Introduction
Evidence based practice is a systematic practice of finding, reviewing and using research materials as a basis of nursing practices. It is applied in the management of diseases, which have prior research and documentation. This paper describes the application of evidence based practice in the management of Acute Otitis Media (AOM). Otitis Media (OM) refers to the inflammation of the middle ear. It occurs between the Eustachian tube and the tympanic membrane. Acute Otitis Media (AOM) refers to the first three weeks of otitis media infection during which the patient exhibits symptoms of inflammation of the middle ear. AOM is a common disease in young children between three months and 12 years (American Academy of Pediatrics & American Academy of Family Physicians, 2004). AOM is a bacterial infection caused by Streptococcus pneumoniae (Block, 1997). The resources used in evidence based practice and research can be classified as filtered, unfiltered, general information sources or evidence summaries. According to Shaneyfelt and her colleagues (2006), filtered resources are appraised studies with recommendations for nursing practice. Filtered resources can be classified further as systematic reviews, appraised topics and appraised articles. Systematic reviews comprise of meta analyses of literatures to establish recommendations for good nursing practices. Appraised articles and topics are critiques of single articles and topics. Unfiltered resources are unappraised sources that require the researcher to search for the primary literature sources and appraise them for best nursing practices. Evidence summaries are summarised recommendations for best practices on research topics of interests. Finally, general information sources are unappraised literature sources on given topics of research.
Review of sources of evidence
Clinical practice guidelines:Diagnosis and Management of Acute Otitis Media by the American Academy of Pediatrics and the American Academy of Family Physicians is a meta analysis of many primary sources. Therefore, it is a filtered source of evidence for the management of AOM. The source was filtered by pediatrics journal (American Academy of Pediatrics & American Academy of Family Physicians, 2004). It was included in the journal because it met the filtration criteria. This source is appropriate for evidence based practice in the management of AOM because it is documented in a journal that specializes in pediatrics and infectious diseases. The initial appraisal involved sifting of 3461 primary sources. Only 136 of them met the appraisal criteria for evidence based nursing practice in the management of AOM. An appraisal of 3461 primary sources in which only 136 met the appraisal criteria is substantive to form evidences for best practices. However, its information might be obsolete owing to the long time elapsed since its publication. Its recommendations can only be valid if they are consistent with current researches in the management of AOM. This source can also be classified as an evidence based guideline because it comprises of recommendations which were formulated from a primary literature review.
Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media by Block is a critically appraised topic. It can thus be classified as a filtered resource. It was filtered by the journal of pediatrics and infectious diseases. The article is a critical appraisal of cause, prevalence and treatment of AOM between 1981 and 1996 (Block, 1997). Block’s article is appropriate for inclusion in the discussion of evidence based nursing practice in the management of AOM. However, it cannot be considered as effective guideline for practice because its information is obsolete. It was published 15 years ago (Block, 1997). Block’s article can also be classified as an evidence summary because it discusses many causative pathogens of AOIM to people of different age groups (Block, 1997). It does not concentrate on one age group and causative agent.
Ear, Nose and Throat in Current pediatric diagnosis and treatment by Kliegman and his colleagues is a general information source. This is because it is not filtered by any special body of knowledge. The evidence is appropriate for inclusion in the discussion. However, it is not appropriate for evidence based practice in the management of AOM. This is because its information is obsolete. In addition, it is a general information source on trends in the treatment of AOM (Kliegman et al., 2007). It has not been appraised by a credible body of knowledge with specialization in pediatrics. This source can not be classified in any of the given categories.
A review of Clinical Practice Guide by AAP and AAFP
This source is a credible reference for evidence based nursing practice in the management of acute otitis media. The source was filtered by a pediatrics journal. Its publication is this journal makes it a credible source. The appraisal process involved an assessment of 3461 primary sources. Out of this, only 136 met the criteria for inclusion in the research review (American Academy of Pediatrics & American Academy of Family Physicians, 2004). A review of 136 credible sources makes the article an appropriate source of evidence based nursing practices. Besides, the six recommendations given in the article are based on a randomised primary research on the effectiveness of the intervention. Randomization reduces experimental bias. The researcher also has described the weight of the intervention benefit against possible risks based on experimental results. The information given in the recommendations shows that the evidences are reliable because of a high degree of experimental success. Randomization and experimental evidence of reliability underscore that the source is a credible reference in the AOM management practice.
Watchful waiting in the treatment of AOM
Watchful waiting refers to deferment of antibacterial treatment. From the given evidence in the source, watchful waiting is not an effective approach in the treatment of children with AOM. This is because of its inconsistencies with variations in age groups of children. From the given recommendations, watchful waiting is only appropriate to certain AOM cases of children between six months and two years. The approach is not appropriate for certain cases of severe symptoms (American Academy of Pediatrics & American Academy of Family Physicians, 2004). The results of application of observation on children between two and 20 years are inconclusive. The results are inconsistent in children of the same age with similar diagnostic symptoms (Chonmaitree et al., 1994).
Application of the source findings in clinical nursing
The recommendations given in the article are based on clinical primary research. Therefore, they are effective references for clinical practices in the management of AOM. The first step in the application of the recommendations is the diagnosis of AOM. This will start by confirmation of acute onset history, identification of middle ear effusion symptoms and evaluation of the presence of middle ear inflammation (American Academy of Pediatrics & American Academy of Family Physicians, 2004). The critical issue here is differentiation of Otitis Media Effusion (OME) and AOM. OME is more common than AOM. Unlike AOM, which can be treated medically, OME has no medical intervention. The latter is common in children with delays in cognitive development.
If AOM is confirmed, the second step is an assessment of pain. Treatment is recommended in cases of symptomatic pains. Observation is recommended in cases of children with uncomplicated cases of AOM. However, its application is limited to children aged between six months and two years. Antibacterial treatment is effective in many cases of patients who are above two years. Amoxicillin will be used in most cases where treatment is prescribed because of its effectiveness in handling AOM causing pathogens.
Ethical issues in research
The ethical issues in research on children and vulnerable people are obtaining their consents and upholding the duty of confidentiality when handling the research information (Ballard, 2004). Professional code of ethics in health sciences require the medical practitioners to obtain the consents of patients before carrying out any form of surgery on them. Medical researchers are also expected to obtain the consents of their patients before involving them in any clinical experiments. The researchers are also supposed to uphold the duty of confidentiality not to divulge patients’ information to third parties.
Vulnerable populations include children with mental disabilities such as dementia. Ethical code of practice requires medical practitioners to obtain the consents of patients before involving them in the research to change the clinical nursing guidelines. It is unethical for the medical practitioners to involve children in research without obtaining their consents (Winslade, 2004). The parents are nominated to give consents in cases involving minors. In this case, the medical practitioners should explain the reasons, benefits and consequences of involving the minors in the research to their parents to obtain their consents. The parents are at liberty not to consent to research if they do not want it done to their children (Ungar et al., 2006). This only applies to young children who cannot give informed consents. For the vulnerable children, the medical practitioners should follow the same process like in other minors. A third party is not allowed to give consent for an adult patient. This implies that even mentally disabled adults must give their informed consents in order to be included in clinical experiments (Kanjilal, 1989). On the other hand, the medical practitioner should explain to the consenters the research findings and keep them confidential between them (Winslade, 2004).
Conclusion
In conclusion, the paper underpins evidence based practice in clinical nursing and research. The described case is the application of evidence based nursing practices in the management of AOM, an infection of the middle ear. Evidence based nursing practices are systematic research based practices in the management of patients. Research sources are classified as filtered, unfiltered, evidence summaries, evidence based guidelines or general information. Filtered sources are sifted and appraised by a reputable body of knowledge. Filtered sources can further be classified as either meta analyses/ systematic reviews, critiqued topics and critiqued articles. Filtered sources published in the journals are credible references for evidence based practices in clinical nursing. However, they must be current. The recommendations in the old sources should be consistent with current trends in research to be used as credible references. Nonetheless, they can be included in discussions of evidence based practices.
Proffesional code of ethics requires a medical practitioner to obtain the consent of children and vulnerable people before involving them in clinical research. Parents or nominated guardians can give consents for minors, including those who are mentally handicapped. However, mentally handicapped adults should give their own informed consents according to the law. Finally, medical practitioners are obliged to uphold the duty of confidentiality in handling patients’ information. In case of a minor, only their nominees should be given access to information.
References
American Academy of Pediatrics & American Academy of Family Physicians. (2004). Clinical practice guidelines:Diagnosis and Management of Acute Otitis Media. Pediatrics, 113(5), 1451-64.
Ballard, O.H., Shook, A.L., Desai, N. & Phill, D. A. (2004). Neonatal Research and the Validity of Informed Consent Obtained in the Perinatal Period. Journal of Perinatology,24, 409-415.
Block, S. L. (1997). Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. The Pediatric Infectious Disease Journal, 16(4), 449-456.
Chonmaitree, T., Patel. A.J., Lett-Brown, A.M.,Uchida, T., Garofalo, R., Owen, J.M, & Howie, V.M. (1994). Virus and bacteria enhance histamine production in the middle ear fluids of children with acute otitis media. Journal of Infectious Diseases,169(6), 1265-1270.
Kanjilal, G. C. (1989). Consent and the mentally handicapped. Psychiatric Bulletin, 13, 82-84.
Kliegman, P.E., Friedman, N., & Johnson, C. (2007). Ear, nose, and throat. In M. J. Levin, W. W. Hay, J.M. Sondheimer, & R.R.Deterding (Eds.), Current pediatric diagnosis and treatment, (18th ed., pp. 459-492). New York: McGraw-Hill.
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Ungar, D.,Joffee, S.& Kodish, E. (2006). Children are Not Small Adults. The Journal of Pediatrics, 149, 31-33.
Winslade, W. J. (2004). Confidentiality. Encyclopedia of Bioethics, 1, 494-503.
