Materia Medica Malaysiana

Keeping up with medical advances: "WITH tremendous advances in technology, many things that doctors and nurses learnt from traditional text books have become obsolete.
Increasingly all over the world, people have begun to ask themselves whether they are doing the right things or doing things the right way,� said Tan Sri Dr Mohamad Taha Ariff, director general of health in his speech Evidence Based Practice: The Way Forward at the recent Asian Regional Conference on Evidence-based Nursing held in Kuala Lumpur recently. Even patients have begun to ask questions like, �Are you sure this is the best way to do this dressing?�
Evidence health care, the process of systematically finding, appraising and using current research findings as the basis for decisions in health care is the basis of medical practice today and it has recently included medical practitioners� tacit knowledge drawn from experience as well as patient�s perspective, he said.
However, the issue with the evidence-based approach is that finding and evaluating evidence is costly in terms of time and money and not everyone is skilled in locating the information and using computers, said Mohamad Taha.
The most common complaint is that it demands knowledge of statistics that few have mastered. Poor indexing too may lead to frustration in literature searches.
The evidence-based approach is also a rigorous and rigid system. It uses the results of studies applied to populations whilst clinicians are used to dealing with single patients on an individual basis. It may also be viewed suspiciously as a form of rationing which could be used to prevent clinicians from using treatments of unproven efficacy even where their clinical acumen suggests it may benefit the patient, said Mohamad Taha.

On the other hand, since evidence-based practice is about improving the quality of patient care, it is likely to show that there are also effective interventions that are underused, he said.

It makes medical and nursing curriculum more problem-centred and less about memorising a static body of knowledge. The practice provides some rules and rationale for group-based problem-solving and teaching, he said.

It also functions as a tool to keep up to date with research and to understand research techniques and encourages health care professionals to be more focussed and productive in their reading habits and data handling. This helps to improve the confidence of health care professionals in decision-making.

Evidence-based practice ensures that good research findings are applied more quickly to clinical practice. For instance, it took 10-15 years for people to adopt thrombolysis after a myocardial infarction despite evidence that this was effective, said Mohamad Taha.

Dr S. Sivalal, the head of the Health Technology Assessment Unit at the Health Ministry, said the practice of evidence-based health enhances knowledge-based components of clinical practice and does not invalidate clinical judgment.

In his paper, Developments in Evidence-Based Medicine, he said medical staff face the frustration of not being able to find the evidence they want for making many clinical decisions.

“There have been a lot of advances from purely research papers to secondary sources of evidence which people appraise and compile into systematic reviews. So rather than going through the original papers, readers can look at these reviews,” he said.

In coping with new findings and overload of new information, medical staff should target readings to specific patient problems, he said.

Evidence-based practice in nursing

“Florence Nightingale believed – and in all the actions of her life acted on that belief – that the administrator could only be successful if he (she) was guided by statistical knowledge. The legislator – to say nothing of the politician – too often failed for want of this knowledge. Nay, she went further: she held that the universe – including human communities – was evolved in accordance with a divine plan. But to understand God’s thoughts, she held we must study statistics, for these are the measures of His purpose. Thus the study of statistics was for her a religious duty.”

Quoting this statement made by well-known applied mathematician and statistician, Karl Pearson (1857-1936), Dr Sivalal pointed out that even the Italian-born Nightingale (1820-1910) stressed on the importance of statistics in nursing. What is less well known about this amazing woman is her love of mathematics, especially statistics, and how this love played an important part in her life’s work.

In Malaysia evidence-based practice in nursing is still limited. Dr Nafsiah Shamsudin, head of the nursing school at University College Sedaya International, said evidence-based nursing is practised here but not uniformly practised throughout the country.

“It’s happening in terms of medicine, and the nursing sector is about to catch up,” she said.

Speakers at the conference pointed out that nurses shy away from research because they lack confidence and research skills and appraisal.

“Nurses are not able to analyse critically articles or journals that are published,” said Dayang Annie Abang Narudin, principal matron at the Health Ministry in her presentation Strategies to introduce evidence-based practice in nursing.

Although evidence-based nursing is today’s password, many nurses tend to remain in the comfort zone and do things the usual way because they do not want to change, however, but change is inevitable for success and improving nursing care services, she said.

Currently, in Malaysia, there are fewer than 500 nurses with degrees and only a handful of nurses have Masters, she said.

Nafsiah is possibly the first to receive a doctorate in nursing.

During a question and answer session the day before, a member of the floor asked how nurses could be mobilised to practise research-based nursing when there is a lack of resources and a limited number of nurses with degrees or Masters.

In response, Dr Linda Johnston, associate professor on nursing practice research from the University of Melbourne, Australia, said: “I don’t believe that every nurse should conduct research or even like research but every nurse should use research.”

“You have to be able to show that the practices are based on evidence. That requires Internet access, some funding to assist in journal clubs being set up,” she said.

In her paper Nursing Research Activities in Malaysia, Lim Pek Hong, a lecturer from the Faculty of Medicine, Universiti Malaya, said that nurses could either be indirectly involved in research as a consumer or directly involved as a research producer.

Few participate in research activities, she said. Even if there were any projects that had been conducted, there is a lack of information dissemination.

Someone from the audience also pointed out that although nurses have been carrying out research work, their work is are not widely known.

Jaye Devi Coomarasamy, a senior nursing officer at the Health Ministry, said a newly-formed Nursing Foundation would be able to fund and publish research carried out by nurses while Sivalal said a lot of research have been done by nurses under the Quality Assurance Programme organised by the Health Ministry.

Nurses rarely have time to be away from the hospital as staffing is tight (especially in public hospitals) and they are busy with work. As a result, hospitals often have difficulty in releasing nurses to go for training, said Christopher Maggs, a professor of clinical practice and development at the Mid Staffordshire General Hospitals in Britain.

In his presentation Nursing research: Can we do it? Maggs said if nurses explore what they do intuitively and with more thought, nursing research can be done.

It takes a team to implement evidence-based nursing and there must be collaboration and interest in it. “If nurses want to implement it, hospital management and doctors must support the effort,” she said.

“Nurses need to identify areas of practice that are questionable. Why are we doing this and why are we doing it this way, for example in injection and dressing,” said Nafsiah in her paper Patient centred nursing: A Paradigm Shift.

“In Hong Kong and China, they use acupressure as part of medical practice. Can urut (massage) lessen the pain of the patient? I hear a ‘yes’ but do we have evidence? How do we get that evidence? If it’s not invasive, why can’t we use it? We have to be brave enough to bring out the evidence,” she said.

One of the things to do in practising evidence-based medicine is to adopt Clinical Practice Guidelines, which are adopted from research results. The guidelines work as a basis for doctors and nurses to draw up clinical pathways, which are standard procedures that medical staffs adhere to in their hospital, said Sivalal.

“That way you get the whole team involved,” he said.