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401168 Evidence Based Health Care

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401168 Evidence Based Health Care Question  Discuss the principles and processes of evidence based practice; Critically discuss the importance of individual patient preferences when making clinical judgements about the implementation of research findings  Critically discuss barriers and facilitators to implementing evidence based practice in the clinical area; Conduct a comprehensive literature search on a clinical question.  The purpose of this two part assessment is to enable postgraduate students to utilise their clinical experience within their learning and skill development associated with critically reviewing the literature as part of evidence based practice.  Part A: Essay Identify the challenges and describe strategies for implementing an evidence-based approach to clinical practice. Incorporate literature into your discussion. You may find some of the readings on the unit vUWS website useful to get you started. However. it is expected that you will conduct your own search for additional reading material.  Part B: Identification Of Evidence  Clinical question and literature search  1. Write a clinical research question then complete the PICO table (Table 1) with type of patients or problem, intervention, comparison intervention and outcome. The clinical research question should be extended from the discussion in part A   2. Identify key words and search terms to describe the problem, intervention, comparison intervention and outcome and write them in the table to assist you with your literature search.  Answer Part A- Essay Introduction Evidence based practice (EBP) refers to the interdisciplinary approach that comprises of the careful, explicit and sensible use of contemporary best evidences in making pronouncements about the care of patients. The process also encompasses the integration of discrete clinical expertise with the best accessible external medical evidence from organised research (LoBiondo-Wood et al., 2013). In other words, EBP can be defined as the incorporation of clinical proficiency, patient standards, and the finest investigation evidence into the process of clinical decision making, for ensuring health and safety of all patients. The primary objective of EBP is to standardise the available health care services to latest evidences, with the aim of minimising all forms of variation in patient care, and avoiding subsequent unanticipated outcomes among the patients (Townsend & Morgan, 2017). In recent years, a plethora of EBP frameworks and models have been developed by healthcare professionals. In the words of DiCenso, Guyatt and Ciliska (2014) these models and outlines have meaningfully contributed to intensifying the clinical field by founding a sound understanding of the abundant facets of the EBP, including the application and information transformation procedures, the premeditated or structural change theory for indorsing acceptance and implementation of new information, and its subsequent exchange. This essay will elaborate on EBP and the challenges faced during its implementation in mental health practice. Mental health care setting- Primary care is associated with the procedure of providing important healthcare services that are universally accessible to people and their family members, in the community. Primary care is given based on the preferences and needs of the target population (Corrigan, Druss & Perlick, 2014). Delivery of mental health services in such settings encompasses the diagnosis and treatment of people suffering from mental disorders, implementing effective strategies for preventing and managing their signs and symptoms, and ensuring the application of key behavioural and psychosocial skills such as, counselling, interviewing, and interpersonal skills. According to Olfson et al. (2014) mental health illnesses, such as, anxiety, depression, and substance abuse, are some of the most common health conditions that are encountered in a mental health ward. These illnesses typically co-occur with chronic and acute medical complications and are responsible for considerably worsening the associated health outcomes among the affected people. This calls for the need of implementing appropriate strategies for managing the illnesses. Under situations when the mental health problems are not effectually managed, they result in an impairment of self-care and obedience to therapeutic treatments. Furthermore, lack of EBP implementation while treating patients suffering from mental disease are also allied with augmented morbidity and mortality, amplified health care costs, and reduced productivity (Vigo, Thornicroft & Atun, 2016). Prevention and management of widely prevalent mental health diseases in primary care comprises of the application of collective care interventions that are based on contemporary evidences, thus increasing patient access to care, enhancing mental and physical health outcomes, and improving the general cost-effectiveness of the interventions. Owing to the huge variations in the readiness and capacity of mental health programs in a hospital setting, it is imperative to adequately assess the patients and customise the treatment services in relation to mental health care. Assessing the function, resources and goals of the evidence based program is a vital step in implementation of EBP in mental health settings. This should be followed by identification of the achievable and the shared objectives. Joint valuation of the wants and viability of EBP integration, recognition of the exact steps that need to be followed, providing training and support to the staff, and supervising the EBP services are also essential in the clinical practice domain. Challenges to EBP- There is mounting evidence for the fact that for sustainable and effective dissemination of EBP services, support from the management facilitates speed initiation. Demonstrating consistency with the already existing practices are also crucial in mental health ward (Karlin & Cross, 2014). Additionally, availability of necessary resources for the implementation of EBP is crucial for enhancing the health and wellbeing of the patients. Initial challenge is encountered during recruitment of the staff who are responsible for implementation of the EBP in mental health ward. Most often the EBP necessary for treatment of mental disorders require adequate expertise and training from the staff, working in the department (Novins et al., 2013). Lack of proper cultural attitude in the hospital system is another potential challenge encountered in the mental health ward. A common perception lies among the management and hospital authorities that the nurses would not receive any benefits or would not get any monetary advantages, upon the implementation of evidence based strategies in the care setting. There is mounting evidence for the fact that under most circumstances, providing adequate information to the patients on the evidence based intervention confuses them (Warren et al., 2016). Complex information about the intervention threatens their decision-making abilities, and make it difficult for the service users to exert their opinion in relation to implementation of the proposed intervention. In addition, each patients suffering from mental health problems have individual issues and associated psychosocial concerns. EBP often fails to be specific and precise for all the individual factors related to the patients. Another common challenge encountered in clinical practice can be accredited to the fact that although trainings have the potential of enhancing EBP and its role in clinical settings, a lack of infrastructure present in the hospital often makes it difficult to conduct training programs that are tailored in accordance to the needs of the practitioners (Gustafsson, Molineux & Bennett, 2014). Although external workshops are able to train the practitioners in EBP, these are most often inadequate for meeting the vocational demands and preferences of the target population. This calls for the need of a preference-based EBP program that is effortlessly accessible that comprises of funding and needs personal class attendance (Weisz et al., 2013). Another factor that has been identified as an obstacle in the implementation of EBP is misunderstanding and undesirable attitudes on scientific research and EBP application. It has been found that most healthcare professionals, specifically nurses portray a negative approach towards clinical research and fail to understand the aspects that entail EBP. This challenge is found to persist specifically under circumstances when there are old nurses who hold the fear that a change in treatment strategy would result in modification of practice culture (Nilsen & Bernhardsson, 2013). This fear of change is likely to be manifested by senior nurses who demonstrate less positive attitude towards investigation and application of EBP, in comparison to the younger nurses. Hence, lack of willingness for undertaking extensive research results in problems while attempting to subject the patient to interventions that have adequate evidence for success. In addition, Berger (2013) stated that the healthcare staff often have insufficient knowledge on the procedures that need to be followed for the application of EBP in mental health practice. Of the plethora of factors that are responsible for determination of the way by which the nurses utilise the contemporary scientific evidences, individual physiognomies of the nurses, features of the concerned healthcare organization, and the environmental characteristics are most responsible for creating barriers. It has also been found that lack of understanding on the research design, statistical results and data interpretation leads to inadequate skills. Multisystem collaboration is imperative for subjecting the patients to treatment approaches that have proved effective in the management of conditions as depression and schizophrenia, in clinical trials. Failure in engaging the key stakeholders in the co-operative arrangement of EBP implementation prevents ensuring presence of adequate resources, enticements, and necessities, thus impeding success of the overall program (Casey et al., 2017). Likewise, multisystem collaboration comprises of buying-in from the greater system, and also includes key personnel from the health department and mental health network, which in turn is difficult to accomplish. The role of greater system variations, such as, rearrangement of the progress notes are imperative in instructing the mental health teams on their commitment to EBP routine (Mick, 2014). Thus, lack of support from the system results in great financial burden and acts in the form of a hurdle to their participation in EBP exercise. Creating provisions that hold the potential of compensating healthcare personnel for the time they spent in consultation and training is typically considered fruitful. However, asking the mental health teams for their participation in EBP exercise efforts, besides their customary responsibilities is often reflected as a barrier in practice (Foster & Flanders, 2014). Owing to the fact that EBP implementation in mental health practice requires changes in health care policies that promote integration of the services in the setting, obstacles are often faced in convincing the authorities and administration for reimbursing the healthcare professionals who are entitled with the duty of promoting integration of the intervention. Most of the time, the authorities fail to recognise the need of replacing conventional treatment procedures by those that have been proved effective in several scholarly articles (Young, 2012). Low levels of engagement among the patients and their family members often results in a drop out, in the mental health setting, owing to lack of motivation for them to remain enrolled in the treatment procedure. According to Cullen (2018) certain strategies need to be adopted for effectively engaging the patients in the EBP event such as, acknowledging the delivery of good treatment, addressing their values and preferences, reinforcing efforts taken to change the treatment, and providing options for accomplishment of the intended goals. However, the professionals often fail to elicit self-motivational modifying statements, thus resulting in their failure in recognising, developing and implementing plans for making the patients adhere to the proposed treatments (Weist et al., 2014). Adequate provisions must be there for accessing the internet and search engines, in order to retrieve scholarly evidences that contain relevant information on the efficacy of certain pharmacological and non-pharmacological interventions, for the management of mental disorders. However, at most instances there is lack of adequate internet facilities in the healthcare setting, which in turn prevents the nursing staff from extracting contemporary evidences to treat a phenomenon under investigation. Collection of adequate scientific information requires unrestricted access to a rich library that acts as a repository of nursing journals (Gosselin, Dalton & Penne, 2015). This organisational barrier also makes it difficult to access the high quality evidences that are pertinent to different mental disorders from which the admitted patients suffer. Despite the increase in the demand for nursing health professionals in mental health wards, the employment rates are constant, thereby leading to a shortage in the workforce. Lessening pipeline of mental nurses can also be accredited to a shortage of faculty, which in turn makes the nursing staff working in the mental ward work for prolonged hours under stressful conditions (Hosking et al., 2016). Subsequent onset of injury, fatigue and job dissatisfaction makes the staff lose interest in implementing better procedures for treating mental disorders, and also increases their likelihood of making medical errors. Conclusion- Thus, it can be concluded that collaboration, mentorship, interdisciplinary communiqué, proper professional network, and helpful organisation as critical to EBP adoption. It is imperative for nurses working in the mental ward to remain equipped to formulating necessary questions, critically assessing their practice, and evaluating the guidelines and evidence levels, for operation in the hospital settings. Despite functional development and organisations in place to indorse EBP, most authorities and administration have yet to assimilate an evidence-based care model. This calls for the need of addressing the identified barriers and creating provisions that will facilitate the implementation of interventions and strategies that are able to effectively reduce severity of mental illnesses, thus enhancing the health and wellbeing of the patients. Part B- Identification Of Evidence Step 1 Question:  Is music therapy more effective than antipsychotic medication for managing schizophrenia? Type of patients or problem Intervention Comparison intervention (if any) Outcome People diagnosed with schizophrenia or schizoaffective disorder (based on DSM-V criteria) Music therapy Usual antipsychotic medications Reduction in symptom severity, preventing relapse, enhancing functioning, averting adverse effects of medications, improving quality of life Keywords: “schizophrenia”, “schizoaffective disorder” Keywords: “music”, “sound” Keywords: “placebo”, “antipsychotic”, “medicines” Keywords: “relapse”, “functioning”, “adverse effects”, “quality of life”, “severity”, “symptoms”                                        Table 1- Research question (PICO components) Step 2                                                                 Figure 1- MEDLINE database search results                                                                              Figure 2- PubMed database search results Article selected: Tseng, P. T., Chen, Y. W., Lin, P. Y., Tu, K. Y., Wang, H. Y., Cheng, Y. S., … & Wu, C. K. (2016). Significant treatment effect of adjunct music therapy to standard treatment on the positive, negative, and mood symptoms of schizophrenic patients: a meta-analysis. BMC psychiatry, 16(1), 16. The PICO components of the article are given below: P Schizophrenic patients I Adjunct music therapy C Usual care O Positive, negative, and mood symptoms                                                Table 2: Components of the identified article References Berger, R. (2013). Incorporating EBP in field education: Where we stand and what we need. Journal of evidence-based social work, 10(2), 127-135. Casey, M., O’connor, L., Nicholson, E., Smith, R., O’brien, D., O’leary, D., … & Egan, C. (2017). The perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners. Journal of advanced nursing, 73(12), 3007-3016. Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest, 15(2), 37-70. Cullen, L. (2018). Translating EBP Into the Reality of Daily Practice: Leadership Solutions for Creating a Path Forward. Journal of PeriAnesthesia Nursing, 33(5), 752-756. DiCenso, A., Guyatt, G., & Ciliska, D. (2014). Evidence-Based Nursing-E-Book: A Guide to Clinical Practice. Elsevier Health Sciences. Foster, J., & Flanders, S. (2014). Challenges in CNS practice and education. OJIN: The Online Journal of Issues in Nursing, 19(2). Gosselin, T. K., Dalton, K. A., & Penne, K. (2015, November). The role of the advanced practice nurse in the academic setting. In Seminars in oncology nursing (Vol. 31, No. 4, pp. 290-297). WB Saunders. Gustafsson, L., Molineux, M., & Bennett, S. (2014). Contemporary occupational therapy practice: the challenges of being evidence based and philosophically congruent. Australian Occupational Therapy Journal, 61(2), 121-123. Hosking, J., Knox, K., Forman, J., Montgomery, L. A., Valde, J. G., & Cullen, L. (2016). Evidence into practice: Leading new graduate nurses to evidence-based practice through a nurse residency program. Journal of PeriAnesthesia Nursing, 31(3), 260-265. Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System. American Psychologist, 69(1), 19. LoBiondo-Wood, G., Haber, J., Berry, C., & Yost, J. (2013). Study Guide for Nursing Research-E-Book: Methods and Critical Appraisal for Evidence-Based Practice. Elsevier Health Sciences. Mick, J. (2014). Nurse interns’ experience with participation in the evidence-based practice project requirement of a Nursing Internship Program. Nurse educator, 39(2), 54-55. Nilsen, P., & Bernhardsson, S. (2013). Towards evidence-based physiotherapy–research challenges and needs. Journal of physiotherapy, 59(3), 143-144. Novins, D. K., Green, A. E., Legha, R. K., & Aarons, G. A. (2013). Dissemination and implementation of evidence-based practices for child and adolescent mental health: A systematic review. Journal of the American Academy of Child & Adolescent Psychiatry, 52(10), 1009-1025. Olfson, M., Blanco, C., Wang, S., Laje, G., & Correll, C. U. (2014). National trends in the mental health care of children, adolescents, and adults by office-based physicians. JAMA psychiatry, 71(1), 81-90. Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health nursing: Concepts of care in evidence-based practice. FA Davis. Vigo, D., Thornicroft, G., & Atun, R. (2016). Estimating the true global burden of mental illness. The Lancet Psychiatry, 3(2), 171-178. Warren, J. I., McLaughlin, M., Bardsley, J., Eich, J., Esche, C. A., Kropkowski, L., & Risch, S. (2016). The strengths and challenges of implementing EBP in healthcare systems. Worldviews on Evidence?Based Nursing, 13(1), 15-24. Weist, M. D., Youngstrom, E. A., Stephan, S., Lever, N., Fowler, J., Taylor, L., … & Hoagwood, K. (2014). Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health. Journal of Clinical Child & Adolescent Psychology, 43(2), 244-255. Weisz, J. R., Ugueto, A. M., Cheron, D. M., & Herren, J. (2013). Evidence-based youth psychotherapy in the mental health ecosystem. Journal of Clinical Child & Adolescent Psychology, 42(2), 274-286. Young, M. (2012). Transitioning evidence to practice. Evidence-Based Practice for Nurses, 386-396.

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