Evidence Based Nursing in Primary Health Care

Strength of a National Development

Prema .P

Principal

Navodaya College Of Nursing

Raichur

Karnataka

Why we are all here???????• To visit Chennai in the Name of

conference• As a part of our academic activity and

meet with our friends• Our teachers told us so we have too…. • To improve our knowledge in EBP • To practice EBP in my future

Ordinary man can try million times, But only a ambition man can try one time in a million ways

Conference theme

Evidence based Nursing Research: Promote Education, inform Practice, Derive Quality Care Policies

Outline Review of

• Primary Health Care • Nursing contribution to

Principles and Values of PHC • EBP• Future of PHC Nursing

Dear Professionals ……….

Your attention is highly and heartly appreciable

Destination to the

World…

Over 32 years ago, we had set a bold aspiration on health in India

India was a signatory to the Alma-Ata declaration 1978, to attain the

global objective of

“Health for All by year 2000”

Why Alma Ata declaration?

What is Primary Health Care?

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

(Declaration of Alma Ata, 1978)

Why Nursing in Primary Health Care ?

Who is PHC Nurse ?

As per ICN these members are under the umbrella of PHC Nursing

• Public Health Nurses• Community Nurses• Health Visitors• Maternity Nurses• Practice Nurses• Nurse practitioners • School Nurses• Community Mental

Health Nurses

• Learning Disability Nurses

• District Nurses• Home Care Nurses• Palliative care Nurses• Community Pediatric

Nurses and • Family Nurses

For example

• A case study was conducted by Patterson, Elizabeth (2000) to describe the current role of these nurses and to identify and analyze the factors that influenced their scope of practice and hence their contribution to PHC. The result of the study showed that the practice nurse's role, and hence contribution to PHC, was found to be constrained by a number of factors . The majority of practice nurses believe their role should be expanded to include autonomous functioning while most of the GPs were amenable to some extension of nursing practice but reticent or opposed to any independent interventions

Nursing contribution to principles and values of primary health care

Equitable Distribution

• National sample survey organization• A comparative study to assess the utilization of

immunization Services among under-five children in a selected areas of Raichur district, Prema(2004)

 

Universal access to care and coverage on the basis of need

• Nursing care of people with HIV/AIDS in South Africa, Uys(2003)

• The prevalence rate of AIDS for people aged 15-49 in south Africa is 18.8% compared to 0.6 in the USA UNAIDS (2006)

Community Participation

• Community health volunteers‘• Village health and sanitation community • Rogi Kalyan Samitis (Patient welfare Society

/hospital Development Committee)• Decentralization :Involvement of Panchayati Raj

Institutions –PRI (local government bodies ) • Community led initiatives to promote HFA

Sheela Pai and Nagarajaiah (1980) compared the cost of treatment of chronic schizophrenic patients at hospital and at community. They found lower cost of home care and improved family participation in treatment process.

Inter-sectoral coordination and convergence of programmes

• Convergence with different health related sectors• Convergence with Indian system of medicine(AYUSH)• Coordination with rural medical practitioners• Coordination with Non- Governmental and civil

Organization• Public Private Partner ship (PPP)

Appropriate Health Technology

• Technology that is scientifically sound, adaptable to local needs, and acceptable to those who apply it and those whom it is used, and that can be maintained by the people themselves keeping with the principle of self reliance with the resources the community and country can afford(WHO)

Cont,,

• The ICN code of ethics for Nurses (2006) refers to the nurse ,in providing care ,ensures that the use of technology and scientific advances are compatible with the safety, dignity, and rights of people’. To practice ethically and responsibility, PHC nurses must be aware of the range of health technologies available to them and be knowledgeable about their safety and efficacy.

Research brings change in nursing education

Joubert, A., Viljoen, M.J. Venter, J. A. & Bester, C.J. (2002) Evaluation of the effect of a computer-based teaching programme. (CBTP) on knowledge, problem-solving and learning approach. Sample : Convenience sample of 120 nursing students in two educational Institutions in South Africa.

Components of PHC

Maternal and child health

Sneha Mathew(2010) A Study to assess the effectiveness of Structured Teaching Programme on knowledge regarding Selected Obstetric Emergencies and Their Management among Junior Health Assistant (Female) Students in selected Training Center Of Raichur, Karnataka”( Navodaya College Of Nursing, Raichur)

 

Immunization

• Kotturesh K.M. “An experimental study to assess the effectiveness of Structured Teaching Programme on Hepatitis B, Vaccination among the mothers of under 5 children, admitted in the paediatric ward at S.C. Hospital, Hassan, 2006, (NDRK College of Nursing)

Nutrition

K.Thilagam (2009)An experimental study to assess the effectiveness of dietary intervention on anemia among adolescence girls in selected area at Thiruvallur District, Saveetha College of Nursing ,Chennai

Prevention and control of locally endemic diseases

• Shankarevva N, “A study to assess the knowledge and attitude of high school children regarding prevention and control of tuberculosis in selected schools at Bilekalli, 2005 (Maaruti College of Nursing, Bangalore).

Treatment of common illness and injuries

• Vijayakumari G. “A study to assess the effectiveness of structured teaching programme regarding nature and prevention of accident among mothers of toddlers in selected area of Raichur, 2004 (Navodaya College of Nursing, Raichur).

Provision of essential drugs

• Fuqua and Stevens (1988) reviewed studies conducted about medication errors. The ward managed by qualified nursing staff showed less medication error than the ward managed by technical staff.

Safe water and basic sanitation

Health education

Lipman (1986) reported that newly diagnosed diabetic children educated by a nurse were discharged from the hospital an average of 2.2 days earlier than children taught only by non nursing staff.

Know yourself …….

Cow , Tiger, Sheep, Horse, Pig

What is EBPHC?

Evidence-based Primary Health Care is defined as the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems, and appropriate use of behavioral science theory and program planning models.

EBPHC is the conscientious explicit and judicious use of current best evidence in making decisions about the care of communities and population in the domain of health protection, disease prevention, health maintenance and improvement

know the Goals • Provide practicing nurses with evidence-

based data• Resolve problems in the clinical setting• Achieve excellence in care delivery• Introduce innovation• Reduce variations in nursing care• Assists with efficient and effective

decision-making

Goals (con’t)• Using best evidence to implement the

regulation of nurses• Resolve regulatory problems• Achieve excellence in regulation

Why is it important? Provides

assurance that decision making is based on scientific evidence and effective practices;

Cont….

• Helps ensure the retrieval of up-to-date and reliable information about what works and doesn’t work for a particular health question;

Cont,,,,

• Provides assurance that one’s time is being used most efficiently and productively in reviewing the “best of the best” information available on the particular health question.

When is it important?

• When it’s important to have scientific evidence to support decision making;

Cont,,,

• When evaluating the effectiveness and cost benefits of health programs;

Cont,,,,

• when implementing new health programs;

Cont,,,,

• when establishing new policies

Cont,,,,,,

• When conducting literature reviews for grant projects.

How to do ?

Step 1 :

Formulate answerable clinical question

P I C O

• Patient, Population or Problem

• What are the characteristics of the patient or population?

• What is the condition or disease you are interested in?

P I C O

• Intervention or exposure

• What do you want to do with this patient (e.g. treat, diagnose, observe)?

P I C O

• Comparison • What is the alternative to the intervention (e.g. different drug, surgery)?

P I C O

Outcome • What are the relevant outcomes (e.g. morbidity, death, complications)?

How to formulate question?

You admit a 75 year old woman with community-acquired pneumonia. She responds nicely to appropriate antibiotics but her hemoglobin remains at 100 g/l with an MCV of 80. Her peripheral blood smear shows hypochromia, she is otherwise well and is on no incriminating medications. You contact her family physician and find out that her Hgb was 105 g/l 6 months ago. She has never been investigated for anaemia. A ferritin has been ordered and comes back at 10 mmol/l. You admit to yourself that you're unsure how to interpret a ferritin result and aren't sure how precise and accurate it is.

Here is the question ?

Patient or Problem: Elderly woman with anaemia

Intervention: Ferritin

Comparison Intervention:

Outcome: Iron deficiency anemia

Question: In an elderly woman with hypo chromic, microcytic anemia, can a low ferritin diagnose iron deficiency anemia?

Step 2 :

Select information sources

57

Sources • Journal literature• Books• Conference proceedings & abstracts• Dissertations & theses• Unpublished scientific papers• Government reports (federal, state and local)• Policy statements, laws & regulations• Surveillance data• Newsletters• Teleconferences & webcasts• Alert systems • Listservs• Internet sources• Expert opinion

Step 3 :

Identify key concepts and terms.

“What are effective programs and interventions for reducing obesity in school-age children

• Some of the key concepts and terms, also known as subject headings, for this question are child, obesity, and program evaluation.

Some terms which helps to expand search...

• adolescent nutrition

• body mass index • body weight • child nutrition• life style • longitudinal studies • nutrition/education

• exercise • health

education/methods • health promotion • health status

Step 4 :

Conduct the search in subject-appropriate databases & Select documents for review.

People reading research reports want investigators to answer four questions:

Why did you start? What did you do? What answer did you get? What does it mean anyway?

Clinical question

• As a nurse practitioner in a primary health care practice, you see many adult patients with asthma. The primary health care team wants to discuss strategies to improve care for these patients. They are particularly interested in whether both regular review by a health practitioner and patient education should be continued or whether giving patients written materials is just as effective.

Answerable Question

"Is a self-management programme that includes asthma education plus regular review by health professionals, effective in improving health outcomes for adults with asthma?"

PubMed <www.pubmed.gov>

Cochrane Collaboration <www.cochrane.org>

Searching Terms and Evidence Source:

["asthma" OR "wheeze"] AND "patient education" in the Cochrane Library. The Cochrane Library is the most comprehensive source of updated systematic reviews, and this simple search identifies the following review which appears to be very relevant to the question: Gibson PG, Coughlan J, Wilson AJ, et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review, latest update 29 May 1998). In: The Cochrane

Step 5 :

Critical appraisal of evidence

.

Read the article and decide

• Is the evidence from this randomized trial valid?

• If valid, is this evidence important? • If valid and important, can you apply this

evidence in caring for your patient?

Step 6 :

Applying evidence to the Patient

Step 7 :

Self evaluation

Know yourself ……..

• Cow for CAREER • Tiger for PRIDE• Sheep for LOVE • Horse for FAMILY • Pig for MONEY

What are the priority areas of PHC Research?

• Evidence based practice, • Quality of care, • Models of organization and delivery of health

care,• Integration, • Economic issue relating to optimal use of

resources, • Health inequalities and the determinants of

health,• Illness prevention and health promotion

Dr .A.P.J Abdul Kalam’s Message for Nurses

How to promote evidence based practice in Nursing research?

Implication to education

• Curriculum for PHC nursing should be based on the principles of PHC

• Multi disciplinary learning should become mandatory component of PHC nursing curriculum

• Nursing curricula should involve innovative learning strategies

• PHC nurses should have equitable access to continuous professional development (CPD)

Implication to research

• Development of methodologies for synthesizing qualitative research

• Systematic reviews of effectiveness• Primary research for effectiveness

Implication to practice

• Practice should be oriented towards participation and empowerment

• Value should be attributed to nursing practice

OK What this prema is trying for ……. IIIIII

Conclusion

Research should not just satisfy the urge of researcher to do research, but it should always be directed to improve the quality of nursing education intervention and administrative approaches.

Thank You

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