Using Evidence-Based Practice for Clinical Decision Making in the Holistic Nursing Process

 

By Ellen Fineout-Overholt Ph.D., RN
Carol M. Baldwin Ph.D., RN, CHTP, AHN-BC, Co-chair, AHNA Research Committee
Edward A. Greenberg Ph.D.

 Evidence-based practice (EBP) is the conscientious use of the best available research in combination with clinicians’ expertise and judgment and patients’ preferences and values to arrive at the best decision that leads to quality outcomes (Melnyk & Fineout-Overholt, 2005). These criteria are fundamental components of the holistic nursing process. The intent of this paper is to assist holistic nurses to understand and apply the steps of the EBP process. To this end, a peer-reviewed paper by McBride et al. (1999) is used as an exemplar for applying these steps. McBride and colleagues examined the use of music to reduce dyspnea and anxiety in 24 home-dwelling patients with COPD. Pre- and post-test repeated outcome measures included the Spielberger State Trait Inventory (STAI) and a Visual Analogue Dyspnea Scale (VADS). Patients also kept a music diary in which they documented their level of dyspnea just before and immediately after listening to the music, and a qualitative questionnaire listing the effects of listening to the music. This article was selected because the authors incorporated patient preference (i.e., patients selected the music that they played while experiencing dyspnea) as part of their intervention in support of practice, and the authors included both qualitative and quantitative data in their evaluation of the intervention.

The initials steps of the EBP process include the clinical issue of interest, formulating the issue into a searchable and answerable question, finding the appropriate evidence to answer the question, and determining the worth of the evidence (Table 1). Once valid, replicable evidence has been found, clinicians are compelled to apply it to their clinical practice and evaluate the effectiveness of the application. All of these steps are necessary for EBP to be successful. Imagine a clinical scenario in which you are caring for a client who has COPD. Your clinical judgment leads you to think that perhaps some of the dyspnea may be associated with anxiety or stress related to difficulty breathing and want to know if there are non-pharmacologic holistic approaches, such as music therapy, that can be use in conjunction with oxygen and/or medication. As a holistic nurse, you know that EBP is a part of the holistic nurse’s handbook for practice (Dossey et al., 2005). You realize that the EBP process can assist you in finding answers for best practices in providing holistic care.

In Step 1 of the EBP process, asking the searchable, answerable question, clinicians must consider using a standardized format. PICO is one such format (Table 2). In our example, the clinical question that you are asking is, "In COPD patients, does music therapy or anxiolytics produce a greater reduction in anxiety and subsequent dyspnea?”

To find the best evidence to answer this question, you implement Step 2 to search for a randomized controlled trial (RCT) that compares these two interventions on the given outcome. Often, RCTs are not available to answer such questions, however, and other evidence may be helpful in guiding practice. You use the key words from your PICO question (i.e., COPD, music therapy, anxiolytics, anxiety, and dyspnea) to start your search keeping in mind that clinicians choose databases carefully in order to gather all relevant evidence. In this case, you search the Cochrane Database of Systematic Reviews, Medline, CINAHL, and PsycINFO databases using keywords and controlled vocabulary headings, which provide a mechanism to gather more relevant evidence (Fineout-Overholt et al., 2005). In the search, you use a combination of key words and headings that are based on your question to reduce the number of studies gathered to answer your given question.

Your search results include one study by McBride et al. (1999) that may provide an answer to your clinical question, but it is not a RCT. When no RCT can be found, it is important to determine the best available evidence and related implications for practice. You realize that you must critically appraise the McBride study, which is Step 3 of the EBP process. In their mixed-methods repeated measures study, 24 participants provided information for five weeks as to how music of their preference affected their anxiety and dyspnea. Their abstract indicates that they are addressing two research questions: a) "What is the effect of music therapy on dyspnea and anxiety in COPD patients?” and b) ”What is the effect of music therapy on the perception of anxiety and dyspnea of COPD patients?”

As you begin your critical appraisal, you note that McBride included both quantitative and qualitative methods, which is an indicator of validity. The study report provided information on the sample, their selection, number of drop outs, the validity and reliability of the outcome measures, the intervention, the collection of qualitative data, and the follow-up. After reading the study and further assessing markers of validity (Table 3), you determine that this study is valid and may apply to your clinical practice. You also note that the anxiety and dyspnea findings are statistically significant, but do not know if the findings are clinically meaningful. You consult a nurse methodologist, who calculates effect size to evaluate the clinical significance of the effect of music therapy on anxiety and dyspnea. You learn that the findings are not only statistically significant but are clinically significant, and that both measures showed moderate effect sizes (Table 4). Because this study was a repeated measures design, pre- and post-test correlations were not available to calculate confidence intervals. You only can make assumptions about the effect size parameters in this particular study. This is not the case with other studies that use two or more groups, and you recognize that it is important to include this information in your studies so that other clinicians and researchers can calculate confidence intervals for effect size, if they so choose. The reported analysis of participant perceptions’ of levels of dyspnea before and after listening to the music was also insufficient to determine clinical meaningfulness of the results because no pre- and post-test mean anxiety scores and standard deviations were reported. This further underscores the importance for researchers to include sufficient data to determine both statistical and clinical significance.

You then evaluate the qualitative data, and it is apparent that clients benefited from the music therapy (Table 5). Participant comments suggest that the music assisted them in pacing their breathing, thereby reducing their demand for oxygen, which allowed them to accomplish their goals. You note that their comments do not indicate that they felt anxious, or that music decreased their anxiety, if it existed. From these data, the expected relationship between anxiety and dyspnea is not apparent. Based on the participant information, it is not known if music therapy reduces anxiety and subsequently dyspnea. Participants reported a perceived reduction in oxygen demand after listening to their chosen music therapy that allowed them a better quality of life. This leaves the second research question unanswered.

Implications for Holistic Nursing Practice
Steps 4 and 5 of the EBP process hold implications for holistic nursing practice. A reduction in anxiety is desirable, whether or not it leads to a reduction in dyspnea. As a holistic nurse, you know that there are numerous approaches to reduce anxiety, including massage, relaxation training, and healing touch. Regardless of the modality, each would require empiric support for their effectiveness in reducing anxiety-associated dyspnea and how the patient perceived the intervention.

Step 4 of the EBP process highlights the integration of all the evidence obtained from the critical appraisal in combination with the holistic nurse’s clinical expertise, patient preferences, and values when making a practice decision or change. As a holistic healthcare provider, you recognize that several of the above mentioned interventions require advance education and/or certification, and the holistic nurse provider may or may not have the required training. However the music therapy supported in this study was driven by patient preference, is readily available, and does not require certification; therefore, it has great potential as an intervention to reduce dyspnea in COPD patients.

The qualitative information provided by the participants gave you insight into their lived experience with dyspnea, and reinforced the idea that holistic nurses need to be considerate regarding clients’ music preferences and the potential effects on dyspnea, such as assisting patients to achieve their goals. The quantitative findings were both statistically and clinically significant. Hence, based on your critical appraisal of the evidence provided by McBride et al. (1999), you decide to incorporate music therapy into your holistic nursing process, knowing that the choice of music will be decided upon by the client.

Finally, you are cognizant of the fact that incorporating music therapy into your clinical practice leads to Step 5 of the EBP process, to evaluate the practice change or decision. After incorporating patient-preferred music therapy into the clinical plan for COPD patients in your care, you continue to collect information on anxiety, perceived dyspnea, oxygen demand and perceived quality of life. These outcomes indicators will assist you in evaluating the success of, or need for changes in the patient-preferred music therapy program. You also recognize that music therapy may have actions other than decreasing anxiety and subsequently reducing oxygen demand. You wonder if perhaps patient-preferred musical selections influence respiratory muscle relaxation separate from anxiety, allowing clients to pace their goal setting, thereby enhancing their quality of life. To this end, relationships between music therapy, oxygen demand, quality of life, or other clinical outcome indicators need to be tested empirically.

In summary, based on your critical analysis, the EBP process has been brought full circle fostered by a spirit of holistic clinical inquiry. Asking new questions to be answered by evidence, generating the evidence and implementing the evidence when merged with clinician judgment and patient preferences provides for a culture of best practice and addresses the holistic needs of the client.

References
Dossey, B. M., Keegan, L., & Guzzetta, C. E. (2005). Holistic nursing: A handbook for practice (4th edition). Sudbury, MA: Jones and Bartlett Plublishers.

Fineout-Overholt, E., Nollan, R., Stephenson, P., & Sollenberger, J. (2005). Finding relevant evidence. In B. M. Melnyk & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins (pp. 40-70).

McBride, S., Graydon, J., Sidani, S., & Hall, L. (1999). The therapeutic use of music for dyspnea and anxiety in patients with COPD who live at home. Journal of Holistic Nursing, 17, (i.e., no pre & post mean anxiety scores & standard deviations reported) 229-250.

Melnyk, M. B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins.

Table 1. The EBP process.

1. Ask the clinical question (PICO).

2. Collect the most relevant and best evidence.

3. Critically appraise and synthesize the evidence.

4. Integrate all evidence with one’s clinical expertise, patient preferences and values in making a practice decision or change.

5. Evaluate the practice decision or change.

 

Table 2. Standardized format (PICO) for formulating a searchable, answerable question.

P          Population of interest (Patients with COPD)

I           Intervention of interest (Music therapy)

C          Comparison of interest (Anxiolytics)

O          Outcome of interest (Reduce anxiety and subsequently reduce dyspnea)

Table 3. Indicators of validity for quantitative/intervention studies (Rapid critical appraisal checklist for a randomized clinical trial).

1. Are the study findings valid?

  • Were the subjects randomly assigned to the experimental and control groups?
  • Were the follow-up assessments conducted long enough to fully study the effects of the intervention?
  • Did at least 80% of the subjects complete the study?
  • Was random assignment concealed from the individuals who were first enrolling subjects into the study?
  • Were the subjects analyzed in the group to which they were randomly assigned?
  • Was the control group appropriate?
  • Were the subjects and providers kept blind to the study group(s)?
  • Were the instruments used to measure the outcomes valid and reliable?
  • Were the subjects in each of the groups similar on demographic and baseline clinical variables?

Yes

No

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. What are the results of the study and are they important?

  • How large is the intervention or treatment effect (NNT, NNH, effect size, level of significance)?
  • How precise is the intervention or treatment (Confidence Intervals)?

 

3. Will the results help in caring for patients?

  • Are the results applicable to my patients?
  • Were all clinically important outcomes measured?
  • Is the treatment feasible in my clinical setting?
  • What are the risks and benefits of the treatment?
  • What are my patient’s/family’s values and expectations for the outcome that is trying to be prevented and the treatment itself?

Yes

No

Unknown

 

 

 

 

 

 

 

 

 

 

*Note: Separate from validity, you might want to determine if the authors provide a relevant theoretical framework, which may contribute to the meaningfulness to clinical practice.

 

Table 4. Effect sizes for anxiety and dyspnea (McBride et al., 1999).

Indicator(s)

Mean ± SD

Effect Size

STAI

Pre-test

Post-test

 

7.75±3.03

6.38±2.32*

 

0.511

VADS

Pre-test

Post-test

 

2.83±2.01

1.88±1.87**

 

0.501

*p<0.05; **p<0.01

Table 5. Qualitative patient statements and music diary documentation (McBride et al., 1999).

Music Effectiveness Questionnaire Comments

Music Diary

"Decreased my concentration on breathing”

Music helped to make daily household chores achievable.

"Dulled the sound of oxygen”

Music helped to accomplish outdoor activities, making the work less strenuous.

”Gave me time to gain control”

Music helped to adapt to a slower pace and more efficient use of oxygen during outdoor activities

 

About the Authors

Ellen Fineout-Overholt PhD, RN is Director of the Center for the Advancement of Evidence-Based Practice at Arizona State University College of Nursing in Tempe, Ariz. Carol M. Baldwin PhD, RN, CHTP, AHN-BC is co-chair of the AHNA Research Committee and affiliated with the Arizona State University College of Nursing (Southwest Borderlands) in Tempe, Ariz. Edward A. Greenberg PhD is Associate Research Scientist at Arizona State University College of Nursing in Tempe, Ariz.

 


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