Introduction
Ambulatory surgery has in the recent past received special attention owing to an increase in the number of procedures that can be carried out as day surgeries. This has necessitated the development of best practice guidelines for nurses in terms of pre-admission care and post-admission care given to patients. This paper will critically examine the best guideline supplement for the management of the day surgery patient available in the Joanna Briggs Institute website. It will also point out some of the challenges facing its incorporation into clinical practice.
Modified AGREE Report Instrument
Domain: Scope and Purpose
Aspect 1. The overall objective(s) of the guideline is (are) specifically and adequately described
The overall objective of the guideline is not specifically and adequately described. The guideline does not state any objective; therefore, it is difficult to tell the health intention and scope of this guideline. The guideline covers management of day care surgery patients but does not seem to have any particular objective and expected outcome for the targeted users of the guideline (AGREE, 2004).
Aspect 2. The clinical question(s) covered by the guideline is (are) specifically described
The guideline does not describe directly any clinical questions. The clinical questions that the guideline was meant to address appear to be the outcomes of care given to patients both preoperatively and post operatively. Clearly stated clinical questions are necessary for the evaluation of the guideline later on. According to AGREE (2004), the questions should directly address the characteristics of the target population, an intervention, a basis for comparison and a means to measure the effectiveness of the interventions used.
Aspect 3. The patients to whom the guideline is meant to apply is specifically described
The guideline provides a clear description of the patients who will be affected by these guidelines. The guideline is meant for those patients who are scheduled to undergo or are currently undergoing surgery without a preceding overnight admission. There is no age delineation in the guideline. All surgeries that can be performed in this setting are included. Some surgeries given specific mention by the guideline include; gynaecological surgery, orthopaedic surgery and plastic surgery.
Domain: Rigour of Development
Aspect 8. Systematic methods were used to search for the evidence
The guideline has named sources of the evidence being put forward. The named sources include journals and other systematic reviews conducted by other special interest groups. Therefore, the search can be replicated by other people interested in testing the recommendations for validity (Fineout-Overholt, 2010).
Aspect 9. The criteria for selecting the evidence are clearly described
The inclusion criterion is clear. Detailed information about the inclusion and exclusion criteria is provided in the guideline. The evidence has been arranged into different levels. Level iv evidence for example was obtained from respected authorities based o their clinical experience. Provision of this information is necessary because it can be used to determine the usefulness of the guideline.
The target group appears to be all day surgery patients. This guideline defines day surgery as any surgical procedure that does not involve an overnight admission before the surgery. The design of the study also aught to have been described in the guideline (Fineout-Overholt, 2006).
Aspect 10. The methods used for formulating the recommendations are clearly described
Methods used to formulate recommendations are not clearly defined. There is no mention of methods used. This raises questions about its usefulness, validity in a clinical setup. The methods that may be used to formulate recommendations include voting, unanimous decisions and selection based on perceived importance.
Aspect 11. The health benefits, side effects and risks have been considered in formulating the recommendations
The potential benefits of these practices in this guideline are not clearly described. Potential benefits, risks and gains verses trade offs are supposed to have been described in the guideline. When no clear benefits and potential risks is not given, the overall benefit of the guideline becomes doubtful.
Aspect 12. There is an explicit link between the recommendation and the supporting evidence
There is a clear link between the recommendations and the evidence gathered. The findings are used to come with precise recommendations that can be used clinically (Worral, 2009).
Aspect 14. Procedures for updating the evidence is provided
This guideline has no procedure to update the evidence In future. Good evidence based practice should have mechanisms which can be used to update it as new knowledge is gathered. The procedure for updating it should clearly state when and how to update it.
Domain: Clarity and Presentation
Aspect 15. The recommendations are specific and unambiguous
The recommendations in this supplement are specific. They are presented in the guideline under the title; ‘implications for practice’.
Aspect 16. The different options for management of the condition are clearly presented
The presentation of management options of the condition is clear and specific. They appear under the sub-topics; pre- operative care, post operative care and staff mixing.
Aspect 17. Key recommendations are easily identifiable
Key recommendations in this guideline can be indentified easily. This is because the recommendations are listed under the relevant sub-topics. Recommendations are a summary of the analyzed data. Therefore, they must be well written and be presented in such a way that it is easy to identify them (CAN, 2009).
Aspect 18. The guideline is supported with tools for application
The guidelines have no tools to support their application.
The quality of the guideline and nursing knowledge
The guideline is a useful guideline to the practice of nursing because it points out areas of nursing care that should be emphasized when caring for day surgery patients. This area of nursing care had not been previously researched. Issues such as pre-operative and post operative care were adequately researched. The findings were useful in formulation of the recommendations. Evidence-based practice in the area of day surgery had been implemented by many institutions that carry out this surgeries.
The guidelines also recommend further research on the issue of staff mixing. Staff mixing during surgery was previously thought to improve outcome. These guidelines suggest that there is no concrete evidence to support this. In fact, it found out that there is no significant gain in terms of efficiency and outcome when the care team is composed of a mixture of professionals. The recommendations formulated point out important areas to concentrate on when giving care.
Nursing is a dynamic field; therefore, there is need for incorporation of new findings in the care of patients (Newhouse et al, 2006). The recommendations were formulated with the aim of guiding clinical practice. The guidelines developed in this supplement can be regarded as best evidence-based practices if they result in the most effective intervention in pre- and postoperative nursing care.
Potential organizational barriers and the cost at a unit level
There are many potential barriers to implementing evidence-based practice. The first is the nurse’s ability to synthesize and utilize research findings (Young, 2006). A care giver may not be in a position to critically evaluate research findings. Accessibility to relevant material like journals may also impede ones ability to get relevant knowledge needed in a particular area. Lack of research skills considerably reduces the implementation of evidence-based practice.
Another barrier is resistance to change (Baumann, 2010). The recommendations may include those that require change in the organizational structure in use currently. The organisation may not be willing to let go of practices that have been tried and tested. These tried and tested methods are perceived to be safe and any new practices are regarded as unsafe. It is difficult to make people believe and trust the results of new research studies. Safety of these new methods is of particular concern if the research was not able to cite authorities in the field.
Another barrier to implementation of evidence-based practice is cost (CNA, 2011). Some guidelines require additional members of staff and equipment. Some may also involve the use of expensive treatment options. Implementing these guidelines may push up the running costs of an institution. The initial capital investment may also be high. If implementing particular guidelines involves additional cost, it may meet resistance (LoBiondo-Wood, 2006).
The feasibility of implementation as evidenced-based practice
The recommendations contained in the guideline can be used to improve the quality of nursing care currently available to patients (Salmond, 2007). The recommendations add value to existing knowledge especially with regard to management of day surgery patients. This group of patients will benefit from better treatment if these guidelines are made operational (Royle et al, 2008).
The guideline contains useful information that can be used clinically to make decisions. They are presented with scientific evidence to support their validity. The recommendations are feasible though some may take some time before they can be effective. Good evidence-based practices are those that result in effectiveness in the clinical management of a condition (Penz, 2009).
Conclusion
The evidence-based guidelines link well with the recommendations made in this supplement. The recommendations add to the existing knowledge in nursing care. The guideline also managed to point out the fact that staff mixing may not have a big effect on outcome of care as previously thought.
The recommendation for further studies in this area is also welcome as it will help shed some light on the issue. Nursing care of day care surgery patients is enhanced by these guidelines. Evidence-based care is beneficial to both the patient and the care giver. The care giver gets an opportunity to critically analyze research and put them to clinical use.
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