Evidence based practice and applied nursing research are interrelated with emphasis being put on utilization of research related nursing practice. Nurses are encouraged to utilize research findings in order to make an impact on the health of individuals and groups that are under their Care and this has been directly linked to the development of the Evidence Based Practice (EBP). EBP is an interdisciplinary approach to clinical practice that is rapidly gaining popularity; its basic principle is that all decisions and interventions are made based on research studies and evidence derived from systematic collection of data, observation, experiment, questionnaire and hypothesis testing. EBP helps nurses to provide care in their practice based on knowledge and research rather than routine practice, tradition, myths and old fashioned practices. It ensures that patients get quality care that is up to date and reflects latest research evidence.
It also ensures better patient outcome, improves science of nursing and helps increase confidence in decision making. A number of clinical practice guidelines that have been developed by nurses in EBP and research application include pain management in infants and children, prevention of pressure sores in adults, identifying and treatment of urinary incontinence in adults just to mention a few. Sources of evidence used by nurses included a clinical practice guidelines by AAP &AAFP, a pediatrics infectious disease journal article on causative pathogens, antibiotics resistance and therapeutic considerations AOM, another journal article from the pediatrics infectious disease treatment of AOM an era of increasing microbial resistance, a book current pediatric diagnosis and treatment 18th edition by Kelly P.E, friedman et al, and finally results from interview with parents and children with AOM. Information from the Clinical Practice Guideline by AAP and AAFP and the two journal articles can be classified as secondary source or filtered information. It’s a form of evidence based guideline integrating evidence based research findings and research summaries.
The book Review Current Pediatric diagnosis and treatment 18th edition by Kelly, P.E et al is a primary source of data with unfiltered information that contains original data and analysis from research studies without external evaluation and interpretation. Basic information about AOM diagnosis and treatment by various E.N.T specialists is useful in this case study.
Interviewing parents of children with AOM to collect data or information about the progression of disease, response to treatment, resistance or worsening of symptoms is important in this clinical research evidence.
Watchful waiting should be limited to infants of 6 months – with signs and symptoms of AOM. It becomes appropriate option only when follow up can be ensured and antibiotic treatment commenced when symptoms persist. One can start anti-bacterial therapy when symptoms such as a temperature of 39 and above with severe otalgia occurs.
Antibiotics recommended for OME and AOM are as follows: - a) first line Antibiotic therapy – Amoxicillin, b) Second line antibiotic therapy – Amoxicillin/Clauvunate, Azithromycin, Cefixime, Clindamycin etc. c) Third line antibiotic therapy – Ceftriaxone, Ciprofloxacin etc.
In this case scenario, I would like to base my study on acute otitis media in children as a clinical guideline and try to identify existing documented literature on evidence based practice and its management. Acute otitis media (AOM) is an inflammation of the middle ear characterized by a rapid onset of signs and symptoms that include otalgia (pulling of ears in infants) irritability, fever and generalized discomfort. To make a diagnosis of AOM, the nurse or clinician has to meet the following criteria. 1) A history of acute onset of signs and symptoms. 2) Presence of middle ear effusion 3) signs and symptoms of middle ear inflammation. The infant or child presents with an abrupt onset signs and symptoms of middle ear inflammation and middle ear effusion (MEE). MEE may also be accompanied by any of the following symptoms – bulging of the tymphanic membrane, fluid behind the tympanic membrane or otorrhoea. Incase of middle ear infection, the following symptoms are elicited; erythema, otalgia and discomfort. Some of these signs and symptoms are also present in viral upper respiratory infections.
While some infants with AOM may also present with cough and nasal discharge as in viral infection of the upper airway therefore making it impossible to discriminate between AOM viral infections of the upper respiratory tract or even OME. Some diagnostic procedures such as pneumatic otoscopy, tympanometry or acoustic reflectometry may be used to aid in diagnosis of AOM and OME .Evidence based clinical practice and guidelines recommends that children between ages 2-12yrs with acute otitis media should undergo a series of evidence based treatment process that includes proper diagnosis, pain management, watchful waiting and observation incase of uncomplicated AOM . A major challenge for nurses undertaking evidence based practice is to distinguish between AOM, OME and other related ear infections. Therefore there is need for nurse practitioners taking part in EBP to adopt evidence based clinical guideline that is widely acceptable and research based.
Going by the guidelines of American Academy of Pediatrics and American academy of family physicians on the management of acute otitis media, the following recommendations were derived:
1) Correct diagnosis of AOM through proper history, signs and symptoms and examination.
2) Pain management and relief
3) Watchful waiting and observation without use of antibiotics in a child with uncomplicated AOM based on age, severity, diagnostic certainty and follow up.
4) Decision to treat with antibiotics incase of complications or failure of symptoms to resolve after 72 hrs. The patient should be evaluated for other causes of disease or effectiveness of antibiotics used.
5) Clinicians should encourage prevention of AOM through reduction of risk factors.
An example of evidence based practice is pain management in acute otitis media. Nurses should develop proven ways of assessing pain in children suffering from AOM by utilizing research findings documented in literatures. Information on relevant research and evidence summary is available in computerized databases that are currently accessible through internet.
Evidence based practice by nurses on management of AOM recommends that overuse of antibiotics in poorly diagnosed ear infection has led to anti bacterial agent’s resistance and that children aged between 2-12yrs do not necessarily need antibiotics in the management of AOM. Use of five days of antibiotics therapy preferably amoxicillin 80-90 mg/kg/day is sufficient first line treatment of uncomplicated AOM.
One of the major ethical issues related to nursing research and evidence based practice is the requirement for accreditation and licensing from ethical committees to carry out research. 1) They examine and regulate research proposals to ensure that ethical rights of individual participants are respected including their privacy, confidentiality, fair treatment and freedom from harm. 2) Participants must also sign consent form. 3) Participants have a right to refuse to take part in the study or withdraw from it. 4) Uncooperative parents/guardians who may not understand the “watchful waiting” 5) Risk of misdiagnosis or complications that could have been averted by early administration of antibiotics can be viewed as negligence.6) Age of children 2-12 years taking part in research is contentious.
In evidence based practice, emphasis is mainly on accurate diagnosis of acute otitis media to help rule out any other cause of infection or even other underlying factors that necessitates the use of antibiotics initially. Practicing nurses of different cadres and educational levels should participate in developing and adopting the EBP protocols that will help improve the health status of the entire population.
AOM is a diseases vey common in infancy and childhood with peak incidences between 6 to 9 months. The disease has a tendency to recur in children who had earlier onset of AOM. Another group of vulnerable children are children in day care centers due to increased chances of respiratory tract infections. There is a seasonal association of AOM with higher cases occurring during winter – this is due to increased rate of viral upper respiratory tract infection. In this study it is important to include prevention of risk factors to the vulnerable population as a recommendation by the clinical guidelines. Some preventable risk factors of AOM among children include exclusive breastfeeding of children for the first 6 months of life, isolation of sick children from day care centers, avoiding exposure to fumes & smoke and proper feeding methods. Some vaccines like the influenza and pneumococcal vaccines may also help to decrease the incidence of AOM. However there are some unpreventable risk factors that include ; genetic predisposition, premature birth, gender, environmental factors, presence of sick children in the household, place of birth, and low socio-economic status.
The clinical guidelines hereby adopted were derived from secondary sources to summarize and refine information that reflects the current recommended evidence based practice in nursing. Most of the sources of information cited in this study are derived from filtered resources which I got from journal reviews, summaries, research abstracts and literature of existing research. All this is classified as filtered resource.
As fact evidence based systematically researched treatment guideline are the most preferred in any clinical settings world wide. Our other sources of information were textbooks and websites that provided primary source of information with original data and analysis from original studies example the PubMed link. This is unfiltered resource whose information is important for it has no outside evaluation or interpretation hence not interfered with. This source of evidence though is not very reliable for clinical practice and has been minimally referred to in this case study.
Fink, R. T. (n.d.). Nursing Adminstration. Barriers of using Research findings in practice , 35 (3) 121-129.(filtered)
Holcomb, S. S. (2004). The Nurse Practitioner. The American Journal Of Primary Health Care , 6-13. (filtered)
J, K. (1994). Otitis Media. In Clinical Infections Disease (pp. 19:823-833).(unfiltered)
Polit, D. &. (2003). Nursing Research: Principles and Methods (7th edition). Philadelphia: Linscott Williams & Wilkins. (filtered) pubmed health - Acute ear infections. (2012, may 16). Retrieved 0ctober 30 th, 2012, from www.pubmed.com: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001662/(unfiltered)
Sacket, D. R. (1996). Evidence Based Medicine. British Medical Journal , 312, 71-72. (filtered)
Using evidence based nursing in practice - University of Calorina. (2011, november 11th). Retrieved October 30th, 2012, from www.cochrane.com: http://guides.lib.unc.edu/content.php?pid=118474&sid=1021243(filtered)