Chapter 4 Evidence-Based Practice and Ethics in Community Health Nursing

Evidence-Based Practice Research: systematic collection and analysis of data related to a particular problem or phenomenon Use of evidence or research findings along with clinical judgment and patients’ wishes in making decisions about how to care for patients Clinical reasoning is an important component Commonalities between evidence-based practice and critical thinking

Evidence-Based Practice (cont.) Sources of information: Integrative or systematic reviews Cochrane Collaboration (www.cochrane.org) AHRQ evidence-based practice centers (http://www.ahrq.gov) Worldviews on Evidence-Based Nursing from Sigma Theta Tau International (www.nursingsociety.org) Evidence-Based Nursing, a British online journal (www.ebn.bmjjournals.com) RAND Corporation research briefs (www.rand.org)

Evidence-Based Practice (cont.) Correctly compose a clinical question. Find an appropriate database to search for systematic reviews. Critically review the evidence. Consult practice guidelines and expert practitioners. Work with clients to develop an appropriate plan of action.

Question Is the following statement true or false? Evidence-based practice involves clinical reasoning.

Answer True Clinical reasoning is an important component of evidence-based practice.

Quantitative and Qualitative Research Quantitative Research Data can be quantified or measured objectively. Helpful in identifying problem or relationship between two or more variables Qualitative Research Emphasis on subjectivity and the meaning of experiences to individuals Possible use of both approaches in research studies Meta-analysis: statistical procedure to analyze research; involves evaluating the results of many similar quantitative research studies in an attempt to integrate findings and combine sample sizes of many small studies to obtain a “single effect measure”

Steps in the Research Process Identify an area of interest (specificity, feasibility, and relevance). Formulate a research question or statement (population of interest, variables, interventions). Review the literature (primary and secondary sources). Select a conceptual model (framework of ideas providing structure and direction for research activities).

Steps in the Research Process (cont.) Choose a research design (experimental [true experiments, randomized control trials, quasi- experimental]; nonexperimental or descriptive). Obtain IRB or Human Subjects Committee approval. Collect and analyze data (instrument, instrument validity and reliability; statistical procedures [descriptive, inferential]). Interpret results. Communicate findings.

Impact of Research on Community Health and Nursing Practice Public policy and community’s health Effectiveness of community health nursing practice Status and influence of nursing as a profession

Question When preparing to perform research, which of the following would the nurse do first? Choose a research design Review the literature Formulate a research question Select a conceptual model

c. Formulate a research question Answer c. Formulate a research question After identifying an area of interest, the next step would be to formulate a research question or statement. This is followed by a review of literature, selection of a conceptual model, and then selection of a research design.

Values Something perceived as desirable or a personally held abstract belief about the truth and worth of thoughts, objects, or behavior Motivation to behave in certain ways Derived from societal norms, family and/or religious beliefs Value system resulting from experiences with others Function as standards that guide actions and behavior in daily situations; code of conduct

Qualities of Values Endurance: relatively stable over time Hierarchical arrangement: certain values have more weight or importance than others Prescriptive-proscriptive belief: descriptive (capable of being true or false); evaluative (judgments of good and bad) Reference: terminal (end states of existence [spiritual salvation, peace of mind]; instrumental (modes of conduct [confidentiality, keeping promises, honesty]) Preference: one mode of behavior over another

Value Systems Organizations of beliefs guiding behaviors Systems of ordered priority allowing for change over time based on changes in society, environment, or personal experience Conflict in values is part of decision-making processes. Persistence in some values (i.e., individual vs. community) has effects on efforts to achieve “health care for all.”

Values Clarification Process of identifying the personal and professional values that guide one’s actions by prompting person to examine what he or she believes about worth, truth, or beauty of any object, thought, or behavior and where this belief ranks compared with other values Helpful in guaranteeing that any course of action chosen is consistent with their beliefs and values

Process of Valuing Choose the value freely and individually. Choose the value from among alternatives. Carefully consider the consequences of the choice. Cherish or prize the value. Publicly affirm the value. Incorporate the value into behavior so that it becomes a standard. Consciously use the value in decision making.

Question Is the following statement true or false? The endurance of a value means that the value has more importance than another.

Answer False The endurance of a value refers to the fact that the value is relatively stable over time.

Value Clarification Strategies Values Clarification Strategy I: Name tag exercise (see Fig. 4.4) Values Clarification Strategy II: Patterns (see Fig. 4.5) Values Clarification Strategy III: Forced choice ranking (see Fig. 4.6)

Ethics Set of moral principles; theory or system of moral values; principles of conduct of a group; guiding philosophy Ethical decision making: making a choice that is consistent with a moral code or that can be justified from an ethical perspective Bioethics: use of ethical principles and methods of decision making that involve biological, medical, or health care issues Ethical situations: typically involving issues with words such as want, desire, refer, should, or ought or benefit, harm, duty, responsibility, right, or obligation.

Ethical Decision-Making Frameworks Key steps: Separate questions of fact from questions of value. Identify both clients’ and nurse’s value systems. Consider ethical principles and concepts. Clarify the ethical dilemma.

DECIDE Model D—Define the problem (or problems) E—Ethical review C—Consider the options I—Investigate outcomes D—Decide on action E—Evaluate results

Values that Guide Decision Making Self-determination Individual autonomy Possible deterioration to self-interest Well-being (state of positive health) Equity (justice, fair or equal treatment)

Ethical Principles Respect Autonomy Beneficence Nonmaleficence Justice (distributive, egalitarian, restorative) Veracity Fidelity

Question Which ethical principle is applied when the nurse ensures the group’s involvement in decision making? Beneficence Autonomy Respect Justice

Answer b. Autonomy Autonomy is applied when the nurse promotes a group’s right to be involved in decision making. Beneficence is demonstrated when the nurse makes decisions that actively promote the community’s best interests and well-being. Respect is demonstrated by acknowledging the clients as participants in shaping their own and the community’s health outcomes. Justice is demonstrated when clients are treated fairly and equally.

Application of Ethical Principles to Decision Making Related to value of self-determination Respect the choices of clients. Protect privacy. Provide for informed consent. Protect diminished capacity for self- determination.

Application of Ethical Principles to Decision Making (cont.) Related to value of well-being Reduce or prevent harm and provide benefits to client populations. Measure the effectiveness of nursing services. Balance costs of services against real client benefits.

Application of Ethical Principles to Decision Making (cont.) Related to the value of equity Broadly distributing health goods (macroallocation issues) Deciding which populations will obtain available health goods and services (microallocation issues)

Internet Resources American Nurses Association: http://www.nursingworld.org Healthy People 2010: http://www.health.gov/healthypeople International Council of Nurses: http://www.icn.ch/index.html United Nations: http://www.un.org U.S. Department of Health and Human Services: http://www.hhs.gov World Health Organization: http://www.who.org