Evidence Based Mental Health Nursing

Introduction
This report will focus on the assessment and care planning for an individual using the mental health services. Evidence based approach will be deploy in order to be able to record, review and monitor the progress of the service user. Evidence-based practice is a structured and systematic approach to using research based knowledge of effectiveness to inform practice (Olfson, 2009). Knowledge includes formal information derived from research, for example from published trials and reviews. It also encompasses the informal knowledge and wisdom of practitioners, sometimes called tacit knowledge. This informal knowledge can include, in addition, the expertise of those who receive an intervention, whether that is medication, talking therapies or attending a parenting skills group.

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Care Programme Approach(CPA)provides the framework for assessing and care planning for a person with mental illness. CPA was introduced in 1991 by Department of Health as a systematic arrangement for assessing the health and social needs of people accepted into specialist mental health services (Kingdon, 1998). The formation of the plan will detail the health and social care required from a variety of provider as well as the appointment of a key worker to keep in close touch with the service user and to monitor and co-ordinate care. In addition, regular reviews will be conducted where necessary, agreed changes to the care plan. Hence, in this report, I will outline the main principles of CPA and deploy the use of Tidal Model and principles throughout the report by Tidal model’s principles to clinical practice and assessment and care planning.
A detailed background and information about the individual receiving care in the clinical section of where I work will be provided. And to make it clearer for the audience of this report, I will highlight the purpose of conducting this assessment as well as the process of the assessment. The discussion will centre on care planning and the strategies or issues that may impact the process. In order to keep the identity of the person under care anonymous in in accordance with confidentiality and the NMC code, only the initial of the individual will be used through the discussion in this report. As a nurse, I owe a duty of confidentiality to all those who are receiving care under me and that includes making sure that they are informed about their care and that information about them is shared appropriately (Maloney, 2016).
Care Programme Approach Framework and The Tidal Model
The Care Programme Approach (CPA) is a way that services are assessed, planned, co-ordinated and reviewed for someone with mental health problems or a range of related complex needs (Nhs.uk, 2017). CPA are generally offered to individual that have been diagnosed for having a severe mental disorder, someone who is at risk of suicide, self-harm, or harm to others and people with history of violence or self-harm. In addition, the service is available for people that vulnerable, this could be for different reasons such as physical or emotional abuse, financial difficulties because of mental illness or cognitive impairment.
The three main core principles of CPA according to Rowland (2013) are the assessments of the needs of the individual, allocation of a care coordinator and plan how to meet the needs of the person. The coordinator will ensure that the plan include the fully assess of the service user needs, it will also show how the NHS and other organisations will meet the needs of the person, including the family in some cases. It has to be regularly reviewed by the coordinator to monitor progress. In addition, the coordinator will have to think about all the mental health needs of the service user, medication and side effects, employment, training or education and personal circumstances including family and carers. The assessment will include the risk of the service user to themselves or other, either there is a problem with drugs or alcohol. The CPA is a model for good practice which remains applicable today.
However, the CPA is a care for those of working age in contact with specialist mental health and social care services (Donohue, 2014). It is crucial to work have an integrated approach across health and social care to minimise the distress and confusion sometimes experienced by people referred to the mental health system and their carers. In addition, professionals have found some aspects of the CPA over-bureaucratic, managers and service users alike have found the lack of consistency confusing (Donohue, 2014). It is they who have been working and living with the CPA for some years now and it is important to take account of their views. In the nutrshell, Bree-Aslan and Hampton (2009) indicated that CPA is not a model of care but a tool and process to guide nurses on how to provide effective service for people with mental illness. By embracing an integrated approach where by a seamless service can be achieved through an integrated approach to care co-ordination which provides for a single point of referral and a unified health and social care assessment process (Koopmans, 2013).
Tidal model will be deployed through the care planning and assessment in this report. This principles and philosophies of this model will help to give an in depth understanding to the process of assessment and care-planning. Tidal model is a mental health recovery model which may be used as the basis for interdisciplinary mental health care. It was developed by Dr Phil Barker and Poppy Buchanan-Barker as a philosophical approach to the discovery of mental health (Barker and Buchanan-Barker, 2010). The Tidal Model accentuates helping people reclaim the personal story of mental distress, by recovering their voice. With service user, own language, metaphors and personal stories, people can begin to reclaim the meaning of their personal experiences. Helping someone to a problem in living is rarely easy because everyone is unique and each person’s reaction to any problem in living also is unique. Hence, what works one person may not always ‘work’ for another.
In Tidal model. The first step towards someone with mental illness recovering control over their lives. The model enable mental health nursing to be used as the basis for interdisciplinary mental health care and the focus begin with begin with the recovery journey when the person is at their lowest ebb experiencing the most serious problems in living (Barker and Buchanan-Barker, 2010). The Tidal Model provides a practice framework for the exploration of the patient’s need for nursing and the provision of individually tailored care. (Barker P, 2001) and it is considered as a mid-range theory of nursing, hence the main focus of the model is on helping individual people, make their own voyage of discovery. From the research, already been conducted by different scholars, the combination of CPA framework and Tidal model with the collaboration with the service user will enable them to recognise areas and needs that will be most suitable for their recovery as well as promoting a culture of person-centred care that is not associated with CPA framework.
Biography
Janet Bonet is a 58-year-old female living with her daughter who is one of her three children. Janet has never been married and also has no partner at the moment, although she said to have been in different relationships in the past but which seem to lead nowhere. My mentor and I have been asked to assess Janet during her inpatient appointment at the centre. Janet has been known to mental health services over the years and has a history of disengagement. She has had a diagnosis of severe depression in the past and also suffers from back problem which impacts on her mental health.
Janet has never been able to keep a job due to her physical health and so she has been in benefits most of her life. Due to financial stress in the past, she has self-neglected and now depend on her carer who is also her daughter for support in daily activities. Also, she was asked by the council to downsize her four-bedroom house to a two-bedroom house which she has done but still waiting on the housing list to be moved closer to her family and she finds this waiting period stressful as she has been waiting for over a year so housing is also her concern.
Recently, she has been experiencing a lot of fluctuations in her mood as she reports that she lost her Dad, Mum,Nan,and Grandad within two weeks of each other and found this extremely distressing and also has been having thoughts of harming herself. Her daughter is her carer and she also claims that her other children along with her grandchildren do visit sometimes which makes her think less about self-harming herself. She says “My children and grandchildren are my protective factors”. She went further to say that she has been experiencing feelings of emptiness and anger due to the fact that she does not feel safe in her neighbourhood as she feels some people are out to get her.
Janet admits that in the past she has not been compliant with her medication due to side effects but is willing to be compliant with treatment now that she feels she is in crisis in order to promote her recovery. Janet has also reported suicidal thoughts in the past and has had two attempts at committing suicide.
Assessment
The assessment of service user with mental illness include collections of different range of information. The information may include mental health symptoms and experiences of the service user, feelings, thoughts and actions physical health and wellbeing, culture and ethnic background, use of drugs or alcohol, social and family relationships and past experiences, especially of similar problems. The whole essence of conducting assessment is for the coordinator to be familiar with the life history of the service user. However, I prefer deploy Barker (2008, p.66) procedures of assessment by trying to answer the question who the service user is. The procedure will enable the coordinator to focus on the individual as a whole by considering their needs instead on focusing on diagnosis. The second question like “what is wrong”? will prompt the service user to give information about their state of mind and wellbeing. For a nurse, the concept is to show empathy for the service user to be at ease and feel unthreatened to give more information about the state of the health and their experience. The correlate with Tidal model of Barker and Buchanan-Barker (2010) that indicated that coordinator can deploy a “holistic assessment whereby the service user is allowed to tell their story and world of experience. Through holistic assessment, therapeutic communication, and the ongoing collection of objective and subjective data, nurses are able to provide improved person-centred care to patients. A holistic assessment approach acknowledges and addresses the physiological, psychological, sociological, developmental, spiritual and cultural needs of the patient (Kreys, 2014).

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However, finding out who the person is and what is wrong with them, is just one part of the assessment. It is essential to form a collaborative and empowering relationship with the service user in order for them to be comfortable around the coordinator. Hence, service user should be treated with respect and dignity no matter the state of their health.
References
Barker, P. (2008). What are psychiatrists for?. Mental Health Practice, 12(1), pp.11-11.
Barker, P. and Buchanan-Barker, P. (2010). The Tidal Model of Mental Health Recovery and Reclamation: Application in Acute Care Settings. Issues in Mental Health Nursing, 31(3), pp.171-180.
Bree-Aslan, C. and Hampton, S. (2009). Pressure care, part two: the importance of assessment. Nursing and Residential Care, 11(1), pp.12-17.
Donohue, P. (2014). Involving families in planning and assessment of community services. Nursing and Residential Care, 16(3), pp.175-176.
Kingdon, D. (1998). Reclaiming the care programme approach. Psychiatric Bulletin, 22(6), pp.341-341.
Koopmans, R. (2013). Mental health in long-term care settings: The Dutch approach. Geriatric Mental Health Care, 1(1), pp.3-6.
Kreys, T. (2014). A holistic approach to patient care in psychiatry. Mental Health Clinician, 4(3), pp.98-99.
Maloney, P. (2016). Nursing Professional Development. Journal for Nurses in Professional Development, 32(6), pp.327-330.
Nhs.uk. (2017). Mental health services: Care Programme Approach – NHS Choices. [online] Available at: http://www.nhs.uk/Conditions/social-care-and-support-guide/Pages/care-programme-approach.aspx [Accessed 28 Feb. 2017].
Olfson, M. (2009). Review: limited evidence to support specialist mental health services as alternatives to inpatient care for young people with severe mental health disorders. Evidence-Based Mental Health, 12(4), pp.117-117.
Rowland, P. (2013). Core principles and values of effective team-based health care. Journal of Interprofessional Care, 28(1), pp.79-80.

Observational Evidence for Dark Energy

In this part we concisely discuss the observational evidence of dark energy. The universe seems to be growing at an increasing rate. Dark energy is one of the ultimate cosmological mysteries in modern physics. Even Albert Einstein thinks of a repulsive force, called the cosmological constant, which would counter gravity and keep the universe stable. He unrestrained the idea when astronomer Edwin Hubble experimentally discovered in 1929 that the universe is expanding. Observational evidence for dark energy didn’t come along until 1998; when two teams of researchers discovered it. Some believe that is because the universe is filled with a dark energy that working in the opposite way of gravity. The value for the expansion rate is 73.8 kilometers per second per mega parsec. It means that for every further million parsecs (3.26 million light-years) a galaxy is from Earth, the galaxy seems to be roving 73.8 kilometers per second quicker away from us.
Luminosity distance:
In 1998 the accelerated expansion of the universe was pointed out by two groups from the observations of Type IA Supernova. We regularly use a redshift to portray the development of the universe. This is identified with the way that light emitted by stellar objects gets to be red-shift because of the emerging of the universe. The wavelength increases proportionally to the scale factor, whose impact might be calculated by the redshift,

An alternate essential idea identified with observational tools in an expanding background is associated to the definition of a distance. Actually there are a few methods for measuring separations in the extending universe. For example one frequently manages the comoving separation which stays unaltered throughout the advancement and the physical separation which scales relatively to the scale variable. An alternative method for characterizing a separation is through the luminosity of stellar objects. The separation known as the luminosity distance, assumes an extremely vital part in space science including the Supernova observations.
In Minkowski space time the absolute luminosity of the source and the energy flux at a distance d is related through

By summing up this to an expanding universe, the luminosity distance, , is defined as

Give us a chance to think about an object with total luminosity located at a coordinate distance from a viewer at .The energy of light emitted from the object with time interval is indicated as while the energy which arrives at the domain with radius is written as . We note that and are relative to the frequencies of light at andi.e. and. The luminosities and are
,
The speed of light is given by, where and are the wavelengths at and. At that point from Eq. (29) we have

Also we have used .Linking eqn and eqn

The light traveling along the χ direction fulfills the geodesic equation .We then get

Where .From the FRW metric [] we find that the region of the circle at is given by .Consequently the observed energy flux is

Substituting eqn () we find the luminosity distance in an expanding universe:

In the flat FRW background with we can find

So the Hubble rate can be stated in term of

If we amount the luminosity distance observationally, we can conclude the expansion rate of the universe. The energy density on the right hand side of Equation contains all components present in the universe.

Here and link to the equation of state and the present energy density of each component, respectively.

where is the density parameter for an individual component at the present age.
Hence the luminosity distance in a flat geometry is given by

Type 1a Supernova (Standard Candles):
To discover distances in space, scientists use entities called “standard candles.” Standard candles are objects that give a certain, known measure of light. Since cosmologists know how intense these objects actually are, they can measure their separation from us by investigating how dim they appear. For instance, say you’re remaining on a road equitably lined with lampposts. As indicated by an equation known as the inverse square law, the second streetlamp will look one-fourth as brilliant as the first streetlamp, and the third streetlamp will look one-ninth as splendid as the first streetlamp, etc. By judging the dimness of their light, you can without much of a stretch figure how far away the streetlamps are as they extend into the separation. For short separations in space — inside our world or inside our neighborhood gathering of adjacent universes — cosmologists utilize a kind of star called a Cepheid variable as a standard candles. These adolescent stars pulse with a brilliance that firmly identifies with the time between beats. By watching the way the star beats, cosmologists can ascertain its real brilliance. Anyway past the neighborhood gathering of universes, telescopes can’t make out distinct stars. They can just recognize substantial gatherings of stars. To measure separations to far-flung systems, in this manner, space experts need to discover inconceivably brilliant objects.
The immediate confirmation for the current acceleration of the universe is identified with the perception of luminosity distances of high redshift supernovae .The clear magnitude of the source with an absolute magnitude is identified to the luminosity distance through the

This originates from taking the logarithm of Eqn () by noting that and are identified with the logarithms of and, individually. The numerical variables emerge in view of customary meanings of and in astronomy.
The Type Ia supernova (SN Ia) might be watched when white small stars surpass the mass of the Chandrasekhar limit and blast. The belief is that (SN Ia) are structured in the same way regardless of where they are in the universe, which implies that they have a typical total size M autonomous of the redshift z. Hence they might be dealt with as a perfect “standard candle”. We can measure the apparent magnitude and the redshift observationally, which obviously relies on the objects we observe. Let us think about two supernovae at low-redshift with and at high-redshift with. As we have effectively said, the radiance separation is roughly given by.By means of the apparent magnitude of at; we find that absolute magnitude is evaluated by from equation. Here we received the quality with At that point the luminosity distance of is gotten by substituting and for equation

From Eq. () the theoretical guess for the luminosity distance in a two component flat universe is

This estimation is obviously predictable with that needed for a dark energy dominated universe. In 2004 Riess et al. [85] reported the measurement of 16 high redshift with redshift with the Hubble Space Telescope (HST). By including 170 previously known data points, they demonstrated that the universe exhibited a transition from deceleration to acceleration at confidence level. A best-fit quality of was discovered to be In Ref. [86] a probability investigation was performed by counting the data set by Tonry et al. [87] together with the one by Riess et al. [85]. The observational qualities of the luminosity density versus redshift together with the theoretical curves determined from Eq. (41). This shows that a matter dominated universe without a cosmological constant does not fit to the facts. A best-fit assessment of got in a joint study of Ref. [86] is, which is reliable with the result by Riess et al. [85]. See additionally Refs. [88] for late papers about the data analysis.
A correlation is made of the constraints on models of dark energy from supernova and CMB insights. The authors argue that models favored by these perceptions lie in unique parts of the parameter space at the same time there is no cover of areas permitted at the 68% certainty level. They happen to propose that this may demonstrate unresolved systematic errors in one of the observations, with supernova observations being more likely to suffer from this problem due to the very heterogeneous nature of the information sets accessible at the time. Current observations of high redshift supernovae from the Super- Nova Legacy Survey have been issued. The overview has planned to diminish efficient failures by utilizing just high quality observations focused around utilizing a solitary instrument to observe the fields. The case is that through a rolling search strategy the sources are not lost and information is of dominant quality. Jassal et al. assert that the information set is in better concurrence with WMAP. At the end of the day the high redshift supernova information from the SNLS (Supernova Legacy Survey) task is in superb concurrence with CMB observations. It leaves open the current state of supernova observation and their examination, as thought about to that of the CMB.
It ought to be highlighted that the accelerated expansion is by cosmological standards truly a late-time phenomenon, beginning at a redshift .From equation the deceleration parameter is given by

For the two component flat cosmology, the universe enters an accelerating phase for

When, we have. The issue of why an accelerated extension ought to happen presently in the long history of the universe is known as the “coincidence problem”. We have focused in this area on the use of as standard candles. There are other conceivable candles that have been proposed and are actively being researched. One such approach has been to utilize FRIIB radio universes [93, 94]. From the comparing redshift angular size information it is conceivable to constrain cosmological parameters in a dark energy scalar field model. The derived constraints are discovered to be reliable with yet for the most part weaker than those decided utilizing Type supernova redshift-magnitude data. Nonetheless, in Ref. [95], the creators have gone further
What’s more created a model-free approach (i.e. free of presumptions about the manifestation of the dim vitality) utilizing a set of 20 radio systems out to a redshift z ∼ 1.8, which is more remote than the SN Ia information can arrive at. They presume that the current perceptions show the universe travels from quickening to deceleration at a redshift more terrific than 0.3, with a best fit assessment of about 0.45, and have best fit qualities for the matter and dull vitality commitments to in wide concurrence with the SN Ia gauge

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An alternate proposed standard candle is that of Gamma Beam Blasts (GRB), which may empower the development rate of our Universe to be apportioned to high redshifts (z > 5). Hooper and Dodelson [96] have investigated this plausibility and found that GRB can possibly distinguish dull vitality at high measurable criticalness, however in the fleeting are unrealistic to be aggressive with future supernovae missions, for example, SNAP, in measuring the properties of the dull vitality. In the event that anyway, it turns out there is obvious dull vitality at promptly times, GRB’s will give a fantastic test of that administration, and will be a genuine supplement for the SN Ia information. This is a quickly advancing field and there has as of late been declared provisional confirmation for a dynamical mathematical statement of state for dim vitality, taking into account GRB information out to redshifts of request 5 [97]. It is excessively early to say whether this is the right translation, or whether GRB are great standard candles, however the exact truth they could be seen out to such expansive redshifts, implies that in the event that they do end up being standard candles, they will be exceptionally huge supplements to the SN Ia information sets, and conceivably more critical.
Cosmic Wave Background
The case for an accelerating universe additionally accepted autonomous support from Cosmic microwave Background (CMB). The presence of Dark energy, in whatever structure, is required to accommodate the measured geometry of space with the aggregate sum of matter in the universe. Estimations of cosmic microwave background anisotropies, most as of late by the WMAP satellite, demonstrate that the universe is nearly flat. For the state of the universe to be flat, the mass-energy density of the universe must be equivalent to a certain critical density. The aggregate sum of matter in the universe (counting baryons and dark matter), as measured by the CMB, represents just about 30% of the critical density. This suggests the presence of an additional form of energy to represent the staying 70% [21].
Dark energy and Inflation
The flatness and the horizon issues of the standard big bang cosmology are serious to the point that the hypothesis appears to oblige some essential adjustments of the theory made in this way. The most exquisite result is to assume that the universe has experienced a non-adiabatic period and additionally through a period of accelerated expansion, throughout which physical scales evolved much quicker than the horizon scale .This time of positive acceleration, of the primitive universe is called inflation.
The inflationary theory is appealing in light of the fact that it holds out the likelihood of determining cosmological amounts, given the Lagrangian portraying the fundamental interactions. In the setting of the Standard Model, it is most certainly not conceivable to join expansion, however this ought not be viewed as a serious problem in light of the fact that the Standard Model itself obliges alterations at higher energy scales, for reasons that have nothing to do with cosmology. The negative dynamic gravitational mass thickness connected with a positive cosmological constant is an early sign of the inflation representation of the early universe; inflation in turn is one sign of the idea that might simplify into evolving dark energy.
 

Challenges and Opportunities for Evidence Based Practice

Introduction
In recent years Evidence-based practice (EBP) has been advocating in nursing profession, however until now there still encounter many difficulties, conflict impact on evidence-based practice development. In this essay will be discussed the challenges and opportunities of future direction of evidence-based practice in nursing.
EBP is a decision making approach introduction in 1992. Sackett et al. (1996) state that EBP is a best evidence method of health care decision making which means to integrate sources from research findings, clinical expertise and consideration of client preferences, clinical setting and other external factors such as cost. (as cited in Hewitt-Taylor, 2002). EBP is a scientific and systematic process rather than traditional approach such as customs, rituals and authority from transmission to improve quality and efficiency of patient outcome (Shaneyfelt et al. 2006).

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Challenges can be defined as barriers, difficulty during apply the evidence-based practice in nursing. Actually, there are many challenges of EBP development, in the article will try to divide into four types to discuss: Challenge of the nurse, Challenge of the clinical environment, Challenge of the research and Challenge of the organization. The part of opportunities is to analysis how to improve or diminish the gap between research evidence and clinical practice, and discuss the factors that help for the future direction of EBP in nursing.
Challenges

Challenge of the nurse relate to the nurses’ beliefs or attitude to EBP, lack of understanding, knowledge and skills of EBP. A recent study (Oranta, Routasalo & Hupli, 2002) indicated nurses have divergence the value between research and practice; some nurses have conservative ideas that do not welcome change the nursing practice. The result reflect nurses have misunderstanding or negative attitude about evidence based care which may create wrong belief i.e. indifference or ignore the value of EBP. Nurse unawareness of research, are not familiar with EBP, and no sense improve the knowledge, not to mention to implement it in clinical care. (Hutchinson & Johnston, 2004; Wang, Jiang, Wang, Wang & Bai, 2013). Attitudes affect behavior, if nurse attitude remain unchanged, would increase degree of difficulty to carry out EBP in the future.
Lack of skills implementation of EBP also a big challenge facing by nursing (Majid et al. 2010; Hutchinson & Johnston, 2004). There are multiple components of EBP include asking suitable questions, selecting the best pertinent information, evaluating the evidence and integration of patient preference, research evidence etc in clinical decision making (Shaneyfelt et al. 2006). Nurse requests ability of integration and critical appraisal research skills i.e. information seeking, understand statistical terms, implementation to run through the EBP process. Provide education and training for EBP should be an important concern in the future for nurse.

Challenge of the research

Next challenge point related to research. Nurses always complain articles from journal are not readily available (Chau, Lopez & Thompson, 2008; Gale & Schaffer 2009; Wang et al. 2013). Actually findings from different research may not always have high level of reliability and validly, methodologies and presentation inadequacies or misconception may exist. Nurses probably feel confused and difficult to appraisal quality of findings, research reports are lengthy, include many academic, jargon terms and statistical analyses cause difficult to comprehension (Oranta, Routasalo & Hupli, 2002).
Furthermore, research finding usually not publishes fast enough and lack of guideline to implement in the clinical practice. Develop the research disseminate type to improve clinical utilization is a main direction in future, otherwise presentation of researches increase barrier to use finding in patient care, eventually obstruct EBP implementation.

Challenge of the clinical environment

Clinical environment seem to be a big challenge which absolute restrict nurse implementing EBP (Lee, 2003). Most studies (Hutchinson & Johnston, 2004; Gale & Schaffer 2009; Wang et al. 2013) stated that nurses have lack of time and heavy workload influences on utilization of research in practice setting. Take Hong Kong as an example, according to the survey conducted by Association of Hong Kong Nursing Staff at 2013, the average of nurse-patient ratio1:17 (normal: 1:4-6) in public hospitals, the bed occupancy rate is 92.9%. Nurses not only have daily heavy workload, also facing a serious shortage problem. Time and labour restrict and clinical safety concerns, nurse tend to use traditional practices and cannot keep frequently follow update journals during working (Hutchinson & Johnston, 2004). The working environment resistant changing tried and definitely threats EBP utilization in future.

Challenge of the organization

EBP is a complex and multifaceted process, cannot apply by individual, administrative support is very important. However lack of organization support is the common complaint by nurses. According to Chau et al. (2008) and Hutchinson & Johnston, (2004) the most important challenge of research utilization are lack of authority and no time to implement new ideas or involve research activity. These concerns related to the organization which include the setting barriers and limitations; e.g. time, resources, support and mentoring.
Besides, conservative attitude of organization such as lack of intention in changes or welcome new ideas must influences EBP utilization (Gale & Schaffer, 2009). It would limit the development of clinical practice to implement EBP and reduce the health care qualities.
In addition, nurse indicated that corporation with other professionals also a barrier of EBP implementation (Oranta, Routasalo & Hupli, 2002). Health care is a team working which involve many different professionals, such as physician, physiotherapist etc. during co-operation may cause differences of decision making. In traditional doctor has the most authority in clinical decision making, nurse advice may cause conflict or challenges by doctor. Therefore relationship between medical and nursing is also an organization related challenge of EBP utilization.
Although there are many challenges of EBP in clinical utilization, challenges creates opportunities, the following part would analysis how to overcome some barriers between research evidence and clinical practice, and talk about the factors that relate to the future direction of EBP in nursing.
Opportunities
Firstly, upgrading of nursing education curriculum improve nurses’ professional status and research knowledge. Nursing students learn of EBP show more potential of ability on clinical decision making (Brown et al. 2010). Although the nursing programme in universities already include research skills teaching to implement evidence-based practice, transferring finding into clinical practice still a big problem for novice nurses. The curriculum should be included how to connect the EBP to the utilization, not just focus the part of research skills training.
Besides, base on shortage of nurse, there are different kind of organizations provide nursing training such as nursing school, hospital nurse training courses, these courses more focus on clinical practice, but not include teaching EBP. At least the basic concept and skills of EBP should be educated in those courses which to improve knowledge of apply EBP into clinical practice.
Second, solidarity and cooperation is also an opportunity to future direction of EBP. No matter clusters, hospitals or ward in Hong Kong tend to working independently and lack of co-ordinate with other. To provide EBP should include cooperate and sharing. The hospitals or clusters can form some research groups from different hospitals or wards; include senior and junior nurses to conduct research-related work. This kind of workshop would improve the stuffs ability to identify the clinical issues, review researches, analysis, promote to implement research finding or conduct research etc. eventually improve the quality of nursing care.
Third relate to organization, the inferiors imitate the superiors; if the organization have positive attitude to motivate and reward EBP can raise the awareness to the staffs pay attention to EBP (Gale & Schaffer, 2009). To improve future develop of EBP, organizational should be modified the nurse ratios. Provide more time and facilities to encourage nurse for discussing and applying research finding in clinical (Lee, 2003).
Fourth, facing of decreasing birth rate, the elderly increasing inevitable, aging population already became a international problem, elderly care must pay more attention in nursing. Community services would be a big tendency and increase outreach services and day care services nursing care. Communities’ services for example community nurse and Nursing Clinic also help to relive the treatment cost, reduce stress and workload of front line nurse and bed occupancy rate. This situation closely relate to EBP because the role of nurses become more arduous and specialization, the case nurse provide professional health care services with integration, multifunction should have both evidence and knowledge to support the practice and patient outcome. The phenomenon provides opportunity to EBP to walk out the hospitals and integrate into the communities.
Fifth, in the future nurses implement EBP may not just focus on Western medicine, also include Chinese medicine. In current years, popularity of Chinese medicine increasing in Hong Kong, most elderly tend to use Chinese treatment such as acupuncture, qigong diet regimen. Chinese medicine research and the utilization on clinical should be part of concern in EBP when making decision. As favorable condition of geography and culture in Hong Kong, combine Chinese and Western medicine would be a tendency, as a nurse should have the knowledge integration and application in clinical care.
In conclude EBP utilization provide a more scientific method to the clinical decision making lead to improve and maintain health care quality, it is definitely the general direction in nursing future development. Base on the restrictive of policies and environment, working environment and organization seems to be two bigger challenges of EBP utilization. Although there are many challenges of EBP, different limitations from nursing and the external environment such as aging population, Chinese medication become more popularity etc provide some opportunities to indicate the future direction of EBP. Nursing profession need to sensitive to those factors, then appropriate to develop or improve, probably reduce the gap between clinical practice and EBP, also may provide a new direction for EBP in nursing utilization.
 

Professional Values and Evidence Based Practice

The Role of a Nurse

The role of the nurse has developed massively from the times of Florence Nightingale to the modern 21st century. Florence Nightingale became an extremely famous heroine after her great efforts during the Crimean war. She fought to get all the wounded bandages, fresh bedding, food and cleaning supplies. Nightingale showed empathy and sympathised with the wounded and dying soldiers, she took the time to comfort and take concern for them. She was also able to manage others who worked around her, directing what could be done, such as assisting with letter writing and helping to wash or dress the men that were incapable. These are all factors that are now necessary skills for a nurse. (M.L.Lobo, Cited in J.B.George pg.43, 2002) Nightingales main priority was to secure and protect the environment that her patients were in. This consisted of keeping them clean and in a condition where infection could be minimised. These main features have been taken on board and have developed a vast amount to provide the most effective and safe practice of health care to date. This essay will aim to talk about the role of the nurse through the 4 principles of the NMC code (2015) and also express the importance of the 6 Cs of nursing whilst integrating them and linking each one to the NMC code. It aims to express the importance of communication, commitment, confidentiality, team work , fundamentals of care and professionalism.

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The NMC code (2015) have set out 4 main categories that describes everything a nurse should be able to do and what a nurse needs to abide by. These categories are; prioritise people, practice effectively, preserve safety and promote professionalism and trust. The first  section to be focused on is Within prioritise people of the NMC Code (2015) it states “treat people as individuals and uphold their dignity” this statement explores the importance of being non-prejudice when working within the nursing profession. Prejudice is defined as “preconceived opinion that is not based on reason or actual experience” (M.Waite, 2012) this is creating a judgement on someone from visual appearances and body language before you get to know a person. Prejudging someone, gives an overall first impression of a person. These are solely controlled by the nonverbal communication that happens when we first come in contact with someone. Therefore, the impressions we make are based on how a person looks, smells and sounds.  This is not always a positive impression. For example, if a new school teacher were to arrive to school in clothes that were creased, and their hair was not fixed, then we would assume that the teacher is incapable of teaching and is as disorganised as their appearance. However, these impressions can change; if the teacher were to perform extremely well and happened to be an outstanding teacher, then our first impressions are completely forgotten as they have over ruled them. Hence why a person should never judge a book by its cover. (Six degrees, 2018). However, regardless of the person, their background or what they have done, nurses and doctors take an oath to treat and care for all patients that come through the health service and prejudice is not even thought of.

Prioritising people also consists of upholding the patient’s dignity. This is key in the profession. Upholding dignity allows for the patient to feel comfortable and respected. Patients are extremely vulnerable in times of care and are exposed to situations that may be distressing for them. Nurses must be mindful of a patient’s morale in these circumstances. In cases where patients need to undress and get into a hospital gown, a nurse must ensure that they have their own private space, even if that means it’s closing the curtain from other patients around them. It consists of listening to a patient’s point of view and understanding how they feel. Its concentrating solely on them and giving them the person centred care that they deserve. There are ten elements of dignity that have been previously described by Dr Hicks in her book “Dignity, its essential role it plays in resolving conflict” that are beneficial in a health care profession. The most important that are relevant to nursing include; the acceptance of every persons individuality and identity, being understanding- taking into account what others are feeling at a distressing time, safety- ensuring that people are to feel at ease, fairness- treating all patients equally and lastly the most important is allowing the patient to have independence- this is to encourage people to have autonomy and to reiterate how they always have a say as to what happens during their care experience; it enables empowerment. (D.Hicks, 2011)

The Fundamentals of care was set out to improve the quality of care for adults. It is now the basis of nursing. The NMC have defined the fundamentals of care as “The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions… making sure you provide help to those who are not able to feed themselves or drink fluid unaided.” (NMC, 2015). The fundamentals of care aim to treat patients with dignity and respect but also ensuring that people’s physical, social and psychological needs are assessed and managed. Consent must be gained before carrying out any needs, such as assisting with feeding, brushing teeth, bed baths, assisting with toilet needs etc. This is the use of beneficence, acting in a way that is beneficial for the patient. Although the fundamentals of care are set out to promote care and have a benefit for the health, it can also have a negative impact on the patient. It is taking away the patients independence, patients are made to feel as though they are incapable of doing daily tasks that they carried out prior to coming into hospital. An example of this is on a cardiac ward; after having a heart attack and even though you are now stable and mobile, you cannot leave your bed area and therefore are made to go to toilet into a disposable bedpan, when in reality they could have gone to the toilet. One study found that 12% of patients aged 70 and over had noticed a decline in their ability to carry out essential tasks independently such as bathing dressing, using the toilet, eating and moving around, between their arrival to hospital and discharge (K.E.Covinsky et al, 2003). It also makes patients very reliant on nurses, they then feel that they can’t carry out tasks without a nurse and because they are so used to nurses assisting them with their care, they become more dependent and less mobile. In terms of mobility, being bed bound for weeks on end in hospital can cause muscles to break down in the body. Evidence has proven how longer stays in hospital can lead to worse health outcomes. Older patients can lose mobility rapidly when not kept active. Monitors recent review had shown how for healthy older adults, 10 days of bed rest can lead to 14% reduction in leg and hip muscle strength. With a further 12% reduction in aerobic capacity (Monitor, 2015 cited on National Audit Office p.14). This expresses how nurses should encourage patients to walk around on regular intervals if they are able and it is safe to do so to decrease the chances of having muscle loss and to ensure that they are able to go back to their own homes rather than to other care facilities.

The NMC Code (2015) second category for nurses to adhere to is “Practice effectively”. One of the points expressed is to “communicate clearly”. Communication amongst all nursing is one of the most important roles that a nurse has. Communication is usually taken for granted and is dismissed to the point where people believe that it is not important. But, in a nursing role, a nurse has to be able to communicate efficiently and effectively with both patients and other members of staff. There are two forms of communication; verbal and non-verbal. (S.Kraszewski & A. McEwen, 2010) Verbal communication is the use of speech or written information in order to express opinions and beliefs or simply for a conversation. The way in which we speak with tone of voice and with pitch is all based around the individual patients. If a patient were to be slightly deaf, then a nurse would understandably be using a higher volume of speech and also using a slow pace to give the patient time to understand what it is that they are actually saying. However, if the patient were to be of a well hearing health then a nurse would use a mediocre tone of voice and perhaps use a faster pace as the patient will understand more clearly. Verbal communication is the most common form. However, non-verbal communication also pays an important role. Non-verbal communication is the use of body language, eye contact and facial expression. This is useful in situations where the use of speech isn’t always appropriate. For example, in cases where a patient has been given a short time frame to live, a nurse may have broken the news and have used a healthy silence to allow the patient to digest the information that has been given. But, maintaining an open body stance and having soft eyes in this situation, allows the patient to recognise that they are there to talk to and ask questions when they feel they can (Nursing times, 2018). Albeit, there are many strengths and weaknesses to both forms of communication. Verbal communication can ensure that a point has gotten across to the patients and that they understand fully everything that has been explained to them. It also allows for a nurse to gain consent, they are able to discuss with a patient the procedure of their care and the patient is then able to decline or consent. This also brings out a sense of autonomy in the patients as they feel in control of their health care; they have a say as to what goes on, such as when they wish to wash, whether they want to go ahead with extensive surgery, to even when they wish to get out of bed. Effective communication also makes a patient feel valued. It shows how you are willing to listen and attempt to understand how they are feeling. This will build a report with a patient which makes them more trusting and they take on board what you have to say. Verbal communication can also have weaknesses. These can include language barriers. Visual and hearing impairments are a form of language barriers. The loss of hearing makes it difficult to understand what a person is saying. You would need to be able to speak sign language and studies have shown how only a minority of health professionals can communicate using sign language. It was reported in 2013 that 46% of reported deaf respondents have communicated with health professionals with the use of pen and paper. Having to write things down in order to have a conversation. 23% have reported they currently communicate using spoken English and the use of lip reading; stating that they would prefer not to. (Research into the health of death people, 2013). This research is only based on the presence of 553 deaf people within the UK. This can suggest how it is not a true representative of the whole deaf community worldwide. 553 deaf people is a small amount compared to the thousands that are present in the UK. This is stating that it only gives a slight insight into the difficulties faced by deaf people within the NHS; it cannot be said that all deaf people feel this certain way. Also, the study was carried out 6 years ago, therefore, it is slightly out of date. There is a possibility that there has been an increased awareness into the struggles that the deaf community face and changes could have been made over recent years to improve the experience these people face during health visits. It is important for a nurse to be aware of all these barriers when in their role.

Team work is also necessary when working within a nursing role. Teams have all different levels of experience and knowledge within the NHS and this has to be recognised and understood to enable the delivery of care to be most effective. The main function of a team during healthcare is to provide a good quality of care. The Harding committee (DHSS 1981, cited in S.Kraszewski & A. McEwen, 2010. pg.76-77) stated that a team has to have four certain key elements in order to function. These are; an overall common objective that is to be accepted by all staff within the team, an understanding of their personal roles, skills and how they function- taking into consideration about their own responsibilities and lastly having mutual respect for all other team members and their role. If a team was able to express and act upon these key elements, then the care delivered would be of a high standard. Even though, the definition is outdated coming from 1981, it is extremely relevant in modern day nursing as the principles of a team remains the same and the emphasis on teamworking is still at a high. However, the Harding committee failed to acknowledge the strength that communication has within a team. Under ‘practice effectively’ of the NMC code (2015) it states “work-co-operatively” and one sub-point says that a nurse must maintain effective communication with colleagues which links with another sub-point of sharing information to identify and reduce risk. Having effective communication whilst in a team can enhance the quality of care given.

The third category of the NMC code (2015) is to “Preserve Safety”. This is essential in nursing care both for the nurse themselves and for patients. This means that nurses have to recognise and notice their capabilities, to work within their own skill set and competence to prevent any harm. It is encouraging that nurses ask for help from suitably qualified staff, this not only increases the quality of care, but also improves and develops the skill sets of the nurse.  It also states how nurses should “always offer help if an emergency arises in your practice setting or anywhere else”. This form of commitment can be shown to the profession itself. If a shift was over and an emergency arises a nurse would not just clock off and leave, they would step in and help to resolve the situation and provide their services when needed. Nurses have a commitment to personal excellence. This is carrying out frequent evaluations of one’s self to further develop the professional care that is being given. It allows for nurses to critically evaluate themselves to make changes or improvements, writing up reflections in order to say what has been done well and what they would do differently. This is showing commitment to the job, making changes to improve and develop further to enhance not only yourself but the patient’s well-being. Commitment to the job can also be shown towards colleagues. Complimenting colleagues on what they have done well and help assist them on what they are still learning. Show care and compassion to other employers as well as patients. (J.R.Ellis&C.L.Hartley, 2004)

4 Promote Professionalism and trust

Confidentiality

Care

Courage

Empathy

RCN 8 principles

Reference List

 

Understanding Evidence Based Nursing Practice

Course Unit: Understanding Evidence Based Nursing Practice

Section 1:

Nursing research is a systematic inquiry aimed at developing trustworthy evidence to create rationale for evidence-based practice (EBP); EBP is using the best evidence to make patient-care decisions and underpins nursing practice (Polit and Beck, 2018).  In order to deliver high-quality care in an ever-changing society, nurses are required to evolve and develop their care in line with EBP (Ellis, 2016).  The Nursing and Midwifery Council (NMC) (2018, p.6.), states nurses should ‘always practice in line with best evidence’.  A fundamental part of evolving is research, it allows the nurse to question nursing phenomena through critical investigation of evidence which has been evaluated and peer reviewed (Lo-Biondo Wood and Haber, 2017). 

The research process contains multiple components, the first is devising a research question; identifying what is to be researched and formulating a focused question (Parahoo, 2014).  The question forms the foundation of the research and offers the idea which will be examined (Lo-Biondo Wood and Haber, 2017).  For example:

“Is manual handling training more effective than no training at preventing back injuries?”

To assist in this process the use of frameworks such as PICO (population, intervention, comparison, outcome) are used (Figure 1) (Richardson et al., 1995).

Figure 1:

P

Nurses

C

No Training

I

Manual Handling Training

O

Back Injuries

This framework works well with quantitative research, for qualitative research an alternative framework SPICE is preferred, as it allows for perspectives to be incorporated (Booth et al., 2016).  There are also variations of the PICO; PICOT, including time frame, PICOS, including study type and PICo.  The question formulated will decide on the most applicable framework.

From this question clear terms and concepts are defined to reduce the amount of results providing higher quality, relevant evidence (Parahoo, 2014), including synonyms and phrases relating to the key concepts to cover all relevant evidence (Figure 2).

Figure 2:  

Key Concepts

Search Terms

Nurses

Nurses, Nursing, Nurse

Manual handling training

Manual handling training, Moving and handling, Patient handling

No training

No training, No support

Back injuries

Back injuries, Back support, Back pain, Back safety, Lumbar pain, Chronic back pain

Once search terms are identified Boolean logic is applied to best combine the search terms, applying Boolean operators ‘AND’, ‘OR’, ‘NOT’ to a search strategy will define how the databases combine each of the terms within the search, providing more relevant research (Figure 3) (Booth et al., 2016).  The addition of a symbol such as ‘*’ will allow the search of words with the same beginning, i.e. Nurs* will cover nurse, nurses and nursing (Polit and Beck, 2018).

Figure 3:

Manual Handling Training

OR

Moving and Handling

OR

Patient Handling

No Training

OR

No Support

Back Injur*

OR

Back Support

OR

Back Pain

OR

Back Safety

OR

Lumbar Pain

OR

Chronic Back Pain

There are numerous databases to apply the search strategy to, for relevance of nursing research, CINAHL and MEDLINE have been chosen for their credibility, and range of sources (Figure 4) (Booth et al., 2016).

Figure 4:

Search Term

CINAHL

MEDLINE

1.

Nurs*

813,469

793,009

2.

Manual Handling Training

47

43

3.

Moving and Handling

290

824

4.

Manual Handling

5.

Patient Handling

1,523

2,766

6.

No Training

3,826

10,965

7.

No Support

4,699

18,132

8.

Back Injur*

2,838

3,693

9.

Back Support

419

948

10.

Back Pain

33,421

59,792

11.

Back Safety

162

238

12.

Lumbar Pain

2,105

5,905

13.

Chronic Back Pain

5,559

8,901

14.

2 or 3 or 4 or 5

2,252

4,436

15.

6 or 7

8,472

28,983

16.

8 or 9 or 10 or 11 or 12 or 13

36,413

65,480

1 and 14 and 15 and 16

36,448

3

From these results, limits can be set to narrow the search (Figure 5):

Language: English

Source Type: Academic Journals for credibility.

Published from 2014 onwards, ensuring up to date research.

Geography: UK (UK not available on MEDLINE).

Abstract available, allowing a brief overview to assure relevance to research.

Figure 5:

CINAHL

MEDLINE

1,128

879 Results

The filters have brought a more manageable amount of research relevant to the question, saving time when researching.  However, there is still a large amount of research involving patient back pain.  The removal of the following search terms: back pain, lumbar pain and chronic back pain has provided more relevant research relating to the question.

Section 2:

For nurses to be successful evidence-based practitioner’s, critical and analytical ability is vital when completing a systematic review (Ellis, 2016).  This ensures limitations and strengths have been explored, strengths should outweigh the limitations to provide credible research (Coughlan et al., 2013).  This reflects the systematic review aims of summarising the best available evidence (Pearson et al., 2009).

A systematic review will be completed of Rylance et al’s. (2017) quantitative research into ‘mental health students feeling prepared to assess physical health’, using CEBMa’s (2014), critical appraisal tool.

1.

The researchers clearly state within the abstract the aims of the study, further supported through the method of the study; a self-assessment questionnaire relating to competency.  The researcher’s developed a focused question which the PICo framework can be applied; Participants – 3rd year mental health students, Interest – feeling competent to assess physical health, Context – during their 3rd year of their studies.  The formulation of the question using a framework allows the researchers to choose the appropriate design method for their study (Lo-Biondo Wood and Haber, 2017). 

Within the aims section, the objectives are reinforced using one unambiguous sentence, displaying clear intentions of the study to the reader (Nieswiadomy, 2012).  Also, within the findings section the results reflect the aims, the questions are related to competency of physical assessment skills.

2.

Research methods are the ‘blueprint’ of the study, they decide how research will be conducted and how data will be gathered (Coughlan et al., 2013).  They should be detailed within the methods section, including why the researcher has chosen the particular design (Gray et al., 2017).

The researchers state questionnaires were used, mainly for the ease of utility.  The study was noninterventional research attempting to describe the variables, as opposed to correlational research which attempts to describe relationships amongst variables (Gray et al., 2017).  Noninterventional research only provides information on the variables as they occur, causality cannot be established (Coughlan et al., 2013).  The researchers intended to gather information surrounding students who did or did not feel prepared to assess physical health, there is no comparison and no causality, leading to the decision of a descriptive design (Gray et al., 2017).  Their intentions are to measure and retrieve data relating to competency, thus the research method an appropriate choice for the study.  However, the research question contains the word ‘feel’ suggesting qualitative research, also the use of open-ended questions.  This type of information gathering is more relevant to qualitative research, as it is an attempt to explore meaning within the phenomena (Aveyard, 2019).

3.

An important aspect when designing a study is the sample size, too small can be difficult to generalise the findings and too large can become timely and costly research (Parahoo, 2014).

The researchers state an opportunist sample was used, a type of non-probability sampling method; meaning the sample was selected using the most convenient people, two cohorts of mental health nursing students at one University.  Using this type of sampling method can lead to the sample being atypical of the population, not representative (Polit and Beck, 2018).  Opportunist sampling is one of the weakest forms of sampling, although one of the most common, due to its ease and cost-effectiveness (Elfil and Negida, 2017).

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The researchers fail to mention how many questionnaires were sent out, nevertheless, report 37 questionnaires were completed.  This is a small sample size and cannot be generalised to the wider population of mental health nurses.  Furthermore, the sample was taken from one University, a cross-sectional sample; aiming to provide a snapshot of the wider population, in this case mental health nurses; issues may arise from this form of sampling as it is not possible to distribute the questionnaire to an entirely representative sample (Aveyard, 2019).  Given the researchers have not informed the reader of the response rate, it is difficult to analyse and non-response bias cannot be reported.  The researchers acknowledge the findings cannot be generalised, accepting nursing programmes and placements differ across the country and suggest further research is necessary. 

Consent was gained from the University, prior to the research commencing.  As such, the research will have been reviewed by the University in line with the Ethical Research Standards (WHO, 2011).  The researchers kept all data anonymised in line with the protection of human rights, protecting confidentiality and anonymity (Lo-Biondo Wood and Haber, 2017). 

4.

Quantitative research is underpinned by positivism, based on scientific laws and truths which emerge from research that is observed and measured (Gerrish and Lathlean, 2015).  Findings from research with minimal or no bias hold greater validity (Gerrish and Lathlean, 2015). 

As previously discussed, selection bias occurred through the non-probability sample method used, thus reducing reliability.  In contrast, the researchers were unknown to the participants and their involvement was voluntary, consequently reducing bias.

5.

In quantitative research a sample must be valid in order to generalise the findings (Wilson, 2014).  The sample refers to those who took part in the research, they should be a group of people who represent the population the research relates to (Aveyard, 2019), meaning the findings can be generalised to the wider population providing higher validity.  Mental health nurses were chosen as the sample, which represents the relative population, however, data was only collected from two cohorts at one University, reducing reliability as the findings cannot be generalised to other mental health nursing students who attended other Universities where training may differ.

6.

To gain higher validity, it is possible for researchers to conduct a power analysis prior to the research (Polit and Beck, 2018), where a sample size estimation is made increasing validity of the research.  Analysis of this method shows limitations; power analyses are unable to tell the researcher whether the study is appropriately powered or not as it is based on the notion of study replications (Taylor and Spurlock, 2018).  Meaning that the power analysis is based on what the researcher already presumes.  Furthermore, it is problematic for the researcher to foresee and include all factors which will affect the power analysis (Taylor and Spurlock, 2018).

Within the paper the researchers fail to mention statistical power, implying this method was not used.  This increases the risk of statistical conclusion validity being wrong, the data cannot support the hypotheses even if proven (Polit and Beck, 2018).

7.

Response rate is the number of participant’s who respond from the sample.  The higher the response rate, the more likely the sample is representative of the target population (Parahoo, 2014).  Following this, those that don’t respond can have different characteristics or interests than those that do, producing response bias.  The research should inform the reader of the response rate as well as acknowledging response bias (Polit and Beck, 2018).

The research does not mention response rate within the paper, only the total completed.  This makes it difficult to make assumptions that the findings represent the target population.

8.

For questionnaires to be of any use within research, they need to produce valid and reliable data.  Validity relates to the questionnaire asking and finding out information relating to the aims of the study (Parahoo, 2014).  Reliability relates to the participant’s understanding of the questions and responding to them in the same way. (Parahoo, 2014).

The researchers asked closed-questions relating to competencies i.e. taking temperature, with the answers ‘yes’, ‘no’ or ‘not relevant to my role’.  The questions relate to the research question and adequately represent the concepts which are being studied.  Furthermore, participants were asked additional open-ended questions relating to the research question i.e. ‘Do you feel that the range of clinical experiences that you have undertaken during your training has influenced your answers?’.  This form of open-ended questioning collects qualitative data, as the process of gathering information involves clustering similar types of answers given through analysis and interpretation of the researcher (Polit and Beck, 2018).

Whilst the closed-questions were clear and unambiguous, response was limited to two answers whereas a scale of competence could have been used providing a more detailed range of response e.g. Like-RT type scale (Gray et al., 2017).  The open-questions were also clear and unambiguous and trends appeared in the responses indicating the participants interpreted the questions similarly.  This concludes the questionnaire holds reliability.  However, the questionnaire includes qualitative methodology and mixes the two methods.

 

9.

Statistical significance relates to hypotheses testing, when the results of a study are unlikely to have occurred by chance at a specified level of probability, pnull hypothesis is true, attempting to disprove this through research (Aveyard, 2019). 

There was no null hypothesis used, as previous studies indicated mental health students lacked competency in assessing physical health.  Therefore, it is impossible to assess statistical significance.

10.

Another way to assess the generalisability of research is to calculate confidence intervals (CI) (Aveyard, 2019).  CI are a range of values based on the sample population, which estimates the precision of the findings applied to the wider population (Lo-Biondo Wood and Haber, 2017).  A larger sample size will effectively create a more precise CI, 95% or above is the threshold; supporting the generalisation of the findings to the target population (Jirojwong et al., 2014).  The researchers did not account for CI.

 

11.

Descriptive quantitative research is concerned with an occurrence of a phenomenon of interest, to make generalisations research needs to be valid, reliable and minimal bias (Gray et al., 2017).  As previously discussed, the findings cannot be generalised to the wider population due to sample bias.  There are no p values or CI mentioned within the paper, again generalisations cannot be made.  If research was conducted at multiple Universities, generalisations could be made from wider range data.  Nevertheless, the methodology was valid and reliable, and all participants received the questionnaire in the same format adding some internal validity.  Assumptions

cannot be made from this research and further investigation is needed.

 

12.

The conclusions of the study was that further research is required, applying this research to another organisation when it is incomplete and unvalidated would be imprudent.  The participants are enrolled on a particular degree course, there is no guarantee that students are receiving the same education from other institutions. 

Aveyard, H. (2019). Doing a Literature Review in Health and Social Care. 4th ed. Berkshire: Open University Press.

Booth, A., Sutton, A. and Papaioannou, D. (2016). Systematic Approaches to a Successful Literature Review. 2nd ed. London: Sage.

Centre for Evidence Based Management. (2014). Critical Appraisal Checklist for Cross-Sectional Study. Available at https://www.cebma.org (accessed 14th January 2019.)

Coughlan, M., Cronin, P. and Ryan, F. (2013). Doing a Literature Review in Health and Social Care. London: Sage.

Elfil, M. and Negida, A. (2017). Sampling Methods in Clinical Research. Emergency (Tehran). 5 (1), pp. e52. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5325924/.

Ellis, P. (2016). Evidence-based Practice in Nursing. 3rd ed. London: Sage.

Gerrish, K. and Lathlean, J. (2015). The Research Process in Nursing. 7th ed. Chichester: Wiley Blackwell.

Gray, J., Grove., S and Sutherland, S. (2017). The Practice of nursing Research: Appraisal, Synthesis and Generation of Evidence. 9th ed. Missouri: Elsevier.

Jirojwong, S., Johnson, M. and Welch, A. (2014). Research Methods in Nursing and Midwifery: Pathways to Evidence-Based Practice. 2nd ed. Oxford: Oxford University Press.

Lo-Biondo Wood, G. and Haber, J. (2017). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 9th ed. Missouri: Elsevier.

Nieswiadomy, R. (2012). Foundations of Nursing Research. London; Pearson.

Nursing and Midwifery Council. (2018). The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: Nursing and Midwifery Council. Oxford: Blackwell Publishing.

Parahoo, K. (2014). Nursing Research: Principles, Process and Issues. 3rd ed. Hampshire: Palgrave Macmillan.

Pearson, A., Field, J. and Jordan, Z. (2009). Evidence-Based Clinical Practice in Nursing and Health Care: Assimilating Research, experience and Expertise.

Polit, D. and Beck, C. (2018). Essentials of Nursing Research: Appraising Evidence for Nursing Practice. 9th ed. Philadelphia: Lippincott Williams & Wilkins.

Richardson, W., Wilson, M., Nishikawa, J. and Hayward, R. (1995). The Well-built Clinical Question: A Key to Evidence-Based Decisions. Annals of Internal Medicine. 123 (3), pp. A12. DOI: 10.7326/ACPJC-1995-12303-A12.

Rylance, R., Daye, S., Chiocchi, A., Jones, A., Jones, G., Harper, A., Potter, M., Reece, C. and Caldwell, K. (2017). Do third-year mental health nursing students feel prepared to assess physical health? Mental Health Practice. 20 (10), pp. 26-30. DOI: 10.7748/mhp.2017.e1147.

Taylor, J. and Spurlock, D. (2018). Statistical Power in Nursing Education Research/ The Journal of Nursing Education. 57 (5), pp. 262 – 264. DOI: 10.3928/010484834-20180420-02.

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Evidence Based Care: Hand Hygiene

Utilising Evidence Based Care
This essay endeavours to investigate hand hygiene, and feel I need to gain more knowledge in this field by utilising the available evidence effectively. I also intend to discuss nurse held traditions, customs and rituals.
The common method of handwasing is usually with unmedicated soaps, whist an anti-bacterial soap may be used for total hand decontamination. (Hugonnet & Pittet 2000). As nursing staff can wash their hands up to forty times per hour, it may be one of the most frequently practiced nursing skills (National Patient Safety Agency, 2004). According to Pittet (2000) healthcare professionals barely reach fifty per cent compliance with handwashing. Holland, Jenkins, Soloman et al (2003) point out that hands are the primary factor is spreading bacteria, especially as they come into contact with body fluids, furniture, dressings and equiptment.

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During a placement on a surgical ward I witnessed poor hand hygiene and felt I needed to deepen my knowledge of effective and appropriate hand washing to be a competent, safe practitioner. Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure against transmission of hospital acquired infection between patient to patient (Gould et al (2007). As a health care professional I am aware I must work within the guidelines of the Nursing and Midwifery Council (NMC) and the government body, the Department of Health (DoH). Within this essay I intend to utilise two sources of research, critique them, and use the findings accordingly.
The Nursing and Midwifery Council Code of Conduct (2008) states that ‘care and advice to patients must be based on the best available evidence’ (NMC 2008 p4). Fitzpatrick (2007) states ‘healthcare professionals must demonstrate effective integration of evidence, including findings of research into their decision making.
‘Evidence based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available clinical evidence from systematic research ‘Sackett et al (1996).
Within evidence available for utilisation is an evidence hierarchy. At the top of the hierarchy are well designed randomised controlled trials. The UK Cochrane Centre specialises in random controlled controlled trials (RCTs). The Cochrane centre operates globally to maintain and publish up to date reviews of randomised controlled tests for health care. (Sheldon and Chalmers 1994). Hamer (1999a) also states that randomised controlled trials (RCTs) are frequently called the gold standard of research evidence. The Cochrane Centre work out the validity of research by grading them. Grading starts at A-C, A being the highest score, and showing it has met all the quality requirements (Mulrow & Oxman, (1997). Hierarchies are also used in clinical guidelines, graded by both standard of evidence and recommendations. The highest standard of evidence grade, matched by the highest recommendation grade, suggests superior validity and ought to be considered to be implemented in practice (Cook et al, 1992)
Research evidence appropriateness can be based on how the data was collected. Examples of different research designs are RCTS, case-controlled studies, cohort studies, professional, or qualitive. The two research paper I am examining use a mix of methods.
Lockett (1997) claims evidence-based practice is a combination of scientific and professional practices. The ‘evidence -based’ aspect refers to scientific rationale and the ‘practice’ part refers to behaviour of the healthcare professional (Lockett 1997). The importance of evidence -based practice is highlighted by Hamer (1999b), stating the primary aim is to aid professionals in effective decision making to reduce ineffective, inappropriate possible hazardous practices. This would suggest, as with guidelines set out by the NMC that the use of evidence-based practice has much rationale. The American Nurses Association (2003) points out that in order to enable nurses to tally with the expectations of society, a strong evidence base for practice is essential. Furthermore, for nursing to be recognised a genuine profession, it is essential to have all of its practices based on evidence (Royal College of Nursing 1982).
Once a topic had been chosen to explore I conducted a search via databases. I found initially to use solely the term handwashing, which yielded a surplus of data.
I set the date parameters on the search to the last 5 years to maximise the validity of the research, which not only provided more suitable data, but narrowed the search to yield less results. This facilitated the search for relevant research. I added other words to the search, such as compliance and the word and/or. Also truncation was used, this maximised the search further. Especially as there are many variations of the work handwashing. Furthermore, handwashing was not the only term used to describe handwashing, hand hygiene was also used. This too, yielded successful results. The term nurse was also added, this too was truncated to nurs*, which allowed terms such as nursing, nurses, nursed to be detected, thus increasing the probability of locating the desired results. I set the parameters to detect full text and on the English language.
As I am not accustomed to using databases I sought the advice of the librarian, EBSCO, CINAHL and BNI were recommended resources. Also the Cochrane library has been praised as the gold standard in randomised controlled studies. As randomised controlled studies are at the top of the hierarchy of evidence I decided to seek a randomised controlled study. I found located the primary piece of evidence from the Cochrane library.
On this occasion I did not use main stream search engines, although I would consider using a search engine in the future to find research. Fitzpatrick (2007) claims internet searches engines can yield credible results.
My second piece of research was discovered on Ovid. Once selected, Ovid requires users to select databases within that database. I excluded paediatrics as this was not relevant to the search.
|Interventions to improve hand hygiene compliance in patient care conducted by Gould (2007) is the selected primary source.
The quality of the abstract was clear, with sub heading, and reflected the aim of the paper and its content. The objectives were to assess the long term success and improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene can lower hospital infections. This was relevant to my search as this is an area I wanted to increase my knowledge on, and utilise in practice, if the research is deemed valid and credible.
The types of studies used were randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analyses (ITSs) meeting the requirements of the Cochrane Effective Practice and Organisation of Care Group (EPOC).The research is a systematic review. According to Mulrow (1995) systematic reviews do the ‘hard work’ of critiquing the research so time limited health care workers can access valid data. Systematic reviews are the gold standard of research (NHS Centre for reviews and Dissemination, p.1 1996):
‘Systematic reviews locate, appraise and synthesis evidence from scientific studies in order to provide informatative, empirical answers to scientific research questions.’
Muir & Gray (1997) and Sackett et al (1997) claim randomised controlled trials are thought to be the most dependable and trustworthy source of evidence.
I interpret the above as indicting the research may be of a high standard to meet the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC). Although the research paper is not yet fully critiqued, this is a positive validity indicator.
The participants were target groups, of doctors and nurse. Theatre staffs were excluded due to different hand hygiene techniques being used. To exclude theatre staff was relevant as hand hygiene is part of the ‘scrubbing in’ ritual, and if included may have caused inaccurate results.
Data collection and analysis was conducted by two reviews, and they accessed the data quality. All of the data they had gathered was via databases searches, and two studies out of over seventy five met the criteria review.
The author concluded no implications for practice, as the review had not been able to provide enough evidence. The implications for research were more studies are urgently needed to evaluate improvements to hand hygiene. The biasness of the paper is not easy to find out as I could not discover the professions of the researchers. It could be suggested that if they were nurses, this could create a potential for bias.
When searching for this primary piece of research I did not need to be concerned about UK and American spellings are the words used did not have UK & American versions. However in future I would chose to look for both to show abundant data. The keywords used for finding this particular piece were, hand*, hygiene, wash*, comlianc*, concordanc* and nurs*.
Quantitive research sample sizes normally exceed one hundred participants. Interviews or questionnaire have set questions. Data is usually recording statistically (Siviter 2005). The data within this research was presented in tabular form. The CASP (2006) quantitive tool was utilised in the critiquing of this research. Had the research paper been qualitive, I would have used the CASP quantitive tool. This is a valuable and effective tool in analysing the research for strengths and weaknesses (Hek & Moule 2006). Although on this occasion I used CASP to critique the paper I would in future consider using other critiquing frameworks, such as Bray and Rees (1995) and Benton and Cormack (2000) or Popay et al (1998).
As to if the research was ethical or not is indistinguishable as no consent issues arose as all evidence was found via databases. Although, consensual issues are not the only ethical issues to be considered. Beauchamp & Childress (1994) claim healthcare ethics is when moral issues and questions are raised within the healthcare realm. Respect to an individual values and beliefs are a part of being ethical. However in terms of the primary research paper there are no visible signs of a breach of ethics.
The results show that both the randomised controlled trials were poorly controlled. One trail shows an increase in hand washing compliance four months after interventions. The second trail has shown no post intervention increase in hand hygiene. The author found both samples were of low quality and was conducted over a too small time frame.
The author concludes there is not any strong evidence to make an informed choice to better hand washing. According to the author, one off teaching sessions will not expected to make any lasting changes to compliance. Further robust research is recommended by the author. Therefore, currently from this research there is inadequate data that could be utilised in evidence-based practice.
‘Hand hygiene practices: student perceptions’ is the second piece of research chosen. This is a qualitive piece of research.
The aim of the research was clear from the abstract and the title. Student nurses were interviewed to gain depth of data. Student nurses were also guaranteed anomity, which may have assisted the researcher gain rich data. Had the researcher chose a quantitive methodology, it would have been complex to achieve student’s perspectives. The NMC (2008) praises qualitive research methods as they respect patient’s individuality and feelings in the way nursing staff are presumed to, and is suitable for nursing research. According to Parahoo (2006), qualitive research may be considered to be of less value than quantitive research. Another positive aspect of qualitive research is the broad picture it provides, history, context, and the causes ( Blaxter, Hughes & Tight, 2006). Siviter (2005) defines the average qualitive research sample size as fairly small, with an average of fifteen to twenty. Data is usually gathered through semi-structured interviews and open ended questions.
The researchers who conducted the research are both nurses and have a professional interest in the paper, and it is noted that the possibility of bias could occur. This was recognised by the nurse researchers.
Evan (2003) Hierarchy of evidence concludes case studies lack validity in comparison to random controlled trials and systemic reviews.
A barrier to utilising research to support evidence-based practice may be lack of knowledge and skill. Hundley et al (2000) noted that although attempts are being made to incorporate research education into current nurse curriculum, poor analysis skills are still a barrier to reading research. Hundley et al (2000) also states time is a primary barrier to utilising evidence-based practice. Retsas (2000) offers advice in conquering the time barrier, advising organisations need to increase time to study in order for evidence-based practice to be achieved. Issues with autonomy, or lack of, have been suggested as potential barriers in the implementation of nursing research. Doctors were named as a potentially obstructive (Lacey 1994). Shaw et al (2005) suggest that to know and understand possible barrier and enablers to utilising evidence is critical in the identification of evidence-practice gaps. Grol and Wensing (2004) discuss the many different enablers and barriers that might be found when change is attempted to be implemented. These range from awareness, knowledge, motivation to change and behavioural routines (Grol and Wensing 2004).
Traditional rituals within nursing are a barrier to implementing evidence -based practice. Walsh and Ford (1990) define rituals as:
‘Ritual action implies carrying out a task without thinking it through in a problem-solving way. The nurse does something because this is the way it has always been done. The nurse does not have to think about the problem and work out an individual solution, the action is a ritual’.
Billy and Wright (1997) defend rituals, claiming some are healing, and have some positive outcomes. Parahoo (2006b) argues that rituals are when practice rationale is forgotten. Thompson (1998) discusses the research-practice gap, claiming there is a gap between knowledge and practice. This would indicate there is a gap between producers and users of research (Caplan 1982).Larsen et al (2002) argues that the research-practice gap does not exist in nursing as it is not an evidence-based profession. One way of passing on the message of evidence-based practice is through clinical guidelines. Woolf et al (1999) clinical guidelines improve quality of decisions made by healthcare professionals, although a downfall may be recommendations are wrongly interpreted.
A First Class Service (Department of Health, 1998) summarizes the government ideas for improving evidence base, and how to implement the findings. This indicates the government’s recognition of the benefits to quality of care, and its links to evidence-based practice. Since then the government has included evidence-based practice in its strategies, such as NHS Research and Development in 1992 and Making a Difference in 1999. Evidence-based healthcare was at the core of these strategies (Department of Health, 1992). In the North Bristol Trust the ‘Clean your Hands’ campaign is in use. This was implemented by The National Patient Safety Agency; Alcohol gels were put all around the trust, in an attempt to make hand hygiene facilities more accessible. Nursing staff also wore ‘it’s ok to ask badges’; encouraging patients to remind busy staff to wash their hands (Infection Control Policy and Manual North Bristol Trust, 2006).
In conclusion I have learnt there is a colossal sum of research to be potentially be utilised in practice. From accessing valid data, to having the time to critique research once in practice, to trying to implement change when in practice, I have realised there are many obstacles to achieving evidence-based practice.
Research should always be analysed to establish whether or not the data it produces is valid and if it ought to be implemented in practice or not. From the two research papers I have analysed I found that neither were valid enough to consider implementing in practice. I have also learnt that change within health care is not as easy to implement as I have previously thought, many parts of the interprofessional team must be involved. Managers are key to helping change take place. I do still believe that effective handwashing is definitely one of the most effective measures in the role of infection control. A valid, robust research paper on this essential nursing skill would aid effective hand hygiene, as currently many research paper out there do not make the grade for them to be implemented in practice.
From this I have learned a valuable lesson that just because research is there, does not necessarily make it credible and valuable.
Reference
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Neoproterozoic in Britain and Evidence for the Hypothesis Snowball Earth

To what extent does Britain’s rock successions during the Neoproterozoic provide evidence for ‘Snowball Earth’, and how reliable is it?

Abstract

Geologic, stratigraphic, palaeomagnetic and geochemical observations have been interpreted to suggest extreme and global glacial events followed by just as severe hothouse conditions (snowball earth hypothesis).  This hypothesis has resulted in much debate, creating discussions regarding the focuses on these various approaches towards research about the existence of a snowball earth. This in turn has developed a somewhat reliable conclusion.  The Port Askaig formation of Scotland is a rock succession in the Argyll super group consisting of diamictite, sandstone, conglomerate and mudstone, all recording glacial conditions in the Dalradian basin. This essay focuses on data collected for the Neoproterozoic in Britain (particularly Scotland) and how reliable the evidence is for the hypothesis snowball earth.

Introduction

When looking back through the geological record, there are substantial changes to the paleoenvironment throughout the Proterozoic. This is shown specifically in the Neoproterozoic, illustrating widespread glaciation followed by warm conditions and major global carbon fluctuations. With regards to the snowball hypotheses, a more recent proposal suggests that there were a number or global glaciation events followed by hot conditions. Data collected at the Port Askaig formation indicates that there is a contradiction between climate and the deposition of sedimentary rocks related to these areas. At the base of the Argyll group and within the Dalradian super group in the Neoproterozoic there are varying deposits. These deposits are mainly diamictite which are also found in other continents and major cratonic regions during this depositional period (Kirschivink, 1992). Using Britain as an example, explicitly the Port Askaig formation, this report will discuss the reliability of the Snowball Earth Hypothesis (first proposed by Joseph L. Kirschivink) by focusing on depositions of glacial deposits in Scotland when located around the equator during the last era of the Precambrian.

Setting the scene

Glaciers flowed throughout the Proterozoic sea, even in the tropics. Debris churned out from these glaciers which then settled on the sea floor thus enabling the switch of climate. This means that carbonate rock was set to deposit on the glacial detritus. During this period of climate, flipping life had seemed to almost completely vanish. Iron deposits completely disappeared by the earth’s new abundant oxygen, reappearing for the last time in the late Neoproterozoic. This is a somewhat helpful aspect when carrying out palaeomagnetic research. Evolution had been stagnating for billions of years, yet proceeding this occurrence, all basic body plans of animals suddenly emerged. Scientists have gone back and forth on the hypothesis known as ‘Snowball earth’, studying the Proterozoic eon in great depth in order to understand what really happened during this time. The theory suggests that there were at least two global ice ages which almost destroyed the very existence of life itself. With evidence for palaeomagnetism signifying that the line of ice was almost equal with sea level and thus close to the equator (Hoffman, 1998), there is significant implication that there were abrupt changes that allowed global warming to turn the earth into a hot mess.

Discussion

Rock Type:

The Port Askaig formation is a thick sedimentary succession abundant in soft sediment deformation features (possibly related to episodic events). This is seen as predominantly marine found in the Argyll super group. The unit consists of poorly sorted Diamictites, cross bedded sandstone with laminations, angular clastic conglomerate and laminated mudstone. This sequence can be located in other continents which would have sat in a similar location in relation to the equator during the late Precambrian whilst the Iapetus Ocean still existed. The different units of the formation are easily identifiable and can be interpreted to show the severe changes in climate during the Neoproterozoic. The Diamictites unit could illustrate a glacially influenced marine setting, possibly relating the conglomerate layer from gravity flows or from other unidirectional currents.

The base section of the Port Askaig unit of sandstone includes that sedimentary structure of particularly large cross bedding, individually reaching 11m thick and with a maximum dip of 14’. This sandstone is seen to be quarzitic, well sorted and medium grained, which helps to illustrate a southern paleocurrent direction in the internal structure of the cross beds (Arnmaud Emmanuelle, 2003). Due to this structure, it becomes clear that this bedding is from the migration in a subaqueous marine environment. Some sections of the structure indicate that there is an association between the unidirectional current and a tidal setting wherein no ice is present. However, referring to the Diamictite and conglomerate including in this succession would indicate ice advancing and retrograding. When associating this inconsistency with snowball earth, it can be seen as contradictory as there is no proven section that confirms the idea of a severe and prolonged global freezing that is followed by rapid heating.

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The exposed succession seen at the Garvellach Islands records 28 glacial, 25 periglacial and 23 non-glacial episodes. The Argyll group shows something different; 7km thick quartzite with accommodation space created rapidly (Dishad O. Ali, 2017).  Diamictite units are attributed by sediment gravity flow processes as previously stated and so this could also indicate that there was possible heavy precipitation. This created a flow of fine grained sediment and debris carried by ice in a glacial marine setting.  Using the work of Emmanuelle Arnmaud 2003-2005 which explores stratigraphic analysis of these islands, it appears that the depositional period can be split into three phases; phase one being dominated by sedimentary flow processes and tectonically controlled sedimentation, phase two seen as transitional, characterized by continued tectonic instability, increasing supply of sand to the basin and preservation of facies, and the final phase demonstrating interbedded sandstone and diamictite layer, illustrating the development of the sand bed forms with ice margin fluctuations in a tectonically stable marine setting.

The stratigraphic and sedimentological analysis of the Port Askaig deposits best exposed on the Garvellach islands, has enabled the establishment of the palaeoenvironmental change during the Neoproterozoic. This research allowed for an understanding of the tectonic activity and how it had significantly influenced the lowermost part of the succession. However, due to this activity it is made much harder to identify the climatic influences. The thick succession of diamictite interbedded with current-deposited sandstone preserved within the Port Askaig Formation is not consistent with deep freeze conditions proposed by the snowball Earth hypothesis.

Tectonics:

The Dalradian group is associated with the breakup of Rodinia through the rifting of plates (Dalziel, Soper, 2001). There is some disagreement on this matter. The research of [INSERT NAME] suggests that it is more likely related to the accumulation of the super group in a foreland basin associated with the Riphean orogenesis due to extensional tectonic activity.               Seen in Figure 2 you can see the abrupt changes of facies likely due to synsedimentary faulting, with possible events of folding, the fining upwards would also indicate the basin filling upwards as well as earthquake induced liquefaction (mainly seen in the quartzite).  However, there is contradictory beliefs thaht there is significant extensional tectonic activity, which had been building up before the Iapetus Ocean had opened. Association with localised faulting has been made in the lower Islay subgroup (Port Askaig and Jura Quartzite) due to the varying thicknesses (Anderton, 1982). With regards to the Conglomerate, it is more than likely a fault generated deposit due to its angular fragment nature, overlain by turbidite facies fining upwards which could be interpreted as basin subsidence and sub-basin differentiation. Eventually this tectonic activity in the basin led to the extrusion of the volcanic layer and the opening of the Iapetus Ocean.

Using the lithological correlation with glacigenic deposits elsewhere in north Atlantic region, the port Askaig formation has long been thought to record glacial conditions (Spencer 1975). In addition, the recent discovery of glaciomarine drop stone horizons overlying the Port Askaig Formation in Ireland and the isotopic signature of ‘cap’ carbonate associated with the Port Askaig Formation, suggest these glacigenic deposits are more likely record an earlier glaciation. This could have been 717-643Ma during the Cryogenian period (Condon and Prave, 2000, Brasier and Shields, 2000).

Palaeo-latitude:

A quantitive basis has been provided by palaeomagnetic data collected from the glaciogenic deposits found in the Port Askaig formation. Recent data of depositional latitudes have created a trend found most dominant near the palaeo-equator (Evans, 2003).  However, the actual palaeo-latitude of the Dalradian basin is still subject to some debate due to the remagnetization of deposits during the Caledonian orogeny (Stupavsky, 1982). This sparked uncertainty of the location of this Scottish region during the Neoproterozoic. However, the data collected from palaeomagnetism and palaeo-latitudes neither supports the entire theory of snowball earth nor rejects it. This research does not contribute much to the theory but despite not being completely certain when accepting the idea that Scotland once sat along the equator, it does reinforce the idea that there were glacial events in warmer parts of the world. If it was indeed situated along the equator this would support the theory of a globally iced over earth. The direct observations of high quantities of carbon fragments in some diamictite beds would imply the ice must have somehow moved across carbonate platforms. Specific carbonate sequences are limited to around 33’ of the equator (Ziegler, 1984), therefore meaning ice would have been present here.

Chemostratigraphy:

The use of new carbonate 87Sr/86Sr data helps to comprehend environmental and climatic change thus allowing further insight into the controversial hypothesis of snowball earth. Certain beds in the Dalradian super group, particularly the limestone, contain specific mineral levels making them ideal for this type of testing. The limestones within the Port Askaig formation are the lowest levels in the entire super group. These levels match elsewhere in the world which date to the Cryogenian glaciation (Citation), therefore reinforcing the theory that the Port Askaig succession was deposited during this glaciation period. Research has enabled the reflection on the 87Sr/86Sr ratio of seawater decrease, before the older glaciation period of the cryogenic can be associated with the breakup of Rodinia due to the enhancement of weathering. In addition, the carbon found in the diamictites provides a means of determining where Scotland was positioned during this time to paleo-latitudes as previous stated.

Results

When gathering all factors from geology, tectonics, palaeomagnetism and chemostratigraphy, it is clear to see that the Port Askaig formation provides an encompassing view of the events during the Neoproterozoic. It illustrates a number of glacial periods which contain time gaps between beds with some folding that in turn suggest erosional periods and tectonic behaviours.

Three phases have been made apparent by the stratigraphic research, identifying as sediment gravity flows (phase 1), later ice free stage (phase 2) and current dominated conditions alternating with glacially influenced sedimentation (phase 3). Phase one and two appear to be tectonically influenced despite climatic impacts on sedimentation, possibly being obscured by the predominance of sediment gravity flow processes. Phase three however, seems to be the only phase that can identify glacial influences as tectonics do not seem to be an asset during this time. Neither do they alter the record such as is the case in the other two phases, thus they make the sea level changes related to ice margin fluctuations apparent in this section.

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 The analysis from sedimentologists have allowed us to understand such activity through the actual geology and structural research. Giant cross beds within the upper section are likely formed as a result of the migration of large subaqueous sand dunes, almost certainly due to open tidal currents. The conglomerate infers localised tectonic activity with the disruption of beds and deformation features and possible periodic seismic activity. Many of the diamictite units were formed as a result of subaqueous debris flows which are often associated with a glacial environment. Other diamictite beds could be formed within glacial influenced rainout deposits. Both diamictite units containing few dropstones which despite being rather rare in this succession suggests a presence of floating ice in the basin. The sandstone and mudstones, have been described as sediment flow settling or possible current-dominated subaqueous conditions.  The entire unit indicates the abrupt changes in climate. When correlating this stratigraphic data alongside paleo-latitudes it reinforces the idea of global episodic events thus accepting the concept of snowball earth.

Conclusion

When concluding it is rather important to establish the significance of the Neoproterozoic glacial episode, it marks a major turning point in the evolution of life. With life almost completely vanishing due to the abrupt changes in climate, without the research into the Argyll super group this would still be a question today. However, using the Port Askaig formation in Scotland it illustrates the nature of the environmental changes that transpired. The succession of diamictites, conglomerates, sandstones and mudstones were all deposited by various processes which indicate this sub-era experienced a glacially and tectonically influenced marine setting. With the amounting evidence gathered by varying scientific researchers throughout a vast field of work, evidence seems to point to the idea that there was a number of global glacial periods, in fact accepting the snowball earth hypothesis rather than discrediting it. However, I regard the gathered information that has been displayed in this report as evident of a snowball earth period. What has been made overt in this paper is that evidence suggests the presence of ‘ice age’ periods, though they would not necessarily be considered as extreme as first suggested by  J.L Kirschvink. The reliability of palaeolatitude evidence depends on the palaeomagnetic data quality but also the confidence in chronostratigraphic correlations.

Strata from the Neoproterozoic is spread across several regions with units sharing an overall similar lithology, all showing fluctuating climate records which would therefore be a result of global scale climate fluctuations. The ice which once drifted across the ocean separating ocean currents and the fetch therefore reducing evaporation. Occurring as they obstruct the exchange between oceanic to atmospheric oxygen, in turn creating anoxicity in the lower ocean waters. Eventually from leaching and creation of mid oceanic ridges ferrous iron was generated would build up due to solution. As the glacial period became to an end circulation of the oceanic waters generated once again enabling iron to oxidized, coming back one last time as banded iron deposits.

Bibliography

Anderton, 1982. Dalradian deposition and the late Precambrian-Cambrian history of the North Atlantic region: a review of the early evolution of the Iapetus Ocean, s.l.: Journal of the Geological Society (London).

Anderton, 1985. Sedimentation and tectonics in the Scottish Dalradian, s.l.: Scottish Journal of Geology.

Arnaud, E., 2003. Giant cross-beds in the Neoproterozoic Port Askaig Formation, Scotland: implications for snowball earth, s.l.: Department of Land Resource Science, University of Guelph.

Eyles, E. A. a., 2002. Catastrophic mass failure of a Neoproteozoic glacially-influenced continental margin, the Great Breccia, Port Askaig Formation, Scotland, s.l.: Sedimentary Geology.

Kerr, R. A., 2000. An Appealing Snowball Earth That’s Still Hard To Swallow. In: Science, New Series Vol. 287 No. 5459. s.l.:American Association for the advancement of science.

Kirschivink, J. L., 1992. Late Proterozoic low-latitude global glaciation: the snowball Earth. s.l.:Cambridge University Press.

Paul F. Hoffman, A. J. K. G. P. H. D. P. S., 1998. A Neoproterozoic Snowball Earth, s.l.: American Assosication for the Advancement of Science.

Differences between QI, EBP, and Research Evidence

Abstract

Nurses must know the difference between Quality Improvement, Evidence-Based Practice, and Original Research Evidence because they must know what they are reading how each one can best be utilized to improve patient care, quality of care, the profession as a whole, and finally the overall field of medicine. Each concept can be best applied in many different fields of nursing. Nurses working in the varying positions can each have a long-lasting impact if they know each research concept and how best to apply the data supplied by those concepts.

Keywords: Quality Improvement, QI, Evidence-Based Practice, EBP, Original Research

Introduction

 Nursing is a multi-faceted profession, one that contains abilities that lay far beyond what the layman believes a nurse to be trained and educated to do One of the facets that belong in the nursing repertoire is understanding research. A nurse must understand research but a nurse must also know the differences between the varying types of research there is. Understanding the differences in research widens the scope of medical comprehension for the nurse but it also has a direct impact on the nurses’ patients, colleagues, and the institution in which they are employed.

Significance and Background

 When nursing began it was not what it is today. Nurses were responsible for taking care of the sick or injured. Rolling bandages and changing the dressings on wounds may have been what nurses started out doing but the profession has expanded and has become a necessary and very important part of the medical field. Now, nurses are the eyes and ears for doctors. They spend time getting to know their patients, and there are instances of nurses catching things that doctors miss, saving the lives of their patients. They are the front line, every day, working to save lives and prevent the spread of disease.

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 Nurses must be able to understand research and be able to interpret the varying types of research so that the information gathered and learned can be applied in a clinical setting in order to increase their abilities and the to improve the care their patients receive. The ever increasing medical education of nurses goes hand-in-hand with medical research. No matter ones profession in the medical field, continuing education is not only necessary it is paramount to the applicability of the latest medical findings.

Quality Improvement

 Quality improvement or QI is when a nurse uses data to evaluate and monitor the outcome of care provided to a patient (or patients) while additionally using said data to improve upon varying methods of care and testing the changes in order to improve the care patients receive as well as improving the overall health care system. The main understanding of what QI is, is in the very name itself, quality improvement. The quality of care being received by patients and the quality of that care’s impact on the overall medical field is something that must be continuously improved upon. If data shows there is a need for improvement, nurses are able to make necessary adjustments or they are able to recommend the necessary adjustments in order for quality to improve. Quality of care has a large and lasting impact across the board in regards to health care.

 Quality improvement is not the same as other types of research in the fact that it only examines the data that results from care processes, and not the care itself. Quality improvement would examine the data resulting in care changes, for example, it would examine the data collected surrounding getting appendectomy patients to ambulate after surgery within a certain time frame, differing from the time frame ambulation was previously. It would then examine that data to determine of moving ambulation up was helping the patients in comparison to a later ambulation time frame model.

Evidence-Based Practice

 Evidence-Based practice or EBP is research that combines clinical expertise, patient values, and research evidence into making decisions surrounding the process of patient care. This type of research would utilize validity, reliability, relevance and the outcomes of the variables they utilize to made decisions. In addition, EBP would also utilize quantitative research as well as qualitative research into their decision making processes. EBP requires evidence in order to make changes in the practice of the medical field.

 Evidence-Based Practice, for example, would look at the clinical studies of those who were made to ambulate after having an appendectomy sooner than they had previously. In addition, they would also take into consideration the values of the patients, whether or not the early ambulation is too mentally taxing for the patients. Research evidence would also be incorporated into the examination of the change and into the applicability of the changes on a wider scale. EBP examines several variables before introducing any changes into the health care field. EPB is moderately-high in regards to use in a clinical setting (Squires, et al., 2011).

 EBP could be used and is used to make changes in the quality of care a patient can receive or in the health care system as a whole, however, it is not the same as Quality Improvement (QI). Quality Improvement can be done on a micro level, such as at a hospital or a health care facility. Data can be collected and analyzed and changes can be put into place regarding the quality of care patients are receiving. EBP is harder to use on a micro-scale, it is still possible but it is utilized more for larger, broader changes such as changes on a state wide level or changes across an entire field in the health care field.

Original Research Evidence

 Original research evidence is evidence that gathered from those groups of researchers or individual researchers who have developed a unique hypothesis and tested their hypothesis resulting in data that can be used to gain a better understanding of a topic, improve the care people receive, or to make changes to the health care field. Original research does not include research that is repeating research done by others. It also does not include research that incorporates information gathered from other research.

 An example of original research would be research surrounding the number of pregnant women who receive an in-utero diagnosis of hydronephrosis in their fetus compared to hydronephrosis that goes undiagnosed in-utero and is not diagnosed until after birth. As long as the researcher did not utilize data from other research studies, and the study has not been conducted prior to their conducting the study it would be considered original research. Original research is something that is conducted by those who specifically perform research or those in the medical field who are seeking to determine if their own hypothesis is valid or invalid. It is much harder for a non-researcher medical professional to conduct original research.

 In order for original research to be deemed of value in order for the data to be utilized, the research must be peer-reviewed. Peer-review can mean the replicating of the study by outside researchers. However, if the data used is the data collected by the replication of the original study it is no longer original research. Original research must be peer-reviewed and preferably published in a reputable medical journal. If neither of this can be said of the original research, the research should be avoided in regards to the utilization of data gathered by said research in order to implement any changes either on a micro-scale or macro-scale.

Discussion

 Nurses work in a variety of settings. Each research concept can be utilized in the variety of settings, in fact, the variety of research concepts strengthen the role nurses have in the medical field. Evidence-Based Practice, for example, would be great utilized in regards to administration and overall policies regarding patient care. Quality Improvement would be best used in regards to direct patient care and even in situations that involve the work place for the nursing staff directly. Original research would be best utilized in terms of research itself and the academia facet of nursing.

 Each concept is different, but each concept shares a common goal. That common goal is to improve the overall healthcare field and improve the abilities of the nurses, no matter what sector of nursing the nurse is employed in. Nursing and the entire medical field is moved into the future by constant evaluation and improvement of existing guidelines, practices, policies, etc. If changes did not occur, nursing, as well as, the medical field would stagnate and the patients would suffer from that stagnation.

 Keep in mind, had research not been conducted and implemented, the medical field would have never understood that medical instruments and hands must be sanitized before moving to a new patient. The medical field learned from observations made during the American Civil War that led to the changes being made. It was a major step in sanitary medical practices that the medical field needed to become better at their jobs but also it would improve the quality of care received by the patients. Modernization is something that every field must embrace in order to improve and remain relevant. Nursing in a digital world is the next frontier (Abbott & Shaw, 2016).

Conclusion

 Understanding the differences in Quality Improvement, Evidence-Based Practice, and Original Research Evidence is necessary in order to understand what one is looking at. Beyond that, the applications of each concept can be specific and aid in differing ways in regards to the position a nurse holds. Academia is very different than clinical work. Each concept is useful and important. Understanding the differences in research widens the scope of medical comprehension for the nurse but it also has a direct impact on the nurses’ patients, colleagues, and the institution in which they are employed.

References

Abbott, M.B., & Shaw, P. (2016). Virtual Nursing Avatars: Nurse Roles and Evolving Concepts of Care. OJIN: The Online Journal of Issues in Nursing, 21,3, doi: 10.3912/OJIN.Vol2No03PPT39,05

Squires, J.E., Hutchinson, A.M., Bostrom, A.M., O’Rourke, H.M., Cobban, S.J., & Estabrooks, C.A. (2011). To What Extent Do Nurses Use Research in Clinical Practice? A Systematic Review. Implementation Science, 6, 21. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068972/

 

Fossil Record Evidence for Evolution

Introduction
In general, the term ‘evolution’ can imply a drastic or gradual change from a very broad perspective. Life on earth, the universe,galaxies, as also the earth in general have evolved through millions of years. In this essay we consider only one aspect of evolution emphasizing on evolution as a biological tool for change among species and consider fossil record as supportive of both evolution theories and also the other theories contrary to evolution. Evolution is the central unifying concept, a theory that successfully connects biology, palaeontology and other branches of science. Evolution is a gradual descent of organisms accompanied by changes that help the organisms to adjust and adapt to the surroundings. ‘Descent with modifications’ as Darwin contended implies changes in organisms in successive generations (Mayr, 1976). These changes are triggered by the derivation of new species and there is a change in the properties of populations of organisms and these properties tend to transcend the lifetime of any single individual. Newers pecies are modified versions of older species.

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Although, individual organisms do not biologically evolve,populations evolve when heritable genetic materials are transmitted from one generation to another. Biological evolution can range from very limited changes to drastic transformations on a large scale changing the entire special together and bringing in new forms. Evolution can thus be defined as inheritable changes in populations of species that are spread and transmitted over many generations (Zimmer, 2002). It is also more scientifically defined as changes in the frequency of alleles within a gene pool carried through different generations as understood in the Darwinian version of the theory(Dawkins, 1989). Evolution studies are supported by detecting changes in gene frequency within a population and the fact that the theory of evolution emphasizes on a common ancestor, only indicates that two or more species show successive heritable changes in populations since they are separated from each other as distinct forms (Allen and Briggs, 1989). Most popular definitions of evolution however highlight not the transmission of heritable traits and changes but the processes of diversity that has given rise to millions of species from the most primitive organisms. Here however we move on to the evidence for and against evolution theories and the role of fossil record in this context. Some researchers claim that the theory of evolution has been supported by four primary sources that serve as evidence (Zimmer, 2002; Allenand Briggs, 1989):

The fossil record that tracks changes in early and primitive forms of life
The anatomical and chemical similarities in the constitutions of different species.
The genetic changes observed and recorded in several living organisms over several generations
The geographical spread and distribution of species that seems to suggest a definite pattern, and

The Fossil Record
Fossils are buried in rock layers as indentations of dead plant and animal materials. The totality of these artefacts and their impressions on the rock formations is considered a fossil record. Fossil record as we have briefly mentioned is the primary source of evidence supporting the theory of evolution and the gaps in these records ironically also forms the bone of contention taken up by anti-evolution theorists. Fossil records are used by scientists to understand the process of evolution in general, and the subsequent changes in several species at several times of the earth’s existence(Donovan and Paul, 1998).
The Fossil Record seems to provide an important clue to the changes in primitive and even now extinct species and this definitely helps us to frame a conceptual graph on how evolution has taken shape. Fossil and rock record forms the primary source of evidence collected by scientists for nearly400 years and the consequent database obtained is mainly observational. The fossil record among all other evidence gives a large database of documented changes in past life on earth. The use of Fossil record to study life forms on earth dates back to pre-Darwinian times and the changes in life forms could be studied from a sequence of layers of sedimentary rocks and fossils of different groups of species were found in each of these successive layers (SA, 1982).Sedimentary rocks are found widely across the earth’s surface and are formed when small particles of sand, mud or gravel, shell or other materials withered off by water or wind accumulates in sea beds and oceans. As these sediments pileup they bury shells, leaves, bones, and parts of living organisms. Layers of sediments are thus formed for every large period of time and all these layers become subsequently cemented to each other to become different layers of sandstone,limestone, shale and so on. Within these layers of sedimentary rocks the plant and animal remains become buried as fossils and are later revealed as fossil records (Allen and Briggs, 1989). From these fossil records several species have been identified, some of which are extinct and some of which have traits transitional between different major groups of organisms. Fossils of transitional forms actually give considerable evidence of species evolution over time. However there is not enough evidence through fossil records to conclusively prove evolution, as there are still talks of ‘missing links’ as very few and according to some, no transitional forms have been actually discovered. The Fossil record data available to us is incomplete and in conclusive at present.
During the late eighteenth and early nineteenth centuries,William Smith, a British Engineer observed different assemblages of fossils preserved at different levels and different ages of rocks. These assemblages succeeded one another in a regular and determinable order (cited in, Wikipedia,2004). This was further bolstered by the fact that rocks collected from different locations showed similar fossil formations according to the different times they represented. Smith named this correlation of rock fossil data as the principle of faunal succession. The occurrence of faunal succession was one of the primary arguments of Darwin who used fossil evidence as supporting the theory of evolution.
Various modern approaches to the theory of evolution have been recently developed. Mayr claims that the theory of Punctuation for instance has two basic points that

most or all evolutionary change occurs during speciation events, and
most species usually enter a phase of total stasis after the end of the speciation process (which involves formation of new species).

Speciation thus involves transformation of species in geological time (Erwin and Anstey, 1995). Formation of new species is explained either by phyletic gradualism or a gradual steady transformation of species by phyletic evolution highlighting the deficiency of the fossil records, or by sympatric saltational speciation that highlighted punctuational equilibria and branching of species rather than transformation as lineages as the real explanation for evolution (Mayr and Provine, 1998). Biologists like Gould and Eldredge have also supported punctuation theories. Richard Dawkins on the other hand stresses on the principle of gene multiplication where genes as replicators seems to be the focal point of defining evolution (Sterelny, 2001).
In quite an important paper Volkenstein (1987) suggests that there can be no contradiction between punctuated equilibrium and phyletic gradualism if synergetics and theory of information are incorporated within the theory of evolution. Punctualism can be seen as phase transition maintaining the directionality of evolution. Volkenstein argues that Punctualism, non-adaptationism and neutralism form the triad of internally connected features of evolution.
Problems with Fossil Records
Of course at that point, the absence of a proper theory of evolution prevented Smith or other researchers from providing an explanation of the actual cause of faunal succession. The cause of faunal succession as is known today is mainly due to evolution of organisms and species that change,transform or become completely extinct, leaving behind their traces on earth as fossils. Age of rocks and the changes in species features are both determined by fossil record and faunal succession used as tools in bio stratigraphy. However fossil data show extremely few records of transitional species,organisms that can conclusively suggest how and when evolution of new and different species occurred (Donovan and Paul, 1998). Darwin himself suggested that the geological record itself is imperfect and incomplete and this is further strengthened by the fact that transitional species were short lived and had very narrow geographical range.
Radiometric and Carbon dating have made it possible to identify fossils more than 3.5 billion years old and have indicated that animal species may have appeared abruptly, a phenomenon which Darwin himself found difficult to accept. Even though one or two forms of organisms which may be considered as transient have been identified, there are no records of transitional plants and thus an evolutionary plant history could not be drawn as of yet. Along with these issues it has also been seen that most of the fossils found are of species which have existing forms and are either similar to existing species or are completely identical. The intermediate temporary stages as serve to act, as links between two related species seems to have been completely downplayed by the fossil data obtained. Animals seem to have remained more or less unchanged through all these years. Despite the collection of a huge number of fossils,nearly all of them being fossils of presently existing animals have created problems for the theory of evolution. It is a general belief that based on fossil discoveries already made, there will be little or no evidence that evolution had actually occurred and continues to occur (Donovan and Paul,1998). If animals die a natural death, they are usually decomposed even before being fossilized. However during sudden catastrophes can bury the animals and embed them deep in the earth. Some rocks and organisms that transformed to show fossils for years and decades were actually deposited within a short period of time.
Although Darwin based his arguments heavily on fossil record, most scientists now believe that fossil record is actually incompatible with evolutionary theory as no transitional links or intermediate forms have been discovered among this huge collection of fossils in all these years. This suggests that there is no real evidential data that the theory of evolution is in fact true. There is no evidence of partially evolved species or intermediate forms either in the past or in the present fossil record and the fossil record available is quite representative of all fossil data that will ever be collected. Evolution seems to point out towards more undefined and partially evolved species, fact completely undermined by available fossil record that shows well-defined organisms rather than gradual gradations. The incomplete fossil record is the primary bone of contention in the evolutionary debate and seems to give an edge to non-evolutionists.
Conclusion:
Considering all the aspects of the debate and gaps in fossil records and weighing this against evolution theories highlighting either generational transformation of lineages or drastic changes and speciation at specific periods, we can conclude that available gaps in fossil record may be more indicative and supportive towards speciation and abrupt changes rather than gradual evolution through phyletic transformation.
 

Benefits of Evidence Based Practice in Nursing

The health care practices that are evidence based are accessible for many diseases and ill health cases like diabetes, heart failure, Asthma etc. The implementations of the evidence-based safety excercises is not an easy job, and require to form policies which deal with the complication of the health-care system. There is a requirement for the healthcare ways to be evidence based as per the changing environments.

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The evidence based practice is considerable and very careful in utilization of the existing finest evidences along with the clinical know-how and the norms of the patients to make right decisions in terms of health care. These best evidences comprise of practical evidences as of unsystematic controlled assessments, as of few scientific approaches like descriptive and qualitative study with the implication of details of some previous researches, reports, and opinions of the skilled people. In case there is not much of the research evidence accessible, then the health care decisions can be taken by non research substantiations like, opinions of the experienced people etc. And in case, the ample research results are accessible, then the practice can be as per the substantiation of it along with the skills in nursing and the norms of the patients (Cullen et al.2005)
The models for the evidence based practice (EBP) are many in number and have been put to use in various clinical situations. All these models have one or two components which are similar. These can be choice of a theme for the EBP, evaluation and syntheses of evidence, application, and assessment of the influence on the care of the patients and the thoughts regarding the situations in which these practices are exercised. The discovering that happens amid the procedure of making an interpretation of examination into practice is profitable data to catch and input into the process, so others can adjust the confirmation based rule and/or the execution methodologies (Straus, 2000).
There is wide acknowledgement of the idea that interdisciplinary joint effort is a vital building square for effective health-care groups. This conviction is grounded in our understanding of how group’s capacity to address complex care needs that change with intense sickness or damage. This general understanding has been accepted in studies that have reported good conclusions connected with effectively executing interdisciplinary models of health-care conveyance in non-discriminating care settings. The brief time spans over which the care needs of basically sick or harmed grown-ups change and the group approach taken by almost all Icus emphatically propose that interdisciplinary cooperation is additionally gainful in this setting. It has been foreseen that those health-care arrangements that productively employ interdisciplinary partnership will be prior to the arc in offering premium care at as small a price as probable. These kinds of institutions will in addition possibly be superior situated for civilizing teaching and offering a better groundwork for decisive care study in their establishments.

Source: Leape, 2005
Steps of advertising reception of EBPs could be seen from the point of view of the individuals who behavior scrutinize or produce knowledge, those who utilize the proof based data in practice, and the individuals who serve as limit spanners to connection learning generators with information clients. These phases of information exchange are seen through the viewpoint of scientists/makers of new learning and start with figuring out what discoveries from the patient security portfolio or individual exploration ventures should be dispersed.
Steps of learning move in the AHRQ model speak to three real stages:
(1) Information creation and refining-
Information creation and refining is leading exploration (with expected variety in preparation for utilization in health care conveyance frameworks) and afterward bundling significant examination discoveries into items that might be put vigorously, for example, particular practice suggestions consequently improving the probability that exploration confirmation will think that its path into practice.37 It is crucial that the learning refining procedure be educated and guided by end clients for examination discoveries to be executed in care conveyance. The criteria utilized within learning refining ought to incorporate viewpoints of the end clients (e.g., transportability to this present reality health care setting, plausibility, volume of confirmation required by health care associations and clinicians), and also customary information era contemplations (e.g., quality of the proof, generalizability).
(2) Dispersion and spread-
Dispersion and spread includes banding together with expert presumption pioneers and health care associations to scatter learning that can structure the premise of activity (e.g., crucial components for release educating for hospitalized patient with heart disappointment) to potential clients. Dispersal organizations join analysts with mediators that can work as learning representatives and connectors to the professionals and health care conveyance associations. Middle people might be proficient associations, for example, the National Patient Safety Foundation or multidisciplinary information exchange groups, for example, those that are powerful in scattering exploration based malignancy avoidance programs. In this model, scattering associations give a legitimate seal of approbation for new learning and help distinguish persuasive gatherings and groups that can make an interest for application of the proof in practice. Both mass correspondence and focused on dispersal are utilized to achieve groups of onlookers with the expectation that early clients will impact the last adopters of the new usable, confirmation based examination discoveries. Focused on dispersal endeavors must use multifaceted spread procedures, with a stress on channels and media that are best for specific client portions (e.g., attendants, doctors, drug specialists)?
(3) Authoritative reception and execution.
End client reception, usage, and systematization is the last phase of the information exchange process.37 This stage concentrates on getting associations, groups, and people to receive and reliably utilize proof based exploration discoveries and advancements in ordinary practice. Actualizing and managing EBPs in health care settings includes complex interrelationships among the EBP point (e.g., lessening of pharmaceutical failures), the hierarchical social framework aspects, (for example, operational structures and qualities, the outer health nature’s domain), and the individual clinicians.35, 37–39 A mixed bag of techniques for execution incorporate utilizing a change champion as a part of the association who can address potential usage difficulties, guiding/attempting the change in a specific patient care territory of the association, and utilizing multidisciplinary execution groups to support in the commonsense parts of inserting developments into continuous authoritative methodologies. Changing practice requires significant exertion at both the individual and authoritative level to apply confirmation based data and items in a specific connection. At the point when changes in care are exhibited in the pilot studies and conveyed to other important units in the association, key faculty might then consent to completely receive and manage the change in practice. Once the EBP change is fused into the structure of the association, the change is no more considered an advancement however a customary of care.
Application of evidence to every patient
Application of evidence to every patient administration is such an argumentative issue, to the point that it merits further elaboration (Titler, Cullen and Ardery, 2002). Once the clinician has found the evidence important to the patient’s clinical condition, he/ she need to choose about its appropriateness. Measures of treatment viability got from clinical trials are normal measures and because of the unavoidable biologic variability, are certain to change over the populace. Be that as it may it pays to remember that patients selected in clinical trials are prone to be significantly more like one another than they are liable to be different. Thus, significant contrasts in the greatness of impact are impossible (Karthikeyan, 2007). Qualitatively diverse impacts (hurt for some and profit for others) are to a great degree uncommon. In this way, the consequences of clinical trials could be connected at the bedside, to patients extensively like those in clinical trials with the reckoning of profits like that seen in the trials. The vicinity of co-dreariness and expansive contrasts in age from the study populace is a few components, which can genuinely impact the clinician’s choice.
A related region of significance to individual-patient choice making is the utilization of subgroup dissects. As clinicians, the aftereffects of subgroup dissects hold instinctive engage us. It is calming to recall that, implanted in any clinical trial populace; there are a limitless number of subgroups and “subgroup impacts”, the vast majority of which are spurious. The genuine trouble is in searching out the genuine subgroup impacts. In assessing subgroup breaks down, the accompanying issues need to be viewed as:
(i) Were the dissects pre-specified or were they left upon in the wake of “looking” at the information,
(ii) How expansive are the impacts?
(iii) Is the subgroup impact biotically conceivable?
(iv) Would it say it is factually not quite the same as whatever is left of the study populace?
v) Is there substantiating evidence from different studies?
The criteria for tolerating subgroup results need to be stringent on the grounds that, as we called attention to, most are spurious and in fact, not very many subgroup breakdowns have rested the test of time.
Nursing division has an important part to play in the plan of evidence-based conveyance of care. EBP just obliges that the clinician be sufficiently acquainted with the evidence-base in his/ her field and have the capacity to unbiasedly evaluate it, so he or she can apply it suitably in practice. Clinicians ought to recognize that EBP is a paramount stage in the advancement of the act of prescription, which endeavors to convey care of consistently high caliber. As the central executors in charge of conveying this care, they ought to instruct and prepare themselves better for this key part.
References
Cullen L, Greiner J, Greiner J, et al. Excellence in evidence-based practice: an organizational and MICU exemplar. Crit Care Nurs Clin North Am 2005;17(2):127-42.
Leape LL. Advances in patient safety: from research to implementation. Vol. 3, Implementation issues. AHRQ Publication No. 05-0021-3. Rockville, MD: Agency for Healthcare Research and Quality; 2005.
Karthikeyan G. Evidence-based medicine and clinical judgment: an imaginary divide. J Am Coll Cardiol 2007; 49 : 1012.
Straus SE, McAlister FA. Evidence-based medicine: a commentary on common criticisms. CMAJ 2000; 163 : 837- 41.
Titler MG, Cullen L, Ardery G. Evidence-based practice: an administrative perspective. Reflect Nurs Leadersh 2002;28(2):26-27, 46.