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Evidence based practice


Decisions made by health care practitioners are guided by statements that are developed systematically; these statements are referred to clinical guidelines (Reed et al, 2008). Clinical guidelines are used to assist in making decisions ranging from symptoms to chronic situations like surgery. The role of the clinical guidelines is to get rid of violations in clinical practice and ensure that quality health care is delivered as it may be considered evident (Stillwell, 2010). In addition, the guidelines provide a method to determine the accountability of health care professionals in clinical practices. Evidence based guidelines are set to meet a set of criteria. According to Haber (2008) the clinical guidelines are adopted from a local, national and regional level so that they become appropriate for the local circumstance. The group of professionals that develop the evidence based guidelines is tasked to assess the scope of the guideline,conduct research evidence and come up with recommendations to guide the clinical practitioners in decision making (Green, 2008). The composition of this group includes representatives from respective disciplines and interested parties. It is worth to note that developing new guidelines can be costly as well as time consuming (Green, 2008). It is thus considered wise to use instruments to appraise published guidelines in order to determine the quality and relevance of published clinical guidelines. The instrument to be used in this paper is the Appraisal of Guidelines Research and Evaluation which is abbreviated as AGREE. This paper will thus employ AGREE in appraising and assessing the management of day to day surgery patient as it is provided by the Joanna Briggs Institute for Evidence Based Nursing and Midwifery. The assessment will be a critical and systematic review of the best practice guideline using the AGREE modified instrument.

Modified AGREE Report Instrument


Aspect 1 The overall objective(s) of the guideline is (are) specifically and adequately described.

Strongly agree (score: 4 points)

A clear description of the clinical practice is fully described. The purpose of the clinical practice is to provide a detailed procedure of managing a patient undergoing day surgery. The aim of coming up with this clinical guideline was to:

  • To determine the best procedure for managing a patient undergoing day surgery

  • To determine the best procedures to eliminate the disadvantages associated with day or ambulatory surgery which includes: uncontrolled nausea, pain, burden imposition on family members and vomiting (Stillwell, 2010).

Aspect 2 The clinical question(s) covered by the guideline is (are) specifically described.

Strongly agree (score: 4 points)

Key areas to be specifically covered by the guideline are clearly stated, these are pre-admission care, post-admission to discharge and staff mix. What are the roles of these key areas covered by the clinical guideline:

  • Pre-admission care ensures that positive results of the surgery will be achieved

  • Post admission to discharge ensures that monitoring and assessment of the patient takes place in order to get rid of complications arising from surgery like uncontrolled nausea, pain and vomiting.

  • Staff mixing brings together many professionals like anaesthetic technician, nursing and medical personnel thus increasing the patient’s expectation (Joanna Briggs Institute, 2004).

Aspect 3 The patients to whom the guideline is meant to apply are specifically described.

A clear definition of a day surgery patient is provided. Specifically, these are those patients who are due to undergo surgery with an overnight admission before the surgery is performed. As such, such patients undergo a specialized for of surgery in a special surgery units attached to a main hospital.


Aspect 8 Systematic methods were used to search for the evidence.

Strongly Agree (score: 4 points)

The guideline provides clear information of the organisations that participated in the systematic reviews. These are La Trobe University, Day Surgery Special Interest Group, Nursing Practice Unit, Victorian Branch and ANF. This information is compiled and stored by the Joanna Briggs Institute; it can be accessed from the Joanna Briggs Institute website.

Aspect 9 The criteria for selecting the evidence are clearly described.

Strongly Agree (score: 4 points)

A detailed criterion of how to classify and categorise depending on the strength of the evidence is provided. The evidence is categorised into three levels: I-II, III.1-III.3 and level IV (Joanna Briggs Institute, 2004). The evidence levels were classified according to the strength of the evidence. For instance, level I evidence was based on systematic review of randomised control trials which seemed to be relevant. On the other hand, level IV evidence was obtained the decisions of respected authorities whose opinions were based on clinical experience, experts’ ideas and descriptive studies.

Aspect 10 The methods used for formulate the recommendations are clearly described.

Agree (score: 3 points)

The author failed to clearly describe the procedure of determining the recommendation to make. The author relied on the response of the participants regarding the satisfaction obtained.

  • This is so because the author indicated that comparative trials of pre-admission clinics were not performed during the pre-admission care. As a result, only some of the patients responded on the satisfaction they got.

  • According to evidence level II, many patients indicated dissatisfaction with the amount of information provided before surgery. When making recommendations on one of the randomised controlled trial, the author argued that such methods like fasting did not help a patient undergoing local anaesthetic only.

Aspect 11 The health benefits, side effects and risks have been considered in formulating the recommendations.

Agree (score: 3 points)

The guideline clearly illustrates some of the benefits of applying the various recommendations. However, not much is stated about the harms associated with applying the respective recommendations. for instance:

  • The author argues that the surgery should be performed later in the day and recommends for flexible discharge time in order to reduce complications. This recommendation is made in respect to tympanic temperature which is not considered as useful for surgery. However, recommendation does not mention if there is any harm associated with performing surgery at this time.

  • Fasting before surgery has been mentioned as a wise decision by the guidelines. Further, it is recommended that fasting is never important for those patient due to undergo local anaesthetic only. This recommendation does not link the benefit and harms of fasting prior to surgery.

Aspect 12 There is an explicit link between the recommendations and the supporting evidence

Strongly Agree (score: 4 points)

In order to add strength to the recommendation, evidence is associated with every recommendation though it is not arranged as per the recommendation guidelines. Level of satisfaction for individual groups is also stated to support the recommendation.

  • Most of the groups admitted that pre-admission care was important since it helped to reduce the level of anxiety of individual patients. In addition, pre-admission care also helped to screen if the patient was ready for surgery.

  • During the post-admission care, patients felt that their health was being looked at since there are bad symptoms that may follow the surgical process.

Aspect 14 A procedure for updating the guideline is provided.

Strongly disagree (score: 1 point)

The evidence based guideline does not mention when the guidelines should be updated and even the procedure of updating.


Aspect 15 The recommendations are specific and unambiguous.

Strongly Agree (score: 4 points)

The recommendations are meant to address each an every case of the guideline thus making them specific. In addition, the recommendations are unambiguous since they are clearly stated.

Aspect 16 The different options for management of the condition are clearly presented.

Strongly Agree(score: 4 points)

The guideline discusses three stages of managing a day surgery patient: pre-admission care, post-admission care and staffing mix. The guideline clearly illustrates what should be done to the patient at each of these stages and the benefits associated with the management strategies used.

Aspect 17 Key recommendations are easily identifiable.

Strongly Agree (score: 4 points)

Recommendations can be easily identified since they are stated under each of the three stages. Specifically, pre-admission care recommended that it was important to prepare the patient for surgery through telephone calls and pre-clinic visits in order to reduce the patient’s anxiety. Post admission care recommended that the patient needed to be assessed after the surgery in order to avoid the outcomes of surgery like vomiting and nausea. Finally, staffing mix recommended for the presence of all specialists when surgery was performed though not adequate research has been done to determine the outcome of this.

Aspect 18 The guideline is supported with tools for application.

Disagree (score: 2 points)

The guideline is just a document without any supportive tool.

Briefly determine the quality of the Guideline (do not give the overall score) and analyse whether nursing knowledge is increased as a result of it.

The quality of the guideline in clinical practice can be determined by considering the total score of the items in the domains. Since in the scope and purpose domain the average score is 4, it implies that the guideline is strongly Agreed and can thus be recommended for evidence based clinical application. The average score for the other domains also rage between 3 and 4 implying that the guideline has yielded positive results for its purpose, development and presentation. Nursing knowledge has increased as a result of this guideline since the items that have not scored high will need to be addressed through further research. More nursing knowledge will be acquired through further research in order to fill the deficiencies existing in the current guideline.

Scope and purpose: 12 out of 12 points= 100%

Rigour and development: 19 out of 24 points= 79%

Clarity and presentation: 14 out of 16 points= 87%

Discuss the application of the Best Practice Guideline relating to potential organisational barriers and cost to an organisation at a unit level.

According toHouser & Oman (2010) barriers that may influence the application of best based practices in an organisation occur at two levels namely: healthcare organisation (resources, organisation structures and the management) and staff level (practicians and management). In addition to this, there are external factors like health policies in a nation and the nature of the patient. However, most researches conducted focus on practitioners’ barrier. Evidence based practices are guidelines that are meant to guide clinicians in their duty. Thus, failure by clinicians to adhere to the guidelines is a major barrier to the application of evidence based practice (Gerrish, 2008).

The best practice guideline application should be put into use according to the regulations provided by Joanna Briggs Institute. The reports relating to the application of this guideline have been derived from systematic review and research by different organizations. Since the systematic review report is a product of many organisations namely: La Trobe University, Day surgery Special Interest Group, Nursing Practice Unit, Victorian Branch and ANF, it would present some form of organisational barrier.

Apply your clinical experience and relevant literature to discuss the feasibility of implementation as evidenced-based practice.

According toKazdin (2008) in order to implement evidence based practice in clinical practice, adequate research is needed in order implement the multifaceted strategies needed. The strategies needed to implement an evidence based clinical practice should aim to fulfil the needs of individual practitioners as well as organizations (Dawes, 2005). The practitioners should not make individual decisions on the evidence to use as they may lead to variability in clinical practice hence leading to negative impacts on a patient’s health (Stout & Hayes, 2005). Some of the medical practitioners may be well equipped with research findings while others may lack such information. The outcome of this variation would be conflicting practices when the practitioners change shift in every 8-10 hours (Melnyk & Overholt, 2010). On the other hand, health care organizations have an integration system in this perspective. Houser & Oman (2010) stated that the nurses and the health care practitioners are required to adopt the organization’s policies and procedures which are integrated in the information systems of the organization. Organizations promote the adoption of the evidence based practice. The policies require that the staff members in a health care organization are equipped with knowledge and skills to perform all the duties as may be required (Dawes, 2005). There are several committees within a health care organization which oversee the implementation of the evidence based practice such as staff education committee, interdisciplinary evidence based practice work groups and practice committee.

For an evidence based topic to be effectively implemented, it should have specific characteristics. For instance, it should be compatible with values, work, and needs of intended users and relevant to the perceived task. For the implementation of EBP, the practitioners need to review the guidelines in order ensure that they are fit and appropriate for the perceived tasks (Gregory, 2009).

Conclusion of this critical reflection

The critical reflection has provided an analysis of the relevance of the evidence based practice in the management of a day surgery patient. The use of AGREE tool in the assessment has helped to determine the effectiveness of the EBP. It has been possible to determine the success of the EBP in the management of a day surgery patient using AGREE since most of the items scored between 3 and 4 points implying that they EBP is a success.


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