Evidence-based practice is a modern approach to decision-making in clinical settings aimed at improving the practical effectiveness of delivered care at the level of individual patients. It involves the integration of best, current evidence from research, considerations of patients’ values, preferences, and desires, and the healthcare professionals’ expertise and experience in clinical decision-making to ensure the quality of care. Critical appraisal and scientific proofing of evidence that applies in such decision-making represent important pillars of EBP. This paper focuses on an assessment of the merit of evidence, current evidence-based medicine (EBM) guidelines, and the impact of evidence on practice concerning the chosen chronic health problem of COPD (chronic obstructive pulmonary disease).
Review of Topic and Rationale
COPD is a progressive disease whose principal feature is the patient’s struggle with breathing. It involves a decrease in the flow of air in and out of the airways in the lungs owing to a loss of elastic quality in the airways and air sacs, damage to the walls between air sacs, thickness and inflammation of the walls of airways, and clogging of the airways with more mucus than usual. The patient experiences progressive fixed airflow limitation and acute exacerbations that necessitate frequent hospitalization (Overington et al., 2014). Research has illustrated that cigarette smoking and long-term exposure to lung irritants, such as chemical fumes, dust, and air pollution, are important contributors to the development of COPD (Gentry & Gentry, 2017). Researchers have further observed a genetic predisposition to the disease, involving the rare genetic condition, alpha-1 antitrypsin (AAT) deficiency. AAT is a liver-produced protein that assists in the protection of organs in the human body from the harmful properties of other proteins. In AAT deficiency, AAT proteins have the wrong shape, such that they are unable to leave liver cells and enter the bloodstream. COPD is a significantly disabling condition, affecting 16m people and serving as the fourth-leading cause of death in the US (Gentry & Gentry, 2017). COPD develops gradually and worsens over time, progressively limiting individuals’ abilities to perform routine activities (including taking care of the self, walking, etc. when severe). It requires constant management through drug therapy (bronchodilators, inhaled glucocorticosteroids, mainly) and positive lifestyle and behavior changes, including quitting smoking, avoiding lung irritants, diet choices to meet particular nutritional needs, and physical activity) (Gentry & Gentry, 2017). COPD is preventable through avoidance of smoking and lung irritants such as chemical fumes, dust, and air pollution. The chronic nature of this condition, the possibility to prevent it, and the need to manage it effectively through quality care and behavioral changes make COPD a suitable topic for the focus of this paper.
Key Relevant Concepts
Based on the assessment above, self-care and adaptation are key concepts relating to the management of COPD. This is because of the need for the patient to take an active position to manage the condition through positive behavior change. This responsibility involves the patient’s focus on adapting his/her own life, choices, and behaviors to the demands of the management of the condition.
Evaluation of Current EBM Guidelines, Diagnosis Procedures
Miravitlles et al. (2018) note that the diagnostic processes and ultimate goals of management and treatment of COPD are uniform across most of the national and international clinical practice guidelines (CPGs) for COPD. There is no particular cure for COPD, but the CPGs target the reduction of symptoms, decreased risks of exacerbation, and improved quality of life. CPGs for the condition require consideration of COPD in any smoker with a productive cough and the basis of diagnosis on assessments of a history of exposure, symptoms, and bronchial constriction observable in post-bronchodilator spirometry. They further note possible co-occurrence of COPD with asthma (Helin, 2019). The CPGs identify cessation of smoking and physical exercise as central parts of effective management, while the choice of medication to reduce symptoms and prevent exacerbation is dependent on the severity of presenting symptoms and the outcomes of tests of lung functioning. These CPGs are valid owing to the use of a long history of observations and research experience involved in their development.
EBP Resources and Merit of Evidence
Two EBP resources that could influence care for COPD patient are those by Kirkpatrick, Wilson, and Wimpenny (2012) and Donaire-Gonzalez et al. (2015). The first resource by Kirkpatrick et al. (2012) utilized the systematic review approach to explore the shared and common experiences of individuals in caring partnerships for COPD patients in a community care and support setting. The review involved 39 studies published between 1990 and 2010, and that investigated the experiences of caregivers, families, nurses, patients, and physicians involved in home-based care for COPD patients. The research concluded that the availability of consistent support for COPD patients, in terms of rehabilitation, information, end-of-life care, and access to services, was essential to enhance their quality of life and that self-care/management and home-based efforts to manage exacerbations can reduce COPD-related anxiety and distress among patients and caregivers. The study further established that individualized care based on assessed needs (rather than on the patient’s disease state) is a critical part of effective COPD care. Evidence from this resource was highly valid and appropriate because of the huge number of studies reviewed (39), the high methodological quality applied in the reviewed studies, and the huge combined sample of 721 participants. The studies further included a mixed-methods study, two qualitative interview studies nested with randomized controlled trials, and 36 interpretative studies. The second resource by Donaire-Gonzalez et al. (2015) utilized the longitudinal study design to assess the independent effects of quantity and intensity of physical activity on the reduction of risk for COPD hospitalizations, noting that physical activity is an important part of effective management of the condition. Participants wore armband accelerometers for eight consecutive days to measure the quantity and intensity of their physical activity, while validated centralized datasets offered information of COPD hospitalizations. The study yielded observations that higher quantity, low-intensity physical activity reduced the risk for COPD hospitalization, but that high-intensity physical activity did not produce any reduction in risk. Evidence from this resource was not sound because, while the researchers used an objective method to measure physical activity (armband accelerometer), the sample size of 177 was not large enough to prevent the potential influence of other characteristics of physical activity, particularly duration and frequency, on the results. It was also not enough to assess the effects on particular subgroups, such as patients with severe and mild COPD.
The similarity between these resources concerns their provision of specific recommendations for COPD management. Both resources featured significant contributions to an understanding of aspects of care that are important to incorporate in management of COPD to ensure its effectiveness. Nonetheless, there are several differences between them. While Kirkpatrick et al. (2012) applied the systematic review approach, which is a qualitative research design, Donaire-Gonzalez et al. (2015) applied the longitudinal study approach, which is a quantitative design. The former study focused on the shared and common experiences of individuals in caring partnerships for COPD patients, while the latter focused on the physical exercise aspect of COPD care.
Impact of Evidence on Practice and Cultural, Socioeconomic, and Spiritual Factors
The impact of this evidence on practice would involve the promotion of individualized care, critical assessments of individual COPD patients’ needs, emphasis on consistent care across a broad range of services (rehabilitation, information, end-of-life care, and care access), and higher quantity, low-intensity physical activity in the effective management of COPD. It would influence nursing leaders’ emphasis on these aspects in staff and patient education to influence more effective management of COPD, particularly in terms of the incorporation of these aspects in patients’ self-care/management efforts to meet COPD management needs. The aspect of individualized care in COPD management would especially be important from the perspective of spiritual, cultural, and socioeconomic differences among patients. Nursing professionals would need cultural competence skills to understand the attitudes, beliefs, and outlooks that underlie COPD patients’ behaviors, lifestyles, and perceptions. This ability would enable the professionals to communicate with the patients effectively to assess their needs and create adaptable models of changes in lifestyle, diet, physical activity, and other areas of life that fit the patients’ cultures, spiritual beliefs, and socioeconomic abilities and environments.
Donaire-Gonzalez, D., Gimeno-Santos, E., Balcells, E., De Batlle, J., Ramon, M., ……. & Garcia-Aymerich, J. (2015). Benefits of physical activity on COPD hospitalization depend on intensity. European Respiratory Journal 46: 1281-1289.
Gentry, S., & Gentry, B. (2017). Chronic obstructive pulmonary disease: Diagnosis and management. American Family Physician 95(7): 433-441.
Helin, T. (2019). Chronic obstructive pulmonary disease. EBM Guidelines. https://www.ebm-guidelines.com/dtk/ebmaz/avaa?p_artikkeli=ebm00123
Kirkpatrick, P., Wilson, E., & Wimpenny, O. (2012). Support for older people with COPD in community settings: a systematic review of qualitative research. JBI Database of Systematic Reviews and Implementation Reports 10(57): 3649-3763.
Miravitlles, M., Roche, N., Cardoso, J., Halpin, D., Aisanov, Z., Kankaanranta, H., Koblizek, V., …… & Vogelmeier, C. (2018). Chronic obstructive pulmonary disease guidelines in Europe: A look into the future. Respiratory Research 19(11): 1-9.
Overington, J., Huang, Y., Abramson, M., Brown, J., Goddard, J., ….. & Yang, I. (2014). Implementing clinical guidelines for chronic obstructive pulmonary disease: Barriers and solutions. Journal of Thoracic Disease 6(11): 1586-1596.