Evidence-based practice is an essential aspect of healthcare in ensuring that medical decisions are made based on the best evidence available. This evidence is acquired through the application of scientific method based on gathering measurable, observable, and empirical evidence subject to reasoning principles. Similarly, evidence-based practice seeks to evaluate the quality of available evidence by evaluating whether the evidence is valid, reliable, and not biased (Wallace, 2017). There are various levels of evidence that depend on the hierarchy of study methods used in acquiring the evidence which ranges from the least to the most useful. Randomized controlled trials provide the highest level of evidence. This paper evaluates evidence from a randomized controlled trial that addresses my clinical question and applies the evidence to my practice.
My clinical question is based on whether patient education has a significant effect on ensuring patients adhere to their prescribed medications. As per the WHO adherence to medication is critical since it can affect the overall healthcare costs, health outcomes length, and quality of life. The responsibility of ensuring adherence to medication falls on both the health care providers and the patients. Therefore there is a need to establish whether patient education can lead to a significant effect on ensuring medication adherence among patients (Kim et al., 2018). In search of evidence to answer this question, I indulged in various databases including PubMed and Purdue Global Library.
Summary of the database used
In obtaining the needed information and data to answer the developed clinical question, I researched peer-reviewed articles from various databases such as the Purdue Global Library and PubMed. PubMed is a free resource that supports the search and retrieval of life sciences and biomedical literature with an aim of enhancing health both personally and globally. The database contains over thirty-three million abstracts and citations of biomedical literature. Though the database doesn’t include the entire text of journal articles, links are often provided when the articles are available from external sources like PubMed Central or the publisher’s website. PubMed, developed by the National Center for Biotechnology Information has been available online for the public since 1996. The citations contained in the database stem from health and biomedicine and other related fields like bioengineering, chemical sciences, behavioral sciences, and life sciences. On the other hand, Purdue Global Library develops and maintains services and information resources that promote the educational goals of staff, faculty, and students. Via the Library’s website, one can have access to thousands of periodicals and e-books trade, scholarly, professionally, and trade journals. By utilizing search strategies, including title searches, subject heading searches, and keyword searches on the identified databases, I managed to obtain articles that I feel would provide the answers needed for my research question.
After extensive research in the two databases, PubMed and the Purdue Global Library, I obtained a quantitative article with a randomized controlled trial studying the effect of patient education on medication adherence among patients with rheumatoid arthritis (Taibanguay et al., 2019). The article by Taibanguay et al. (2019) was aimed at assessing the influence of various modes of patient education on patients adhering to the medication. The researchers indicate that the rate of medication adherence in patients diagnosed with rheumatoid arthritis is very low resulting in higher healthcare costs, low quality of life, disability, radiographic damage, and increased disease activity. Various intervention trials including multi-component, cognitive-behavioral, behavioral, and educational interventions have been conducted to enhance medication adherence. The researchers highlight a systematic review that established the effect of various interventions on adherence to medication and discovered that multicomponent interventions had more likelihood of enhancing adherence (Taibanguay et al., 2019). Nevertheless, it’s still uncertain their effectiveness at improving adherence. For this paper, we are going to summarize the selected case study and apply the evidence from this review to practice.
Case study summary
The study approach is a randomized controlled trial study design where the participants were randomized through block randomization and assigned to two study arms, single-intervention and multiple intervention groups, in an allocation ratio of 1:1. Study participants under the multi-component intervention received a pamphlet with disease information and thirty-minute directed counseling (Taibanguay et al., 2019). Participants under the single intervention were only provided with a disease information pamphlet. The pamphlet only offered brief information on rheumatoid arthritis including dosage and usage information. In obtaining the data, the researchers had various objective measures including the rate of pill count adherence, self-reported adherence, quality of life, disease activity, anxiety and depression, illness perception, and outcome measures. In analysis, the researchers analyzed the data through standard descriptive statistics. For categorical variables, the researchers used relative and absolute frequencies while continuous variables were defined by range and mean (Taibanguay et al., 2019). The randomization was tested by Fisher’s exact test or chi-squared test for categorical variables. The continuous variables were randomized through an independent Student’s t-test.
The researchers enrolled a total of a hundred and eighty-five patients diagnosed with rheumatoid arthritis. Fifty-six of the 185 enrolled patients with a pill count of greater than 80% were excluded due to their good adherence. Of the remaining participants, seven couldn’t adhere to the study protocol while another two participants denied taking part in the study (Taibanguay et al., 2019). This left a total of 120 patients as the final sample size for the study.
The research studied Thailand patients that met the American College of Rheumatology criteria for rheumatoid arthritis. The study participants were recruited from the rheumatology clinic of the Phramongkutklao Hospital (Taibanguay et al., 2019). Patients less than eighteen years, with severe mental disorders, high disease activity, unable to self-administer medication, unable to read Thailand, or diagnosed with any life-threatening conditions were excluded. Similarly, the enrolled patients had to be non-adherent to medication whereas patients with good adherence were excluded from the study sample.
Applying evidence to your nursing practice
Research findings during the twelve-week period indicate that the rate of adherence indicated by pill count in both the multi-component intervention and single intervention groups was significantly enhanced. However, the score on medication-taking behavior was only enhanced in the multi-component-intervention group. The two measures, medication-taking behavior score, and pill count are indirect measures of adherence with the pill count method being the more reliable of the two (Taibanguay et al., 2019). The researchers indicate that the data obtained suggest that patient education could enhance adherence to medication with no differences being observed between the multi-component and the single intervention groups. In their discussion, the authors highlight a British randomized control study among patients with rheumatoid arthritis which reveals a correlation between patient education and adherence. In the study, participants were randomized into either an intervention group that received seven face-to-face sessions of thirty minutes each with rheumatology nurses aimed at enhancing self-efficacy or were randomized into a control group that was offered standard treatment such as a disease information pamphlet. After the six months study period, participants in the intervention group showed more adherence to medication. The researchers indicate that the delivery of educational interventions with only instructive information can lead to enhanced adherence to medication while the provision of pamphlets doesn’t provide any additional benefits (Taibanguay et al., 2019). The researchers indicate that the provision of pamphlets presumes that a patient has no understanding of their medication and disease, thus attributing a passive role to the patient, failing to reflect lay beliefs that a patient may have acquired from other sources. For an educational intervention to be successful it may require the participation of both the patient and the physician, with most patients wishing to entrust the treating physician with making decisions. Therefore, as a care provider, it’s essential that one determines how involved a patient wants to be.
These research findings can significantly influence my nursing practice in ensuring increased adherence to medication for my patients. The findings outline the benefits of comprehensive patient education in ensuring increased patients adhere to their medication. As a nurse, we are often faced with cases of patients failing to take their medicines as prescribed, and as the WHO indicates medication adherence can have a significant impact on care outcomes compared to the specific treatment (Kim et al., 2018). Non-adherence can lead to a 50% likelihood of treatment failure, increased death rates, and hospitalizations. As care providers, it’s our responsibility to ensure patients adhere to their medications. While adherence is reported to be much higher while patients are hospitalized due to patients’ accessibility and the ability to dispense and administer medications on schedule. However, there is usually a decline when there is a transition of care and patients are discharged and now have to self-administer themselves with medication (Kim et al., 2018). Thus as a nurse, I can apply the evidence that patient education indeed enhances patient education and therefore take up the responsibility of educating patients on the significance of taking medications as described and the potential risks of failing to adhere to medications. Via these sessions of patient education, patients may feel free to communicate their barriers to adherence, and together we can come up with patient-centered solutions.
Evaluating the Outcomes
A research study’s validity entails how well research findings among study participants represent the actual findings among individuals with similar characteristics outside the study. The validity of a study includes two spheres, external and internal validity (Patino & Ferreira, 2018). Internal validity refers to the extent to which research findings represent the truth in a given study population and thus aren’t as a result of methodological errors. Internal validity is threatened by various factors including measurement errors and study participants’ selections. The external validity is judged based on whether the research findings can be applied in a different setting to similar patients. It’s defined as the extent to which the research findings are applicable are generalizable to patients mainly the population thought to be represented by the sample. Research that lacks internal validity implies that the study deviates from the truth and hence the results deviate from reality (Patino & Ferreira, 2018). However, this isn’t the case with our research as the researchers ## ensure adequate quality control, careful study planning, and implementation strategies including adequate sample size, data analysis, data collection, and recruitment strategies. The researchers use broad inclusion criteria, resulting in a study population that closely resembles patients in real life. Thus the study has internal validity and hence findings are applicable to similar patients in different settings.
Reliability in a study relates to the measure of consistency. It is nearly impossible to give an exact reliability calculation, but an estimate can be achieved via various measures including stability, equivalence, and homogeneity. Reliability entails the exact replicability of the study results and processes. The test results and processes have to be consistent with a margin of variability being tolerated provided the methodology yield ontologically similar data which may differ in ambiance and richness within similar dimensions (Heale & Twycross, 2015). In the case of this randomized controlled trial, we can conclude that the research findings are reliable since the methods of data collection including measures of pill adherence and medication-taking behavior score were standard for all the study participants and thus yielded consistent data that could be replicated if the test were to be done again.
In a research study, bias arises when there is the introduction of a systematic error into testing or sampling by encouraging or selecting one outcome or finding over others. It can arise at any research phase, including data collection, study design, or during data analysis and publication. In the case of our research, there are no identifiable biases as the researchers ensure there is a criterion to be met for one to be enrolled as a study participant in the research (Pannucci & Wilkins, 2015). Patients had to meet the American College of Rheumatology criteria and be not less than eighteen years, with no life-threatening conditions, and with no severe mental disorder. Patients with good medication adherence were also excluded as this would have resulted in bias as this was the expected result. Similarly, the researchers ensured well-balanced patient allocation with the underlying disease, income, education, and baseline age being not different between the single and multi-component intervention groups.
However, as per the authors, the study had a share of its limitations including the issue that it’s challenging to measure patient adherence and all approaches have downsides. Both the pill count and self-reported questionnaire methods are indicated to have low sensitivity and tend to overestimate the adherence behavior. In addition, a twelve-week study period is perceived to be short and maybe a longer time period could have been required to demonstrate maximal efficacy. Similarly, it’s indicated that some patients reported perceptions of having experienced adverse drug interactions which may have affected their adherence to medication.
Determining the level of evidence
As per the John Hopkins levels of evidence in nursing evidence-based practice, randomized controlled trials provide level 1 evidence which is the highest level of evidence. The high level of evidence in randomized controlled trials is due to their interventions standardization, prospective collection of data, and concealed outcome measures (Wallace, 2017). Therefore, since our study design, in this case, is a randomized controlled study the level of evidence provided is level 1 evidence.
Through evidence-based practice, as care providers, we can be able to use the most current research findings available to enhance the safety and health of patients while ensuring a reduction in the overall cost of care and variation in care outcomes. The randomized control trial study design summarized in this paper offers high-level evidence of the significant impact of patient education in ensuring increased adherence to medication among patients. This evidence offers answers to my clinical question where indeed thorough patient education can ensure enhanced adherence to medication where it would ensure increased blood control among elderly African-American women diagnosed with hypertension. This can be applied by ensuring lifestyle counseling and monitoring of patients to ensure they adhere to their blood pressure control medications. The counseling can entail educating the patients on the severe risk of blood pressure for individuals diagnosed with hypertension.
Heale, R., & Twycross, A. (2015). Validity and Reliability in Quantitative Studies. Evidence-Based Nursing, 18(3), 66–67. https://doi.org/10.1136/eb-2015-102129
Kim, J., Combs, K., Downs, J., & Tillman, F. (2018). Medication Adherence: The Elephant in the Room. Www.uspharmacist.com. https://www.uspharmacist.com/article/medication-adherence-the-elephant-in-the-room
Pannucci, C. J., & Wilkins, E. G. (2015). Identifying and avoiding bias in research. Plastic and reconstructive surgery, 126(2), 619.
Patino, C. M., & Ferreira, J. C. (2018). Internal and external validity: can you apply research study results to your patients?. Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia, 44(3), 183. https://doi.org/10.1590/S1806-37562018000000164
Taibanguay, N., Chaiamnuay, S., Asavatanabodee, P., & Narongroeknawin, P. (2019). Effect of patient education on medication adherence of patients with rheumatoid arthritis: a randomized controlled trial. Patient preference and adherence, 13, 119.
Wallace, D. K. (2017). Evidence-based medicine and levels of evidence. American Orthoptic Journal, 60(1), 1-5.