Discuss about the Evidence of Nursing for Tanners Model.
Why is it important to use short and specific search terms in database search instead of long descriptive sentences?
Databases have certain features which allow an individual to build their search so as to focus their search on the information that is relevant. The features include subject and keyword searching truncation, search limiting, nesting, Boolean operators and phrase searching. It is important to use short and specific search terms so that accurate information that one looks for is found. This is because computers index words that are significant in databases in summary, title, subject or article’s text fields.
Describe the relationship between the two frameworks that underpin this subject: Tanner’s Model of Clinical Judgement and Evidence Based Practice?
Tanner’s Model of Clinical judgement is a conclusion or an interpretation about the health problems, concerns or needs of a patient and the decision of whether or not an action should be taken or certain standard approaches modified or used. In clinical judgement analytical reasoning skills, inquisitiveness, sound judgement skills, persistence, and patient and self- awareness must be applied. The antecendents that are found on Evidence-based practice (EBP) explain what takes place in the integration of the best evidence with patient and clinical expertise in order to deliver optimal health care. In the evidence-based practice, the nurse begins by identifying the problem. He/ she then understands the essence of research in the nursing field. After this, the nurse has to identify what the patient/family prefers or values and uphold it. Both Tanner’s Model of Clinical judgement and Evidence-based practice relate because there are attributes that measure whether they are successful.
Describe the purpose of a systematic review compared with a single randomized controlled trial?
A systematic review focuses on clinical topic and answers a question that is specific. Studies are reviewed, their quality assessed and findings summarized in a manner that was predetermined depending on the review question. In contrast to systematic reviews, randomized controlled trials are experiments which introduce exposure or treatment so that its effect can be studied on real patients.
Week 6 online discussion
What is the advantage of using randomized control trial study design in this particular study?
The advantage with randomized control trial as a study design in this study is that it eliminates biases. This study design certify that systemic variances are not there between various groups for both the unknown and the known (Abernethy et al, 2013). The other advantage is that randomized control trial in this study provided the safest way of testing evidence based approaches that are required to improve palliative care. This type of design was the only the safest that could assure the participants that the evidence- based approaches discovered would actually work on their palliative care.
What were the primary and secondary outcome/outcomes in this study?
Dyspnoea in the evening and morning as indicated on a 100mm visual analogue scale, wellbeing, quality of sleep, performance on the physical exertion as well as the side effects that were measured after the four days of treatment (Abernethy et al, 2013).
Why did the study use a cross over design?
The cross over design allowed for the conduction of three parallel randomized trials. This design allowed a strategy that was less expensive, with a timeframe that was shorter and individuals to participate efficiently. This design was important because it enabled the comparison of the three studies to be done within a single cohort thereby making it fundable.
Has the study used adequate sample size? Justify your answer.
The study has used an adequate sample size. Since a factorial design was used for the study, the sample size used was considered according to the outcome where the largest number of participants was required. In this study, greater numbers were required in the improvement of usual pain intensity (Abernethy et al, 2013). Also, according to the table that determines the sample size from the given populations, the sample size in this study is adequate.
How did the authors assess dyspnoea in this study?
Dyspnoea refers to severe breath shortness or the difficulty in breathing. This has been known to be the most common reasons why individuals visit the accident and emergency hospital departments. During this study, dyspnoea was measured on a visual analogue scale in the evening of the last day of the period (Abernethy et al, 2013). On the scale, anchors were “no breathlessness” at 0mm and at 100mm it was “worst possible breathlessness”.
Patients treated with morphine reported average improvement of 9.5mm (95% CI 7.4 mm, p=0.006) in the evening compared to those who received the placebo.
In the mentioned study, the mean difference between intervention and control groups is 9.5mm with a 95% confidence interval around that mean of 7.4mm-11.6mm, what does this tell you?
Confidence Intervals (CI) are used in research and statistics as a type of population parameters in interval estimates (Zapf et al., 2016). CI is calculated from observations from various samples which frequently include values of parameters that cannot be observed if the experiment is repeated. 95% confidence interval in this study means that there is 95 percent accuracy of estimate in which the mean difference between the intervention and control groups appears.
Looking at figure 2, the p value is
P- value is used for comparison with the significant level that is desired in the test. 0.05 is used as a significance cutoff. When p- value results below 0.05, the null hypothesis should be rejected. If there is no difference between means, it is concluded that significance differences exist. When p- value is larger, it cannot be concluded that there is a significant difference. When p is smaller, the result is significant but when p- value is more than, then the test was not significant (Zapf et al., 2016). For instance, if the null hypothesis are to be rejected at 0.05 like in this study, then small values suggest that the null hypothesis would unlikely be true. In this case, use of oral morphine shows high improvement because 0.006 is a very small value, meaning that there is a significant difference.
Thinking of the overall results from the case study and the figure, what do the results tell you about the effects of oral morphine compared with placebo in patients with refractory dyspnoea?
According to the overall results in the study and the diagram on the comparison of improvement in breathlessness, patients with refractory dyspnoea show high improvement when they use oral morphine. However, if patients with the same condition use placebo, there would be no improvement in their breathing. A p- value of 0.006 as indicated in the diagram indicates that there is a very large significant difference (Abernethy et al, 2013). A patient with refractory dyspnoea is likely to be in a good position towards gaining back breath after consuming oral morphine than the one consuming placebo.
What did the author find about the effect of morphine on the participant’s sleep? (provide statistics)
The author did not indicate any effect of morphine on the participant’s sleep. However, several other effects were mentioned. Some of the known side-effects of morphine include slowing of the heart rate, sighs, shallow or weak breathing; pains in the chest, pounding or fast heart beats; drowsiness to the extreme levels, passing out feelings; missed menstrual periods, infertility; sexual problems, impotence, loss of interest in sex; nausea, loss of appetite, low cortisol levels, vomiting loss of appetite, weakness, dizziness and worsening tiredness. Some of these effects were mentioned by the author when providing the figures of participants who did not go on with the study.
Would you consider morphine therapy for your patients who are suffering from refractory dyspnoea? Justify your answer taking into consideration the positive effects and side effects of morphine therapy
According to the study, ten patients withdrew from participation due to various reasons: three withdrew as a result of morphine side effects, two due to potential effects of morphine and five due to reasons unlikely related to morphine (Abernethy et al, 2013). I would consider morphine therapy for my patients because not a large number of the sample was affected by morphine side effects. However, the main reason why I would recommend morphine would be because of the positive effects that the medicine has. The study indicates that a large number of participants experiences great levels of improvement as compared to those who used placebo. In fact, there was no improvement to placebo users.
Bandage A and bandage B are alternative compression bandages for treating venous leg ulcers. In an RCT comparing the two bandages, 60% of patients had healed ulcers after 12 weeks of treatment with Bandage A compared to 75% of patients treated ether Bandage B.
Calculate Relative risk of healing (RR), Absolute risk difference (ARD) and numbers needed to treat (NNT)
Relative risk of healing (RR) are the number of healing events found divided by control = healed outcomes in the mentioned group divided by the proportion of outcomes that are bad in the control group =0.6 /0.75
RR= 0.8
Absolute Risk Difference (ARD) is the same as the absolute risk reduction (ARR) = (Bad events minus good events) divided by bad events = (0.75-0.6) 0.75
ARD= 0.2
Numbers Needed to treat (NNT) is the number needed to treat = 1/ ARD = 1/0.2
NNT= 5
How would you interpret your findings for RR, ARD and NNT?
ARD is one of the most important ways of representing research results that would be helpful in making decisions (Comhaire and Decleer, 2012). In this case, an ARD of 0.2 or 20 percent means that if 100 individuals were treated, 20 individuals would be prevented from lack of healing, that is, 20 of them would be healed by their bandages.
This can also be represented by the number needed to treat (NNT). If 20 individuals would be healed out of the 100 treated then NNT for one individual to benefit would be about five (100 ÷ 5).
The relative risk (RR) of an outcome that is bad in a certain group is given the intervention provides the proportional measure for estimating size of the treatment effect in comparison to no treatment or other interventions (Comhaire and Decleer, 2012). In this case, the RR of healing is the size of healing in a bandage compared to not healing in a bandage at all. In this case, RR is 0.8 or 80 percent.
If treatment had an RR more than 1, there would have increased rates of not healing. RR less than 1 decreases incidences of not healing.
Is it worth using bandage B over A? (Do you think that the results are clinically significant?)
According to the results, an individual would heal if they were in Bandage A than when they are in Bandage B. Bandage B is not worth over Bandage A. I think the results are significantly significant because the number of those who do not heal is reduced by the fact that the value of RR which is less than 1.
What are some of the barriers to implementing new research findings into clinical practice?
Evidence-based practice is a problem solving approach to the care of patients and it integrates evidence that is best from studies that are well designed with patient assessments, clinician’s expertise and the preferences of the patients. If they are implemented, they would lead to better outcomes and safer care. Studies indicate that the frequently cited barriers are organizational cultures that do not support the implementation and the lack of time to implement the new findings. Nurses face resistance from nurse leaders and managers thereby misleading the subordinates from providing the best care from new research findings.
Why do you think it is important for you to take this subject as preparation for you role as a junior clinician?
As a junior clinician, most of my work will be dealing with patients who have different problems. When faced with all sorts of problems, I will be required to be a nurse who notices the specific problem, interprets the problem, respond to the issue and finally reflect on it. Clinical judgement as well as Evidence- Based Practice will have to be my job so that I may succeed in effectively caring for the patients. It will be important for me to take this subject because it will guide me on how to conduct research and finally produce evidence-based results that will be of importance to patients.
References
Abernethy, A., Currow, D., Frith, P., Fazekas, B., McHugh, A. and Bui, C. (2013). Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ, 327(7414), pp.523-528.
Comhaire, F, & Decleer, W 2012, ‘Comparing the effectiveness of infertility treatments by numbers needed to treat ( NNT)’, Andrologia, 44, 6, pp. 401-404
Zapf, A, Castell, S, Morawietz, L, & Karch, A 2016, ‘Measuring inter-rater reliability for nominal data – which coefficients and confidence intervals are appropriate?’, BMC Medical Research Methodology, 16, pp. 1-10.
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