Many health institutions do not have explicit mechanisms to support nurses with a systematic approach to develop and evaluate interventions, protocols, policies, as well as critical pathways which are scientifically based. Such a systematic approach would definitely have positive impact on service delivery to patients through fostering higher levels of professionalism in nursing and also improving nurse retention and recruitment in health institutions (Spring, Neville & Russell, 2012, p. 1). With this realization, many institutions have embarked on various nursing models, which are evidence based, so as to enhance service delivery by nurses.
According to Dodson, Baker and Brownson (2010, p. 12), evidence based practice in nursing means a judicious, thorough, as well as clear utilization of the ‘best evidence’, which is in existence in the making of decisions regarding how to improve the care given to the patients. The practice of evidence based in nursing requires the integration of personal clinical proficiency with the most efficient and, therefore, best clinical evidence that is available for the nurses from external systematic research. This practice requires that nurses use the best research-proven approaches to clinical issues and treatment of patients, with each case being approached uniquely from the others, with the ultimate goal of enhancing patient care and service delivery. To this end, EBP is implemented through continuous update with the current development in the nursing profession. It enables nurses to use the new knowledge as part of the clinical decision making; thus, requires a commitment to life-long learning in terms of new discoveries and developments in nursing (Baker & Brownson, 2009, p. 13).
Though the practice has had its challenges, it has a number of advantages. By utilizing evidence based practice (EBP) in nursing, nurses are now able to stipulate actual and solid reasons for providing particular services to a patient and can explain and justify their actions whenever they are required to do so by any authority. As argued by proponents of EBP, clinical practitioners, who have adopted it in their professional practice, provide the best possible care to their patients while, at the same time, getting rid of the old and ineffective practices in nursing (Spring & Hitchcock, 2009, p. 34). It also implies that modern day nursing, through the adaption of EBP in their nursing practice, is a focused approach that uses service delivery and evidence oriented means to explain certain actions. Clinicians are thus able to avoid the situation where nurse managers are forced to be budget conscious in their service delivery simply because they do not have a way of justifying the effectiveness of their treatments to patients.
Irrespective of the advantages of EBP, the practice has a number of challenges. Though the practice has been widely accepted among the nurses, organizations have been dragging on its implementation. Among the reasons advocating for this trend is its emphasis on the need to review all the available current and relevant literature on the topic. Moreover, the practice requires a high level of expertise and experience for a practitioner to be able to analyse all the current literature on his/her topic of study while seeking to improve the same. Finally, the fact that patients do not fit into one category makes the practice even more complicated (Shaheen et al., 2011, p. 229).
The article presents a research study on, “analgesia after total knee replacement: local infiltration versus epidural combined with a femoral nerve blockade” (YaDeau et al., 2013). The researchers utilized a prospective randomized pragmatic trial in their study. In its critique of the article, the paper will consider the ways in which the authors incorporated different forms of evidences used in the contemporary practice; the methods used to obtain and utilize evidences; the strengths and weaknesses of the different research methodologies used in the collection of data; the data analysis and how they were accounted for, as well as the strategies that the authors used to their evidence based approach as required of professionals during the research. Overall, the research meets the requirement of the evidenced based practice.
A Brief Summary of the Article
The authors had utilized a randomized controlled pragmatic trial framework in their investigation of whether earlier readiness of a patient who had undergone total knee replacement would be possible through local infiltration analgesia. The result in terms of time taken was to be compared with another case where the patients’ femoral nerve had been blocked while patience controlled epidural analgesia is also being administered.
The study considered 45 participants whose age-mean was 65 years and ranged between 49 and 81 for the administration of such injections as a bupivacaine, methylprednisolone, adjuvant analgesics, as well as morphine; with a local infiltration. On the other hand, there were 45 patients considered for PCEA+ blockage of femoral nerve. This group featured ages falling between age 50 and 84. Their mean age was 67. The mean time taken by the patients to be discharged was 3.2 days. The study also established that the patients, who had received the local infiltration, recorded higher mean scores for pain when the patients were put to walk. The difference was, however, not significant when the patients were observed while at rest. Equally, those receiving local infiltration registered higher opiod consumption mean.
The researchers were keen not to make a choice from among the two analgesic pathways depending on time one would take to be discharge after the surgery. The study revealed similarities in most secondary outcomes. However, lower scores on pain were experienced by the patients who had undergone the PCEA+ the blockage of the femoral nerve. This was true as the patients were put to either walk or move passively but continuously. It was concluded that, in cases where PCEA+ the blockage of the femoral nerve cannot be administered, local infiltration can be considered because of its provision of equal duration as well as at-rest pain scores after total knee replacement. Before we criticize this article, we will consider some of the steps that are basic to evidence based practice since the critique will be based on this information.
The Steps in the EBP Process
EBP is implemented through identified steps so that the nurse involved has a blueprint to guide the entire process. The first thing is to assess the condition of the patient, which will provide a clinical problem of the issue which is arising from the care that the patient is receiving in the health care institution (Beverly, 2011, p. 72). The second step is the construction of the clinical question which is derived directly from the case. The questions will act as guidance to the entire process. The next step involves the acquiring of evidence through research and search of literature. The final step is that of self-evaluation to determine the performance with each patient (Odom, 2009, p. 158).
It is also good to note that the success of evidence based practice in health care is dependent on several factors that the clinical practitioners need to consider before embarking on the entire process. First, it is important to engage all concerned parties in the process (Bryant, Steinberg & Marrone, 2009, p. 667). It is also important that, whatever data and information is gathered through the process, it must be used systematically in accordance to the laid out rules and regulations in the practice of health care provision. Equally, all research-based decisions made must be based on the best available evidence, which is peer reviewed in terms of qualitative and quantitative approaches. Any researcher in a clinical field must also endeavour to apply programs in utilizing the frameworks that are utilised, which are usually based on the health behaviour theory. This is done besides conducting a sound evaluation of the entire process, as well as disseminating the lessons and knowledge acquired throughout the entire process for others (to use and improve on it) (Castro, Barrera & Holleran, 2010, p. 220). With this knowledge, the critique the article will be considered further in this paper.
Article Critique Based on EBP Framework
It is imperative that, whatever evidence a nurse is going to utilise to enable him/her implement an EBP in a health care institution, it should be clinically relevant. It should also be founded on research, which is conducted with sound methodologies (Jacobs & Brownson, 2010, p. 737). The authors of the article have adhered to the requirement through the use of a number of sources to provide the basis of its research. This falls in line with the EBP practice, which requires the nurses to utilize their accumulated knowledge and research findings on the same study topic in seeking to come up with the best or alternative ways of administering services to their patients. In their literature review, the authors began by seeking to justify the relevance of their study topic, by presenting information regarding the findings of past researchers on the same topic.
Equally, the researchers underscored the role played by in clinical research. This falls also in line with the requirements of EBP, which emphasize that literature search is specifically important because nursing practices and standards keep changing (Means, Toyama & Karla, 2010, p. 24; Gebbie, 2009, p. 45). The researchers were thus required to integrate their clinical expertise with patient values and research based evidence, so that they could make clinical decisions, which are real and justifiable in provision of the best care for patients. All the individual researchers were thus expected to come into this study with a stock of experience, which has been accumulated through actual practice, clinical skills, and education. This is exactly what is reflected in the study which analyses methods, tools, and techniques.
The researchers were thus greatly informed of the current practices in the area of research which they were seeking to improve. They participate in identifying and analysing relevant information sources for proven evidence, which is current and relevant to the clinical process to be performed and which will be used in the patients’ care (Turnock, 2009, p. 13). The process of searching for literature yielded overwhelming information that provided the researchers with differing views on their study topic (Glisson, Schoenwald & Armstrong, 2010, p. 545; Chorpita & Daleiden, 2009, p. 56).
For instance, they considered the fact that patient-controlled epidural analgesia was, by the time of the study, largely accepted as a better approach versus intravenous opioids in as far as relieving patients of pain after major surgeries are concerned. They add that it is also considered by others to even provide the best way to relief pain after the total knee replacement. It was important for them to consider the approach, which uses the continuous blockage of femoral nerve since this is another approach, which has received a wide support. Equally, the introduction of single injection femoral nerve to be used in addition to PCEA was in line with the findings that combined the results with a trend of a pain reduction while not slowing down the goals of physiotherapy, which advocated the motive of total knee replacement. The researchers were thus in line with evidence based practice in nursing that requires an evaluation of current literature to determine the best way of applying a theory or a model (Brownson, Fielding & Maylahn, 2009, p. 191).
It is from their findings from the literatures that the extent, to which patients may be able to participate in psychotherapy, the duration it may take for patients to receive a discharge, as well as the outcome in the long-term, may all be influenced by the way in which pain is managed after the replacement of the patients’ knees. This is how the hypothesis is developed. Their study hypothesis was made clear. The researchers had hypothesized that local infiltration would lead to an earlier discharge and that it would be linked to consumption of lower opioid as well as its scores on symptom distress, higher patient satisfaction, and finally, improved recovery.
The Ethical and Legal Considerations
Being able to observe the ethical and legal considerations in any clinical study largely depends on the ability of the nurse to communicate effectively with the relevant parties that are involved in the whole process. Any researcher must thus aim at protecting the privacy of patients’ information, through establishing of minimum standards, based on which health care providers can disclose data to the public (Gurses, Murphy & Martinez, 2010, p. 2).
In the case of the study presented in the journal, the researcher sought ethical approval to secure the consents of all the patients that were considered for the study. The researchers were thus in compliance with the ethical and legal requirements as required by their study. For instance, the recommendation by a local infiltration protocol requires that the surgical site infiltration should be done using bupivacaine and other additives. By observing this recommendation, the researchers were able to avoid the blockage of the patient’s nerves, epidural analgesia, as well as parenteral opioids. At the same time, they also ensured that the patients, who were receiving local infiltration, were also given oral opioids, transdermal clonidine patch, as well as meloxicam.
The findings were in line with what is presented in the literature; therein, when the blockage of femoral nerve is compared to the approach involving local infiltration, there may be an insignificant achievement in as far as the reduction of pain following a local infiltration surgery is concerned. The findings quoted DanaInfo’ report which notes that using an intraarticular catheter, which is used to deliver a local analgesia, normally lowers the amount of pain felt by the patient. It also results into the use of less opioid while ensuring a better mobilization as compared to the blockage of femoral nerve; that is, on the day after the operation.
However, even with all these considerations, there was a report of occurrences of adverse effects of the study on the patients, in two instances. One patient fell and suffered a knee dislocation. The second case involved a patient who developed delirium, which took a number of days to be corrected; thus, resulting into his withdrawal from the study. Such hiccups are what the evidence based practice aims at correcting. It is on this premise that evidence based practice is turning out as an essential practice in the management and analysis of health services. Moreover, it also provides clinical officers with a more enhanced opportunity to control and manage their care during trial studies, as well as the delivery of services to the patients (Gale & Schaffer, 2009, p. 20).
As stated by Karel, Douglas & Vergouwe, 2009, p. 1488), EBP largely depends on clear assessment of treatments that clinical officers are going to employ in their daily service delivery. This means that any researcher must come up with a very clear study design to guide the study from its start to the end. The authors of this article utilized a randomised prospective pragmatic trial. This was an appropriate approach since it enabled them to compare their variables, which were the local infiltration and combination of the PCEA, and the femoral nerve blockage. They further went ahead to explain the reason as to why they chose on the pragmatic approach. It was based on the fact that the study was mainly aimed at helping the clinicians in the making their choice between the two different treatment approaches. The authors explained that their study could not be blinded since the two protocols had differences, which were too marked to make it possible for such achievements. Moreover, the use of non-steroidal anti-inflammatory drugs for both limbs (as were used during the trial) improved physiotherapy outcome, as well as the pain treatment (as were analyzed after the TKR).
A typical evidence based practice approach is also necessary in developing, implementing, and evaluating effective and efficient methods of dealing with clinical issues. It is clear that the research had elements of a number of research methods ranging from randomized controlled trials, to case controlled study, cohort study, survey, as well as qualitative study. For instance, the researchers consecutively randomize their participants. Some were considered for the administration of infiltration while the other groups were taken for the combination of PCEA and femoral nerve blockage approach. This was done on an equal basis; that is, parallel design of a trial. To avoid a miss-presentation of information, the researchers ensured that each participant had labels showing the groups, to which they belong; this has proved to be an element of case controlled and cohort study. The labels were in form of numbered sealed envelopes which had been prepared by another researcher independent of the study. They also entrusted the opening of the envelopes to the anaesthetist, to whom the procedure had been assigned.
An element of survey and qualitative research came in, when the researchers allowed the patients to self-rate the amount of pain that they felt while at rest, as well as thir experiences when they took part in an activity just before the operation. Through qualitative study, the researchers were able to obtain pertinent information that relates with the prevailing patient’s situation. This was useful since the research was conducted with the view of coming up with suggestions regarding the best professional way to deal with the health situation (Aarons, Fettes & Sommerfeld, 2009, p. 957). The researchers also seem to have relied on the use of questionnaires as a survey method to have a succinct comprehension of the evidence based on the clinical practice (Anke, Taryn & Schalkwyk, 2013, p. 45).
The researchers also employed the use of a number of tools which were equally simple and consistent with other researches in their field. An example was the numerical scale. Researchers used a numerical rating scale ranging from 1 to 10. While 0 represented no pain, the worst level of pain one can ever imagine was represented by 10. In their calculation of discharge readiness, as well as a discharge, the researchers considered the time, when the patients had left the theatre room until the participants had met all the criteria required for discharge. Walking abilities, as well stretching of the knees were of great significance regarding the set criteria.
Other tools used were the LANSS pain scale and an SF-8. The latter was administered just prior to the surgery, and six months after the discharge. The choice of these tools was widely predetermined since SF-8 has been widely accepted among the clinicians to be used in a questionnaire. On the other hand, the LANSS test was instrumental in identifying neuropathic pain. It is thus important that all the tools used in the study were validated. In their strategy, the researchers thus used proved research methodologies that enabled them to use quantifiable methods. They also ensured that the patient and other stakeholders are incorporated in every step of the process, which is in line with clinical policies (Brownson & Heath, 2011, p. 70).
One of the outstanding features of evidence based practice, which was also utilized in this study, is the ability of the researcher to ask clinical questions. This way, they were able to obtain the information needed about the patient. The answers were thus useful in coming up with ways of delivering relevant and effective services in alleviating the clinical problem at hand. In this case, the researchers asked questions related to the level of pain felt by the patients (Menon, Korner-Bitensky & Kastner, 2009, p. 37). This position is supported by Bonnie and Abbie (2009, p. 230), who argue that the application of the categorical questions in assessing an issue should mainly be aimed at simplifying the process of evidence based practice.
As noted by Scott and McSherry (2009, p. 1090), including clinical questions in the evidence based practice mainly serve the purpose of allowing a researcher to inculcate research evidence in the process of carrying out the procedure. It is also notable that the questions that were asked in this study depended upon the literature search which was carried out prior to the implementation of the evidence based practice. This has improved the level of professionalism of this research (Serenko, Bontis & Hull, 2011, p. 7; Harmeet & Rajinder, 2013, p. 23).
The researchers must have also noted that their ability to identify relevant information to allow them answer specific questions could greatly be facilitated by breaking down the question into different components (Arnd-Caddigan, 2012, p. 20). They seemed to have identified a number of components. These include the patient or a problem under consideration, the considered indicator or treatment, the anticipated outcomes or results of treatment, and the comparison of elements at hand (Toma, Bensimon & Dainty, 2010, p. 221; Pierluigi, Allen & Kramer, 2009, p. 20).
It is important that the criteria used for sampling is made clear to avoid having respondents, who will not be useful for the study (Scott, Lilienfeld & Ritschel, 2013, p. 3; Aarons, Glisson & Cafri, 2010, p. 34; Wallerstein & Duran, 2010, p. 27). The authors of the article are equally clear on the factors that they used in their sampling. Those considered for the study were had osteoarthritis and were between the ages of 18 through 85. The participants had to have varus not higher than 15o. Alternatively, those whose flexion contracture was 15o were considered for the study. The researchers used the patient’ s drug allergy, the grade provided by the American Society of Anaesthesiologists, the renal or hepatic failures, the duration for which the patient had used chronic epioid, whether the patient were insulin dependent , and whether he/she had had an open surgery on the knees. These characteristics were applicable to the patients in both the two groups.
One factor that is common to researches, whether evidence based practice or research based practice, is that the evidence to be used can only be gathered through relevant and approved research methodologies and test procedures that guarantee a proved evidence (Satterfield & Brownson, 2009, p. 380). One of these forms of evidences applied in this study is the clinical trials which involve research studies that seek to discover the level of applicability of new medical processes received by the patients. The researchers have also included comparing of new forms of treatment with the current treatment processes that are in use (Briner & Denise, 2010, p. 35). While carrying out the clinical trial, the researchers have managed to explicitly document precisely what is to be done during the entire study. They have also given reasons for each part of the study, set rules of who to take part in the study, sought approval of the participants as by the regulating bodies. The researchers have also assessed and put measures in place to mitigate the risks associated with this particular study in terms of the proposed participants (Arnd?Caddigan & Pozzuto, 2010, p. 25).
The method of analysis used by the researchers was in line with the findings of the preliminary data, which had not been published. The data had indicated the readiness for discharge among the patients, to whom PCEA and femoral nerve blockage had been performed; the mean time was 3.2 days. The hypothesis that this time would be reduced by local infiltration to enable the patients to be discharged within a half a day was also considered in the analysis. The analysis was done using the widely accepted Microsoft Excel and SPSS aid. Just as common with other studies, student’s t-test was also used in the comparison of the patients’ discharge readiness. Equally, the analysis of the scores of pain NRS was done using generalized estimated equations (GEE). This technique has been widely accepted among the clinicians in cases, where repeated pain measurements were required. Finally, the researchers presented their discrete variables in proportions and used chi-square tests in their analysis. With such effective and widely accepted tools, the researchers managed to carry out an evaluation and analysis of the current sources to obtain more information regarding some clinical procedures they were to undertake (Eun-Ok & Chang, 2012, p. 23).
Results and Discussion
Effective presentation of research is an integral part of the research. The results were well communicated. The study found no difference in terms of the time the patients took to be ready to be discharged. The results were also well presented using the Kaplan-Meier survival curves, which allows for the plotting of time against the patients readiness for discharge. Moreover, the lines used for the two categories of participants were differentiated for easy understanding. Other measures of pain utilized included ORSDS and QOR-40. The use of a number of tools allowed the researchers to compare the median values and come up with their research mean, for greater accuracy. The results obtained from this study could thus be useful in providing the necessary changes in medical prescriptions, where patients who undergo knee surgery do not show improvements in their health status even after medications have been administered (Gee, Greenwood & Kim, 2012, p. 19).
The researchers were in tandem with a recommendation by Gregory, Aarons and Horwitz (2011, p. 15) that clinical practitioners must adapt to the new changes brought about by the introduction of technological tools, which can be used in the assessment and evaluation of the literature related to effective health care delivery. Moreover, the researchers used current and accurate information from various sources. This makes their findings valid and recommendable for the relevant practitioners (Gee, Greenwood & Kim, 2012, p. 16).
Another aspect of EBR which has adequately been applied in this research is the need to to conducet a study on the available information while seeking to provide a basis for further research. In its discussion, the researchers have acknowledged the need for future researchers to use their findings as the basis for another research (YaDeau et al., 2013, p. 634). They suggest that future researchers should aim at determining the effects that adding various adjuncts could have on either of the cases considered in their research. Another area of possible future research identified was whether or not by adding a nerve block during local infiltration; one would improve analgesia experienced after the operation (Brownson et al., 2011, p. 206).
The article is thus a successful representation of what should happen in application of an evidence based practice. The practice is commonly implemented in six steps, which are all reflected in the study. First, the researchers did formulate clinical questions which enabled them obtain information from their participants. Secondly, they adhered to the requirement of conducting a continuous search for literature. This enabled them to identify and utilized the relevant information, tools, and methods in their study. This way, they were able to come up with comprehensive findings; thus, could provide an alternative way of dealing with the issue at hand. The comparison of past findings also enabled the researchers to ensure that major concepts, which need to be included in the EBP, are included in their study. The study also considered the use of recommended and approved techniques based on the various available literatures. The findings of the study are also well presented, thus enabling to form a basis for the research process in the future.