefulness, particularly to the nurses. In this regard, it has been found that patients accustomed to receiving care integrated with the latest research have achieved much more benefits than their counterparts who benefited from normal care. The benefits were most evident in the psychological, behavioral, and to a large extent in the psychosocial outcomes. Although its application has not received massive acceptance among nurses, actually the recorded benefits should act as an eye-opener to all nurses to embrace the incorporation of evidence-based practice in real nursing practice. The utilization of this practice has invariably helped address the patients’ preferences while impacting positively on their health outcomes.
A lot of resources on patient care are available for the nursing practitioners to utilize while making informed decisions. Concrete efforts have resulted in the introduction of major initiatives aimed at availing the most relevant and latest quality research findings. Evidence-based journals serve as the major avenue for facilityting the utilization of this knowledge (Estabrooks, 1998). Journals offer a summary of the clinically useful and the most valid studies. Despite their similarities in approach, the journals identify and structure the qualitative and to some extent the quantitative data in a systematic way that allows for their comparison with other studies. The review and assessment carried out by the nurses help the practitioners to gauge the clinical usefulness of each study before applying it to the patients.
The research question must be structured to give access to the most relevant literature. The clinical questions should also be asked in a PICO format that ensures that the patient population and the intervention of interest are highly considered. The comparison intervention and the associated outcome of the application of the evidence-based practice are also regarded during the development of the question. This is imperative in influencing the applicability of the research designs in nursing practice.
Finding primary literature materials is a cumbersome task for nursing practitioners. The sources are mainly comprised of publications that touch on original research materials. The publication of these materials is instrumental in the furthering of scientific knowledge, particularly in the nursing field. The research designs follow procedures in the clinical research. The designs make observations while describing the clinical scenarios before formulating hypotheses that are aimed at expounding on the implications of the same. The utilization of unpublished literature takes center stage at the initial stages. Moreover, case studies and cross-sectional studies are also useful as primary sources of evidence. Other study designs include randomized clinical trials which are almost similar to the prospective cohort studies (McKeon, Medina &Hertel, 2006, p.42).
Synthesis of unpublished clinical research is paramount in the development of anecdotal evidence that plays a major role in supporting clinical decisions. Even though most of these findings are never published, they form a major step in the understanding of the clinical problem in question. The case studies and series offer useful information on specific single cases which. They offer vital information on the differential diagnosis and also shed light on the treatment while expounding on the possible complications that may arise especially in this case. Case series offer the best retrospective outcomes observed in a predetermined number of patients suffering from a particular problem. These sources are not highly regarded since they rely on the observations in a few patients (McKeon, Medina & Hertel, 2006, p.42). Prospective cohort studies dwell much on the collection of baseline measurements of selected traits in healthy individuals, who are henceforth observed over some time in order to record any change in their health. Their main role is to try to link the occurrence of new cases of a particular disease with selected characteristics of particular interest. In this regard, it becomes easier for the researchers to compare the outcomes in both those who or failed to develop the conditions in the long run. Another unique feature of this study is its propensity to offer the researchers a chance to carry out verification procedures that aim in developing the conditions that predispose the individuals to the eventual development of the illness (Ciliska et al, 2001, p.527).
Outcome studies work prospectively in the tracking of a certain number of individuals suffering from a preexisting condition and who benefit from a specific type of intervention. The individuals are then tracked down for a specific duration to ascertain the outcomes in terms of clinical manifestation. Patient and disease-oriented outcomes are helpful to the nurses since they avail first-hand experiences on their applicability. The self-reported assessments in the patients offer the best alternative for determining outcomes in patients. Nevertheless, the disease-oriented outcomes are believed to impart little on nursing practice due to the propensity of bias whereby the clinicians are more focused on recording improvements on the patients. This coupled with the drawbacks offered by the patient-oriented outcomes makes this study design unreliable in the application (McKeon, Medina &Hertel, 2006, p.42). an important and reliable design is the randomized clinical trial where individuals are selected and put into treatment groups with another group forming the control group. The design employs a procedure where one group is put into treatment developed mainly from previous research while the other group is put in standardized treatment. The outcomes in the two groups are then determined at the end of this period thereby lowing for the comparative analysis of the two outcomes. The randomized clinical trials offer the best evidence that has found application in the nursing practice due to the efficacy offered by the interventions when they are incorporated in real nursing situations. The systematic reviews and to a larger extent the meta-analyses help in the critical evaluation of the results put forward by various studies. More importantly, they offer summarized literature on the critical evaluation and the overly quantitative assessment particularly of the available statistics from the literature search. The advantage it confers to nursing practice is that a conclusive consensus is built thus assisting in the utilization of the evidence (Ramadan, 2000). This is imperative in informing the improvement of evidence-based practice.
The study on the ‘’Pharmacologic Management of Acute Attacks of Migraine and Prevention of Migraine Headache” was utilized to offer a clear understanding of the evidence-based practice. The utilization of several randomized clinical trials and several forms of interventions are useful in informing the mode of treatment applicable to each patient (Snow et al, 2002, p. 840). This study utilizes the randomized clinical trials made on the several as the main basis of determining the expected outcome in the patients. The study has also taken into consideration the primary and secondary literature sources which are imperative in informing their subsequent incorporation into the treatment procedures. The primary literature offers several case studies and case series carried out in different settings and sheds light on their implication and outcomes on the health of the patient. In this regard, their utilization gives credibility to this study since all the factors in the prognosis are taken into account (Snow et al, 2002, p. 840). Secondary literature (especially evidence-based guidelines) has also impacted the applicability of this study. The combination of all the research evidence and guidelines bolsters the applicability and usefulness of the recommendations in clinical practice. That the study gives a clear critique of the available treatment options for migraine makes it more acceptable to the nurses. The utilization of several forms of research evidence such as statistical and analogical helps nurses while dispensing the treatment regimens (Matchar et al, 2000). Of particular importance, is the wide array of conclusive consensus offered thus ensuring that as many practitioners as possible can find its usefulness in the management of various forms and stages of migraines. The utilization of the various forms of research evidence has found useful application in clinical practice due to its tendency of supporting the evidence. Anecdotal evidence offers generally weak but positive evidence in the description of the specific instances where the research is applicable in clinical practice. On the other hand, testimonial evidence has moderately strong evidence collected from credible sources and sometimes from well-renowned scholars. The evidence is mainly supportive of evidence explained in another area. Statistical evidence offers supportive material which is mainly in form of quantitative representations such as graphs or comparative analysis of the figures adduced from case series or randomized clinical trials. The analogical evidence offers supportive confirmation that is fairly strong and which achieves its purpose through comparison with a well-understood related phenomenon (Seech, 1993).
In this study, the application of analogical, statistical, and anecdotal evidence has been applied thoroughly to offer a comprehensive conclusion on the study topic. In this regard, the descriptive statistics derived from the randomized clinical trials offer the best available evidence that is useful in the comparative analysis of the treatment options. More importantly, the adverse effect of each regimen is well documented thereby assisting the nurses to monitor and evaluate the whole treatment procedure in the patient. The efficacy dosages observed in clinical trials have also been elaborated together with the relevant combination of medications. Analog evidence on the main triggers and the incorporated recommendations adds credibility that helps the nurses to weigh the treatment to apply based on the above factors (Seech, 1993).
The hierarchy approach has gained increasing momentum through immense promotion by educational materials and reports available to the clinicians. Although much credence has been given to randomized clinical trials, there is a paradigm shift from this assumption. They are followed by the observational studies while the descriptive studies fall in the lowest category in the hierarchy. More emphasis on observational and descriptive studies despite this study relying mainly on the randomized clinical trials, it also acknowledges the role of observation and descriptive studies particularly in the determination of symptoms and side effects. Nonetheless, the accuracy of evidence-based practice is entirely dependent on randomized clinical trials and to a larger extent, the systematic reviews and Meta-analyses offer the best treatment option for the patients. It is for that reason, that the nurses have embraced these options since they offer a greater assurance in terms of efficacy (Concato, 2004, p. 341-347). The hierarchy design is also paramount in the provision of a checklist that is useful in the evaluation of clinical studies. Canto thereby argued that the dependence on randomized clinical trials may bring disadvantages such as restriction on the sample, outcome, and intervention in the process. On the other hand, observational studies are taken to produce biased results regardless of the manner they were executed. Systematic reviews and guidelines are imperative in the development of effective intervention which results in the best outcomes for the patient. The systematic review on medications utilized by this study has helped in shedding more light and comparison of the available medications. The summaries from technical reviews and supplementation from policy research institutions take into account the most popular drugs in terms of published trials. The availability of data on the efficacy in terms of clinical impression, scientific effect, and overall quality of the evidence assists the nurses in making rational decisions on their application (Ramadhan et al, 2000; McCrory et al, 2000). The systematic reviews are helpful since they help policymakers in the integration of the enormous existing knowledge while providing data for rational decision-making. They also offer an in-depth view of whether generalization of results can occur across a wide population experiencing different variations. Systematic reviews and guidelines enhance the limitation of bias thereby improving reliability and also offering precise conclusions (Murlow, 1994, p. 597).
Critical appraisal of the article
Are the results of this systematic review valid?
The study on the ”Pharmacologic Management of Acute Attacks of Migraine and Prevention of Migraine Headache” was utilized to offer a clear understanding of the evidence-based practice. The study is a systematic review of two evidenced-based guidelines that rely mainly on several randomized clinical trials in the management of acute attacks of migraines. The trials were carried on many groups of varying characteristics thereby bringing out the relevance of the results of the review (Ciliska et al, 2001, p.527). Of particular importance is the thoroughness with which the randomized clinical trials were selected making it easy to come up with a concrete decision on the medication. The evidence-based guidelines utilized articles from the conventional databases and unpublished materials contributed by interested stakeholders. The systematic review has shown considerable bias in usage of the high-quality randomized clinical trials that have clearly understood methodologies of achieving their results (Snow et al, 2002, p. 840). Consistency in the trials was found in areas of comparability of the groups and the extent to which the patients received follow-up. However, some of the trials lacked credibility due to their failure to utilize the correct methodology thus impacting the overall outcome of the study. In line with this, the systematic review, therefore, failed to produce impressive results thereby the outcomes do not offer overly the best options in the management of acute attacks of migraines.
The reliance on a wide pool of studies ensured that the review had a varying magnitude of effect. However, this adds strength to the systematic reviews due to the critique it offers to the various studies thereby informing the ranking of the treatment schedules. Statistical significance was recorded in the majority of the clinical trials as outlined in the Glazener and Evans review. The application of aggregate data was instrumental in the comparisons of the relative risks. Taking into account majority of the evaluated studies were placebo-controlled ensured that bias was lowered thereby enhancing the comparability of the treatment effect in the patients. This helped the systematic review achieve its mandate due to reliance on blinded trials (Ramadhan et al, 2000; McCrory et al, 2000). Furthermore, the comparability of the findings ensured that a more consensual treatment procedure was achieved and therefore the patient was overly informed on the therapy to utilize.
What were the results?
The results were achieved through a comparison of more than 200 articles with the majority of them having received ratings in their effect on the patients. In line with this the studies that showed the most consistency contributed largely to coming up with the recommendations on the mode of treatment. However, the reliance of the comparisons on studies that has a positive effect on those with a negative effect is misleading to some extent. For instance, in the treatment by ergot alkaloids, most of the trials were found to be older, inconsistent, and offered some difficulty in the interpretation. Like the treatment schedules, this was occasioned by the differences in the dosing strategies and in the outcome measures. The inadequacy in the information on the relative risk makes it difficult to assess the effectiveness of the treatment effect. The utilization of the wide array of information from the sources means that the results failed to meet the required methodological approaches. More importantly, the processes in the randomized clinical trials lacked ways of minimizing bias and also failed to show the statistical significance imperative in deciding the efficacy of a given regimen of treatment (Ciliska et al, 2001, p.132).
The precision of the results varies depending on the methodologies utilized in the clinical trials. Moreover, the systematic review has failed to utilize the relative risk on the various studies. However, the study has extensively used other methods to rate the efficacy of the drugs thereby grading them into excellent, good, and average. The excellent drug therapy achieved the considerable success of treatment while recording very low treatment failures (Ciliska et al, 2001, p.527). The rating relies on consistent methodologies that enhance the utilization of the findings, particularly by the healthcare workers and patients as well. Furthermore, the fact that the wide array of drugs offers treatment and prevention therapies makes the systematic review a major contributor to the management of acute attacks of migraines. The recommendation also sheds light on the benefits and also points out any harm that may result from the usage of the drugs especially by different age groups or persons suffering from special conditions (Ciliska et al, 2001, p.127). More importantly, the endorsement of the findings by the regulators in the field of pharmacology in the United States also adds weight to the acceptability of the findings. In line with this, the healthcare workers find it easier to utilize these findings owing to the fact that they are provided with relevant and crucial information on the overall utilization of drug therapy.
In this study, the application of analogical, statistical, and anecdotal evidence has been applied thoroughly to offer a comprehensive conclusion on the study topic. In this regard, the descriptive statistics derived from the randomized clinical trials offer the best available evidence that is useful in the comparative analysis of the treatment options. More importantly, the adverse effect of each regimen is well documented thereby assisting the nurses to monitor and evaluate the whole treatment procedure in the patient. The efficacy dosages observed in clinical trials have also been elaborated together with the relevant combination of medications. Analog evidence on the main triggers and the incorporated recommendations adds credibility that helps the nurses to weigh the treatment to apply based on the above factors (Seech, 1993).
Will the results help me in caring for my patients?
The treatment strategies discussed in the dwelt on a patient of different characteristics in terms of age and sex. This makes the findings applicable to my clinical practice since the condition is widely distributed among all patients of all groups in society. The outlining of recommendations has also brought out the utilization of the treatment schedules while relating them to their effectiveness. The treatment is feasible in the clinical setting owing to the number of patients suffering from acute attacks of migraines (Concato, 2004, p. 341-347). Prevention therapy has more application to my clinical practice since it provides a wide array of information imperative in advising the patients. The consideration of the potential benefits and side effects occasioned by the utilization of the drugs is an impetus in the embracement of the outcomes (Matchar et al, 2000).
The utilization of placebo-controlled trials enhances the knowledge of the physician and the patients in that it provides quality information on the mortality and the patient satisfaction of the drug therapies in the cases and the cohorts. The systematic review recommends the drug therapy in terms of their effectiveness thereby offering the patient preference in their utilization depending on the affordability and availability in the hospitals (Seech, 1993). More importantly, the side effects and the contraindications are important in informing the patient to decide on the uptake of the drug therapy.
The validity of the results is imperative in helping the patients and the healthcare workers to reach a decision on the implementation of the treatment program. The level of treatment failure, cost-effectiveness, and the associated side effects are among the factors that influence the reaching of a consensus by the patient and the healthcare provider (Penz & Bassendowski, 2006, p 123).
Applicability of evidence-based practice
Development of practice guidelines gained momentum in the early 1990’s. Practice guidelines are generally referred to as systematically developed and detailed documents that delve into patient care strategies vital in helping the practitioners in clinical decision-making. The first step in the development process involves the selection of a topic before relevant contributions from interested stakeholders are taken. A wide array of evidence base is collected from published materials such as randomized clinical trials and analysis of any other relevant study. The literature review is done systematically to optimize the search while lowering the level of bias. The standardized guideline is then formulated and is reviewed severally by various committees. Several drafts starting from the preliminary outlines are usually reviewed and amended before a final draft is submitted for final approval by the APA review board (APA Review Board).
Nursing research has impacted positively the improvement of practice development. The emergence of evidence-based practice that integrates the research has helped improve productivity and efficiency in nurses while at the same time bettering the patient care strategies. The rigorous training of nurses on the utilization of research materials has played a major role in the overall improvement of the work environment. The research has also helped reinforce the commitment of nurses in their work since they are more satisfied in their undertakings. The propensity of applying research-based practice has been driven by the change in preferences in patients and the dynamic environment in medicine. It is therefore worth noting that the demand for high standards in the patient has pushed the nursing practitioners to incorporate the research into practice. It is also meant to improve the psychological, behavioral and to large extent the psychosocial outcomes in the patients. The benefits accrued from the integration have resulted in many health care institutions achieving milestones in terms of productivity, efficiency, and recognition.
Evidence-based nursing practice impacts policymakers, health care administrators, and nurses. The implications have far-reaching consequences in the development of policy and dictation of the work environment. Evidence-based nursing practice offers various advantages and disadvantages to individuals and groups. The interaction of several factors coupled with the evidence-based practice produces positive or negative implications in the workplace (Yvonne & Nancee, 1995). The practice offers more satisfaction to the nurses in the nurses thereby improving their productivity. However, the practice means that the nurses must undergo training on researching skills that are against their wishes. The managers benefit through receiving the necessary tools that are aimed at helping them improve productivity and efficiency in the delivery of healthcare thereby resulting in patient satisfaction. The managers are also faced with a managerial dilemma since they have to spend colossal amounts of money to equip the nurses with the relevant skills vital in the implementation of evidence-based nursing practice. On the other hand, the policymakers benefit since they receive a foundation upon which they can develop a policy framework depicting the running of the institutions. However, the evidence-based practice may offer a headache to the policymakers particularly when it contradicts the laid down policies.
Conclusion
Evidence-based practice in nursing is gaining momentum in many hospitals due to its usefulness in achieving maximum benefits for the patients and nurses. Research has become necessary to be integrated into the practice due to the dynamic nature evident in the patients and nurses. The appraisal and applicability of the evidence-based nursing practice particularly the study on migraine has played a major role in shedding light on the applicability in modern nursing practice. The evaluation of systematic reviews is imperative in shedding light on the efficacy and applicability of the findings by healthcare workers. In addition, the patients are better placed to make decisions on the medications or therapy to use depending on their preferences and the cost-effectiveness. The validity of the results is also measured thereby informing the decision-making of stakeholders. The healthcare workers must embrace the utilization of systematic reviews and meta-analyses in deciding the course of treatment of prevention therapy while since they provide the best options for treatment. More importantly, the governments and the concerned should encourage and invest in concerted efforts aimed at conducting well-planned systematic reviews thereby improving the overall outcomes of therapies.
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