Definition: “Evidence based nursing practice” is probably best understood as a decision – making framework that facilitates complex decisions across different and sometimes conflicting groups. It involves considering research and other forms of evidence on a routine basis when making health care decisions. Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003).
There are essential differences between traditional nursing and Evidence Based Nursing Practice. Traditional nursing practice has always drawn upon the personal experience, case studies and research of the physician. In “Evidence Based” Nursing Practice, health care decisions are based on a structured organized process to help physicians, nurses and patients alike to choose the best health care options and their consequences.
At a broader level, Evidence Based Nursing Practice works by providing a safe framework in which different groups can make tough decisions by safe guarding their concerns by a fair and scientifically sound process.
Relevance of Evidence based Nursing Practice Today.
Changes occurring in health care delivery and nursing are the result of social, economic, technological, scientific forces that have evolved in the 21st century. Among the most significant changes are shift in disease patterns, advanced technology, increased consumer expectations and high costs of health care. These factors have redefined nursing practices to fit into the changing health care delivery system.
Thus, as a profession, nursing is ‘accountable’ to the society. i.e. obliged to the laws regulating the professional activity. This accountability is spelled out in the ‘American Hospital Association’s Patient Care Partnership Document (Suzanne, 2004). In addition to accepting this document, nursing profession has further defined its standards of accountability through a formal code of ethics established by the American Nurses Association. (Suzanne, 2004).
Nursing’s social policy statement(ANA 1995), defines Nursing as “The diagnosis and treatment of Human responses to health and illness”. This supports that Nurses should be actively involved in the decision making process of health care delivery system. Legal challenges and court decisions can seriously affect a Nurse’s professional future. The Nursing practice is liable for six kinds of legal authourity,viz, ‘The Federal or Central law’, ‘The law of the State’, ‘The International code of Nurses’, ‘Institutional rules and regulations’, ‘Standing orders’ and ‘Precedent court decisions’. (Zwemer 1995). There are certain areas in nursing practice which have important legal implications called ‘Legal hazards’ of a nurse. These include:
1. ‘Environment hazards’ like slippery floors, faulty equipment, absence of bedside rails when necessary, presence of inflammable substances, inadequate protection from stray animals and inadequate lighting.
2. ‘Procedural hazards’ like not taking written orders from the physician for treatment of the patient; non- registering of births, deaths and still births; non–charting medicine administration; not -reporting accidents and errors.
Negligence in all the above mentioned aspects can bring about serious legal difficulties. With increased patient awareness of the health care delivery situations, media flare up and public opinions, evidence based nursing practice has become more relevant today.
The relevance of evidence based Nursing in “Nursing Care for Terminally ill patients” and the rationale in Practice experience.
One of the most difficult realities the nurses face is that, despite efforts and good care, some patients will die, either due to the nature of the diseases like cancer or AIDS or due to developments related to patient’s age and health conditions. Although, technological advances in health can bring extended and improved quality of life, the ability of these technologies to prolong life beyond a meaningful point has raised ethical issues, especially in “nothing more can be done” patients.
Denial on the part of the patient and family members about the seriousness of Terminal illness has been a barrier to discuss about end of treatment options (Kubler-Ross 1969). The mode of Palliative care i.e. the comprehensive care of the patients whose disease is not responding to cure in today’s scenario should be done only by Evidence Based Practice to safeguard the concerns of the physician, nurses and the patient. Studies have conformed that patients want information about their illness and end of life choices (McSkimming et.al, 1994).
The case of Nancy Curzon helped enormously to the evolution of ‘Evidence Based Nursing Practice’. Nancy Curzon was a young woman involved in a car crash after which she remained in a persistent vegetative state. Inspite of a three year legal battle by her family to have her feeding tube removed to let her die, the U.S Supreme court decided that a state requires a “Clear and Convincing Evidence” of the patient’s wishes before withdrawal of life-support. This gave rise to the ‘Patient’s Self-Determination Act, Dec. 1991’.
The intent of this legislation is to encourage people to prepare ‘Advance directives’ in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.
Advance directives :
Advance directives’ are legal documents that specify a patient’s wishes before hospitalization and provide the necessary information for tough decision making situations. Thus, proper documentation of the ‘Advanced directives’ is a key function in Evidence based nursing care of the terminally ill patients (Suzanne 2004).
The Advance directive is usually composed of
1. Living will: Living will is a medical directive issued by an individual with sound mind. This documents treatment preferences and provides instructions of care. This is often accompanied by a ‘Proxy directive’.
2. Proxy directive: This is the appointment and authorization of another individual to make medical directives on behalf of the person who created an advanced directive when he/she is no longer able to speak for himself/herself. This is known as Health Care Power of Attorney or ‘Durable Power of Attorney’ .
Assisted suicide is a criminal offence except in the state of Oregon, U.S.A where there is a statute legalizing physician assisted suicide.
Diagnosis and Treatment Report :
Every Health Care delivery center today provides a report to the patient on the details of the diagnosis of the disease with follow up instructions, the Medicine information and the allergy reactions that could follow; dietary restrictions, dos and don’ts, restrictions and exercises prescribed. They take an acknowledgement either from the patient or an authorized person after receiving the report.
This documentation serves a key purpose in Evidence Based Nursing Practice (Hackensack University Medical Center, 2006).
The Health Record :
Documentation of records of all treatments and medications, as well as a record of a patient’s reactions and behaviour should be understood. The health record is the written and legal evidence of treatment. This reflects only facts and not the judgement of the nurse. Careful and accurate documentation is vital for patient welfare and that of the nurse. The use of electronic documentation is becoming increasingly prevalent (Bunker, 1999). Documentation should include, medication administered, treatments done with date & time, factual, objective and complete data with no blank spaces left in charting, on flow sheets or on check lists, calls made to health care team, client’s response, signature of the nurse in every entry and consent for treatment (Julia ,1998)
Before any terminally ill person receives his chemotherapy or an invasive procedure, he or his health attorney should give a well documented Informed Consent.This means that tests, treatments and medications have been explained to the person, as well as outcomes, possible complications and alternative procedures. The duty of the nurse is to confirm that the signed consent is in patient’s health record (Bunker, 1999)
In the context of Evidence based Nursing Practice, the ultimate goal of nursing is to care keeping in view the trust issues in dealing with the terminally ill patient. The nurse’s primary commitment is to the patient and profession. The idea of evidence based nursing practice is to keep oneself updated and to base health care decisions more firmly on evidence as opposed to anecdotal information of the past.
Factors which facilitate and hinder Evidence Based Nursing Practice:
Evidence Based Nursing provides a practice with a strong application of the scientific method. This enables practice to proceed by a process of skeptical questioning rather than by embellishment with rhetoric (Baum, 2003). Evidence Based Nursing provides all the groups involved in providing health care with a rigorous and acceptable frame work for making complex decisions, at a time when effective decision is badly needed.
Evidence Based Nursing Practice helps in developing more transparent working practices to establish guidelines and standards. We have incredible amounts of information available to us about the etiology, prevalence, and pathophysiology of disease. This information is absolutely crucial but does not clearly tell us how to ultimately treat patients. Also, patients now are much more sophisticated than they were 20 years ago. No longer can we tell patients what to do without them questioning our decisions. Over the past 10 years, Evidence Based Nursing has become the basis for thousands of clinical and policy decisions about most aspects of health care, such as tests, treatments, risk factors, screening programs, and other forms of disease management.
Evidence based practice has been particularly useful for addressing questions that do not have intuitive answers or those for which our impressions can actually cause more harm than good. The list of medical procedures that everyone, at one time, felt to be beneficial, but which later proved to be either effective or harmful, is long. Evidence Based Practice has been particularly useful for addressing questions that do not have intuitive answers or those for which our impressions can actually cause more harm than good.
The list of medical procedures that everyone, at one time, felt to be beneficial, but which later proved to be either effective or harmful, is long. (Baum, 2003). Evidence based nursing practice involves four important aspects.
Defining a structured question or problem from patient’s perspective
Searching the data sources for answers
Evaluation of the data. (because value of an evidence is based on credibility).
Application of the findings to practice situations.
Evidence based Nursing does have theoretical and practical limitations. Theoretically, Evidence Based Practice only addresses issues relating to patients. It does not help the medical or scientific study of the patient’s behaviour on such situations. Practical limitations usually involve absence of the support structures needed for sustained evidence, lack of commitment & insufficient evidence for too many problems.
The Internet allows us to gain access to large volumes of information quickly and is easily within the reach of most Nurses. Excellent resources include the web sites of the American College of Physicians (http://ebm.bmjjournaks.com) and the centre for Evidenced Based Medicine (http://cebm.jr2.ox.ac.uk) in Oxford, England. The Cochrane Collaboration (www.cochrane.org) is an international collection on a wide range of medical topics.
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