Practical Application of Evidence Based Practice
Nurses relate the contributing factors involved in medication errors
A decision-making process as it is, evidence based practice generally refers to the practice of integrating the best available evidences including patient reported, clinician observed and research-derived evidences. Evidences are used in such a way that it could support or reject utilization of a specific intervention. When applied specifically, considerations would also include the situations, patient characteristics and preferences. Melnyk and Fineout-Overholt (2004) noted that evidence based practice requires the conscientious use of current best evidence in making decisions about patient care (p. 6). Because it is evidence based, this practice aims at making clinical decisions for individual patients for the purpose of achieving positive and beneficial health outcomes. This practice could also be therefore applied to improve the quality of clinical judgments, reasoning and decision-making as well as to facilitate cost-effective care for the patients. In turn, evidence based practice not only benefits the patients but also the hospital institutions and the medical practitioners community belonging in these institutions. As such, this practice acknowledges the individuality of care that is ever-changing and involving uncertainties and probabilities.
Evidence based practice has its key strong point which is the encouragement of a problem-solving approach, informing only the highest quality solution to a medical problem in hand. A practice that values debate and discussions among clinicians and medical practitioners involved, it also encourages people’s ideas in a creative and innovative fashion while also discouraging negative criticism. This is carried out by means of questioning and exploring all sides of the argument. In a way, it promotes thinking objectively by looking at the meaning behind the facts and identifying issues arising from these facts (Hamer and Collison, 2005, pp. 11-12). Melnyk and Fineout-Overholt (2004, p. 16), on the other hand, noted that there are barriers to effective evidence based practice. Initially, nurses, physicians and other health professionals struggle to deliver evidence based care while managing demanding patient loads and attempting to keep pace with the volume of journal articles related to their clinical practices. Other barriers identified are lack of knowledge about evidence base strategies, misperceptions or negative views about research and evidence based care and lack of belief that this practice will result in more positive outcomes than traditional care.
The rise and expansion of evidence-based practice is not without difficulties. On the one hand, supporters and advocates claim that the approach had resulted in the best practice and the best use of resources. Key advantages of evidence-based practice is that it impacts policymaking and it merits investigation (Trinder and Reynolds, 2000, pp. 2-3). As various clinical conditions and nursing situations presaged the adoption of evidence-based practice, the spread is understood against the background of increasing preoccupation with managing risk, critiques of science and professionalism. On the other hand, opponents criticize the process saying it is a covert method of rationing resources, is over simplistic and constrains professional autonomy. The main drawback pointed out is that there is no proof that evidence-based practice actually works. What is immediately apparent is that there is limited consensus on the merits of evidence-based practice.
Evidence-based approach to clinical practice aims at delivering appropriate care in an efficient manner to individual patients. Such a process entails the utilization of research evidence as well as clinical expertise and interpretation of patient’s needs which in turn will inform decision-making. A known fact is that the nursing care involves a wide range of interventions and hence draws on diverse evidence base. To wit, there is the necessity for individual nurses to develop key skills for the purpose of accessing and using evidence appropriately in clinical practice. In the case when evidence is not available, to make considered decisions. According to Craig and Smyth (2002), sources of synthesized evidence are evolving and are being made accessible to nurses. When it comes to developing nurse researchers, there are issues which will be encountered and must be dealt with in order to come up with quality evidences. These issues include organizational culture, management support and career paths that accommodate both clinical and research work need to be addressed.
Clinical decisions need to consider the current best evidence available. A process that undergoes a series of steps, it would be inevitable for nurses to start with formulating a clearly defined question. Such question drives each step of the process and should therefore be carefully considered at the outset. The rationale behind this is that a well-formulated question maximizes the potential of finding relevant evidence which can be applied to specific patient in a specific setting (Macnee and McCabe, 2006). Questioning is also critical in deciding the relevance of evidence-based practice for nursing and its place within contemporary health care. Notably, there is the unyielding need for nurses to develop an identity based upon a solid understanding of its position within a health service which is modern and dependable.
With this said, the goal of nursing research is also changing and now includes the establishment of scientifically defensible reasons for activities and provision of an increased repertoire of scientifically defensible intervention options. Nursing research also aims at increasing cost-effectiveness of activities, providing a basis for standard setting and quality assurance, providing evidence of weaknesses and strengths, providing evidence in support for demand for resources, satisfying academic curiosity and facilitating interdisciplinary collaboration. What has been the most pressing though is to earn and defend their professional status. This points to the essential value of evidence-based nursing practice is the emphasis it places on rational action through structured appraisal of empirical evidence, rather than the adherence to blind conjecture, dogmatic ritual or private intuition. As such, the value for the delivery of effective health care interventions is unquestionable.
However, there are barriers for nurses in implementing new knowledge. Lack of awareness of new evidence and the absence of relevant and/or quality research are two among these barriers. There is also the tendency of nurses to rely on out-of-date information especially when nurses are anxious over the idea of changing practice (Hamer and Collinson, 1999). In evidence-based practice, nonetheless, even where evidence is hard to find the practitioner is still expected to find and assess what evidence there is, appraise it, utilize it and evaluate its use. These barriers and the expectations from nurses requires new set of skills for nurses. Such abilities consist of the ability to define criteria such as effectiveness, safety and acceptability, to assess the quality of evidence, to assess whether the results of the research are generalisable and to assess whether the results of the research are applicable.
Medication errors are one of the most common types of medical errors which can have untoward outcomes for clients. According to Craven and Hirnle (2006, p. 565), medication errors, in is broader sense, reflects basic flaws in the way the healthcare system is organized. Prevention should be therefore a priority for healthcare professionals and institutions because medication errors could damage the reputation of both in the long run. It is in this aspect that quality improvement efforts should be emphasized in healthcare facilities especially through analyzing the root causes of error and recommending changes to the system to prevent the occurrence of the same error in the future. This is critical due to the fact that medication error basically violates the five rights of the patients that should uphold in reality. These rights include right client, right medication, right dosage, right route and right time. Of course, medical practitioners understand and live by these rights although there are circumstances that cannot be avoided. What medical practitioners should better understand is that any error is not only economic cost but could also cost the very life of the patient.
One central theme is evident then: medication errors are resultant from the complexity of the systems combined with nursing performance. Because evidence based practice is rooted in the belief that identifying the best nursing practice will improve outcomes (Iyer and Aiken, 2001, p. 26), medical practitioners including nurses must be put in a context wherein they will be provided with evidences that will enable them to improve own practices. How relevant evidence based practice in relation to medication errors will be explored in this assignment. Addressing and mitigating the risks of errors as much as possible would be a relevant step towards ensuring patients that their rights and interests are protected, preserved and defended. This is particularly important because medication errors could lead to varying degrees of harm and injury to the patient and near harm leading to death. Human factors including cross-professional blunders should be investigated to determine how they could likely to contribute in medication errors. With this said, I have chosen an original research entitled ‘Nurses relate the contributing factors involved in medical errors.’
Authored by Tang et al (2004), the research looked into the processes by which nurses administer medication leading to minimization of medication errors. Nurses’ views about the factors which contribute to committing error are scrutinized in order that improvements to medication administration process could be facilitated. It is of my best belief that aside from human and financial cost there is also the reputation or image cost associated with medication errors. When an error occurs, all became victims with the patients, and their respective families, as the first victims who may be injured, disabled or die. Healthcare team will be the next victim, conflicting loyalties to patient, colleagues and institutions. Physician and healthcare workers could experience guilt, remorse and possible litigation as well questioning their own expertise and capability. The next victim would be the institution and the staff themselves resulting to lost of public confidence with the healthcare system and healthcare institutions. If we could understand the consequences of medication errors based on these costs, then we could tap into the necessity of generating and acquiring evidences that could make certain sustainable medication administration process (Naylor, 2002, p. 73).
As a female healthcare practitioner in a well-established healthcare organization in Saudi Arabia, I understand that it is my responsibility to contribute on patient’s quality of life specifically through protecting their five rights. In my clinical setting which is a 33-bedded male surgical unit, I have observed the ‘normalness’ of medication errors that are always attributed to other factors but not competence and knowledge. I say this because this ‘normalness’ had created a complacent, blaming culture within the setting which could lead to more adverse consequences in the future if it will not be given intervention at this stage. It is only right that medication errors must be revisited and should be taken from the perspectives of nurses as it can result in building experiences and in enhancing capabilities. Evidence based medication administration practice then could possibly give healthcare practitioners like me the incentive to adhere into nursing protocols, as a way to ensure that quality will be integrated to the process of medication administration. Whether how a healthcare practitioner could contribute to the error would be distinguished in addition to how the healthcare organization would address the error occurrence.
A number of features of the study are worth pointing out before conducting a detailed critical appraisal of the original research. The authors have provided a detailed account on the aims and objectives, design and methods, results, conclusions and relevance to clinical practice in the abstract part, providing readers meaningful insights of what the study is all about. The researchers also offered a comprehensive discussion of the rationale behind why they came up with such study. According to them, it is the nurse’s responsibility for reducing errors which occur during the administration of medication. Medication errors should be viewed as both system failure and personal inadequacy as taken from the perspectives of the nurses themselves. Instrument development, sampling procedures and ethical considerations are stipulated which can eliminate specific bias such as information and systematic in the process. Tables and figures are also used to aid the discussions of results and findings of the research. Limitations of the study are also discussed, pointing to sampling bias as the primary limitation.
When it comes to the researchers, four among the five researchers came from National Yang-Ming University in Taipei, Taiwan as associate professor, assistant professors and professor. Another associate professor came from the National Cheng-Kung University in Tainan, Taiwan. The authors also noted that the research was supported by the National Science Council. It would be important to know the background of the researchers to evaluate the legitimacy of the research because only knowledgeable to the field could deliver this kind of research. Burns and Grove (2004, p. 73) claim that building a sound research knowledge base for nursing practice requires collaboration between nurse researchers and clinicians as well as collaborations with researchers from other health-related disciplines. Although the researchers had collaborated with nurse participants, sampling bias could be inherent and this is especially true considering that the participants of the research are registered nurses (RN) students at Yang-Ming University whereby the majority of the researchers are associated with. Such sampling bias could influence the outcomes and findings of the study especially that they are involve in the same educational setting. Connivance, though it can be ruled out, could be considered particularly because there is no blinding involve.
As a qualitative research, qualitative elements with no definite or have no standard measures including behavior, attitudes, opinions and beliefs within the healthcare context are analyzed. This is specifically observable in the use of focus group interviews that passes through four sessions of discussing situations leading to errors. This was used to develop a semi-structured questionnaire of three parts: narrative description of the incident, nurse’s background and contributing factors. Such questionnaire was used to collect quantitative data. In this way, the study had arrived at more objective conclusions and subjectivity of judgment of the researchers was minimized. Though the researchers failed to adopt a distant and non-interactive posture with the research subject, the combination of the qualitative and quantitative study complemented each other and had generated different kinds of knowledge that are useful for the study (Burns and Grove, 2004, p. 23; Polit and Beck, 2003, p. 273). Empiricism is endorsed in the study wherein the position of the study and its researchers is that nurses’ knowledge comes essentially from their own experiences. As such, the study had both described and examined relationships and determined causality between nursing performance and medication errors and generated knowledge concerned with meaning and discovery apparent in categories and conditions of errors identified.
One can easily identify the phenomenon of interest which is the medication errors and the purpose of the study that is to explore contributing factors from the views of the nurses. Nurses are regarded as the first member of the multidisciplinary team hence a primary figure that contributes to the quality of care. Appreciating the significance of the experience of medication administration and respecting the individuality of the patient as well are critical. Burns and Grove (2002, p. 138) assert that there are various phenomenon of interest related to nursing. For instance, caring is a phenomenon that is perceptible in nursing practice. Self-competence is also considered a phenomenon central to nursing practice. Because nurses facilitate self-care of patients, it is important that they themselves are competent about their duties. When it comes to medication administration, it is not only important that nurses know the five rights but also religiously adhere into these rights as part of the care provided to the patients. The breadth of phenomenon was explored based on the self-knowledge of nurses about the contributing factors to medication errors. Evidence is that categories such as personal neglect, heavy workload, unfamiliarity with medication and with patient’s condition and insufficient training implicate knowledge base of nurses administering medication.
The research made use of survey strategy and focus group interviews. From a personal standpoint, the research design was the most suitable design as it intends to explicitly eliminate sampling bias. The research design as highly anonymous and confidential given the issue to be explored. What makes the design plausible is that it applied distinctive considerations so that findings and results could maintain its validity and credibility. Privacy in completing the questionnaires was prioritized. When it comes to the focus group interviews, face and content validity were considered. Questionnaires are validated and ensured to be capable of maintaining confidentiality. Experts also reviewed and assisted in modifying the questionnaire. As such, although there is the existence of sampling bias, one can consider that the study design is strong. Polit and Beck (2007, p. 458) maintain that face validity should not be considered strong evidence for an instrument’s validity. Nevertheless, if other validity types are demonstrated, the instrumentation could be considered effective. Tang et al (2004) considered content validity which is relevant for both affective and cognitive measures.
It would be easy to assess that the questionnaire method was used so that the descriptive survey of the population could help in understanding the existence and magnitude of medication errors. Questionnaires are the most convenient instrument to use in the combination of qualitative and quantitative study (Houser, 2008, p. 277). As such, the researchers were able to diagnose and analyze the situation based on the information extracted from the questionnaires. However, the weakness of the questionnaire is that it cannot guarantee the participants the confidentiality that they demanded. The completion of the questionnaire required the participants to handwrite their answers. Because of fear of recognition of handwriting, they are provided with the option to be interviewed; none opted for an interview though. I consider this as a weakness because it complicates with the study design of anonymity and confidentiality. Therefore, questionnaire is not that appropriate based on the study design. The paradox is that it is the questionnaire itself which had given the breadth and depth to the research as it produces significant insights from that of the nurses as it address the aim of the study.
As opposed to validity that was discussed thoroughly, the study offered no conceptual explanation of reliability. Validity and reliability of the instruments used in the study are important to determine the soundness of these selections in relations to the concepts or variables under investigation. LoBiondo-Wood and Haber (2006, p. 336) stress that the appropriateness of the instruments and the extent to which reliability and validity are demonstrated have a profound influence on the findings and internal and external validity. Reliability also concerns random errors that are unsystematic in nature. Nevertheless, based on the definition of reliability that is defined as the extent to which the instrument yields the same results on repeated measures, the semi-structured questionnaire could be consistent, accurate, precise and stable enough to be repeated. I say this because of the categories and condition identified through the focus group and which is validated by a total of 19 RNs and 5 experts. Nurses’ identification of conditions that resulted in medication errors could be replicated to determine the types of errors committed.
Prior to offering suggestions to improve validity and reliability, I should take note first that there is a strong relationship between validity and reliability of measures: a scale can be reliable but not valid. On the other hand, a scale cannot be valid and also not be reliable hence a scale may consistently measure something (reliability) but not the something it is supposed to measure (validity). From this, we can assess that if a scale measures what it is supposed to measure (validity) then it will inherently also be consistent (reliable). Considerably, the instrument used by Tang et al could be both valid and reliable although the researchers did not provide any information on its reliability. Further, since face validity is considered inadequate, content validity is regarded as the sole legit indicator of validity. Tang et al could have integrated construct validity or the extent to which the scale or instrument measures what it is supposed to measure. In addition, piloting the instrument could ensure reliability of the questionnaire used (Macnee and McCabe, 2006, p. 186). Minor changes were implemented as critiqued by the experts who also agreed on the categories and conditions.
Focus group interview, as already noted, was intended for instrument development. There are nine RN students at the National Yang-Ming University who possessed at least three years of clinical experience and had worked in inpatient and outpatient settings comprised the focus group. The categories and conditions are identified by this group. From this group, ideas, thoughts and perceptions relating to phenomenon of medication errors are elicited. Focus group is considered as an effective alternative in caring profession compared to one-on-one interview. In the study, the focus group had generated findings to be used in the construction of the questionnaire. The traditional process is questionnaire into focus group interview but in nursing practice it is the opposite though the latter is considered in nursing research at times. The advantage of the former is the opportunity to probe survey answers but in the latter the advantage is that inputs of the questionnaire were informed by the experiences of the participants of the focus group. This is an acceptable process particularly that the questionnaire is based on solid information on categories and conditions of medication errors.
What is objectionable about instrument development is that the participants of the focus group are students with very limited exposure to clinical setting; inclusion criterion is 3 years clinical experience. The participants could be treated as professionally inadequate especially that the range of such experiences is not stipulated: from what year to what year. This would be important due to the fact medication administration process is also an ever-changing process whereby new strategies such as, for example, computerized physician order entry (CPOE) are introduced overtime. This would have a bearing because experiences of the RN students are considered and these experiences vary greatly depending on the time and setting where these experiences are accumulated. Would it be more clinically effective if focus group participants are not students but are fully-experienced RNs? Focus group in nursing aimed at identifying flaws for potential improvement (Holloway and Wheeler, 2002, p. 112), however, in the case that experiences of participants are limited the flaws that they could determine could be also limited, leading to limited improvements.
Tang et al claimed that the snowball sampling technique used in the study was consistent with the study design. The focus group participants were asked to contact RN coworkers and other RN acquaintances who might be willing to be recruited to participate. As originally planned, focus group members agreed to recruit between six to eight participants. Gerrish and Lacey (2006, p. 181) put emphasis on selecting a sample strategy that will reflect a naturally occurring phenomenon through naturally occurring population. Sufficient commonalities shared by the respondents or simply the inclusion criteria for the survey were not specified, and this may have significant effect on the findings of the study. Given that snowball sampling was used, it would be understandable that the respondents recruited are of the same practice. However, snowball sampling could be also a confounder because the manner by which people define or self-define themselves as a group member would not be easily reconciled. In relation to the study, this is critical particularly that the researchers offer no information on how they define respondents of the study. No proofs are collected to determine that they are indeed belonged to the same practice.
Further, participants were asked to recall a significant error in which they have been involved in person. Aside from selection of survey respondent bias, there is also the inexistence of recall bias. Thomas et al (2005, p. 316) define recall bias as the systematic error introduced by differences in the recall accuracy. Sensitivity and specificity to recall is imperative relating to the phenomenon of interest under investigation. There constraints inherent to the process which include the time interval and the degree of detail required to be recalled, personal attributes of the study subject and the significance and meaningfulness of the events asked to be recalled (Nelson et al, 2004, p. 70). As such, it would not be easy to reconcile whether the accounts of the respondents are in line with the purpose of the questionnaire. To exacerbate this, the respondents are entitled to the degree of information s/he will choose to disclose. There is thereby the presence of confounder on the part of the respondents wherein their contribution will definitely depend on self-restrictions.
Compliance with ethical protocols is one of the strongest points of the study wherein ethical considerations were explained in written and oral consents were acquired. A thorough explanation of the purpose of the research and the procedures involved therein were given to the respondents including a request for their oral consent to participate, notification of right to refuse to answer and right to refuse to provide further clarification and withdraw information and the guarantee that only the focus group member who recruited them to participate would know of their identity and involvement in the research. Tang et al had underlain the ethical conduct of research because the researchers have integrated the principles of respect for human dignity, rights to full disclosure and self-determination, beneficence and justice. No coercion is evident instead participants are given the free will to choose to participate after the research purpose, expected commitment and ways that anonymity and confidentiality will be addressed. Risks, however, are not discussed. Ethical treatment of data is not discussed as well. Both of which could further demonstrate the integrity of research protocols and honesty in reporting data (Dossey and Keegan, 2008, p. 135).
Tang et al made use of through the SPSS statistic software to descriptively analyze the background and demographics of the nurse participants. The use of the software is commendable as it can assists both type of data manipulation. Narrative statements were analyzed through coding errors and reading the statements independently. In case of unclear and inconsistent interpretations, members of the focus group are asked to ask the respondent for clarification. Generally, the data analysis is appropriate and statistics are used. This led to written and graphical representations of the findings to aid the discussion of the results. As such, data analysis has demonstrated consistency and stability (Hannah et al, 2006, p. 164) in relation to the purpose of the study. Graphics also illustrated the depth of the research, making it easy for the readers to interpret what the researchers have discovered through the research and how it could likely to impact their own practice knowing that medication errors could be attributed to several categories and conditions.
Discussions are divided into three themes: background of errors, contributing factors and types of errors as taken from the perspectives of nurses. Throughout the discussion, Tang et al referred to various several studies for the purpose of providing comparisons with other previous researches. All in all, nurses believe that medication errors cause by the combination of multiple factors including system errors. Personal neglect, heavy workload and new staff are the primary contributing factors of medication errors. Discussion appeared to be consistent with the aim and objectives of the study and is objective. In fact, the study accurately mirrors the contributing factors to which nurses attribute medication errors. Findings are discussed and presented though suggestions for improvements for future study are not offered. The next probable step is to decide on the scientific worth of findings to use the findings in clinical practice as evidence (Watson et al, 2008, p. 6). The relevance of the findings of Tang et al’s study to nursing practice must be determined before this can be regarded as evidence.
In sum, the study offers quality outcomes on the contributing factors leading to medication errors. I say this because although confounders and bias are present in the entirety of the research, Tang et al compensates these through its validity and ethical considerations. Confounders and bias are eliminated as much as possible so that these would not affect or influence the findings of the research. While the researchers offer no discussion on the significance of the study, implications for nursing practice is conferred. Tang et al assessed that the implications of the study centered on the documentation of incidents of medication errors. Error-prone conditions could be minimized through proper training and increasing nursing manpower. Implications of the study are different from the scientific merit of the study yet the authors did not left the readers in an ambiguous state. As such, Tang et al successfully analyzed the contributing factors leading to medication errors as according to nurses who experienced such phenomenon first hand.
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