Running Head: Evidence Based Nursing Practice: Management of Uncomplicated Fever in Children.
Evidence Based Nursing Practice: Management of Uncomplicated Fever in Children.
[Author’s Name]
[Institution’s Name]
Evidence Based Nursing Practice: Management of Uncomplicated Fever in Children.
Evidence-based practice is the integration of best research evidence with nursing expertise and patient values. The synthesis of "best research evidence" is at the core of biostatistics and epidemiology. What, however, is the scientific basis for "nursing expertise"? It can be defined as "the ability to use our nursing skills and past experience to rapidly identify each patient"s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations". The content of their handbook, however, deals mainly with searching and processing evidence. It contains little about nursing expertise. It seems as if evidence-based practice in reality offers no methods for improving nursing skills, or takes it for granted that doctors obtain nursing expertise by practicing medicine. This is surprising, because studies of nursing decision making tend to demonstrate that nurses are not handling information in a consistent and comprehensive way. Rather, they use heuristics and base their decisions on parts of the available information because to cope with the totality is in practice too difficult. One used to demonstrate the problems of medical decision making by asking nurses to decide on therapy for 20 "paper patients" and subsequently identify what patient factors were important for the decisions. It turned out that many doctors seemed to be unaware of what factors they used in their decision making. They claimed that certain factors were important, yet regression analyses pointed to some totally different ones. Perhaps Archie Cochrane"s concept "the relative unimportance of therapy" may explain why "nursing expertise" is considered relatively unimportant. The most common origin of questions is professional practice itself. For example, a clinician may have a child on her caseload for whom she would like to explore the use of a speech-generating device (SGD) on a trial basis. Although the child and his family agree with such a trial period, collectively, the clinician and her team might be unsure whether to try a dynamic display, a static display, or a combination thereof. The clinician may also wonder whether only one of these options or multiple options should be tested; and if so, should it be simultaneously or successively.
Usually, febrile illness are not dangerous. More than 30% of emergency department diagnoses included febrile illness as a symptom. Treatment for febrile illness varies among health care professionals and parents; however, evidence-based guidelines provide the safest and effective methods to treat febrile illness in children and should be used. The average cost for a nonhospitalized infant/child was US$192.29, as compared with US$3,412.82 for a hospitalized infant/child. Febrile illness is a primary symptom for most physician visits, with more than 52% receiving antibiotics. Interventions aimed at controlling or reducing febrile illness present a common problem for both health care professionals and parents. Available literature targeting febrile illness treatment in children depicts inconsistency among interventions that are not therapeutic, cost-effective, or evidence-based. Barriers to proper management include inaccurate information among media and Internet sites, knowledge deficits, misconceptions, and parental anxiety.
Outcomes: Implementing this EVIDENCE-BASED PRACTICE in relation to febrile illness treatment can facilitate vital outcomes to parents, children, and the health care industry. The outcomes are as follows:
1. Decrease in ER visits and/or hospitalizations
2. Increased child comfort
3. Decreased febrile convulsions
4. Reduced parental anxiety
5. Best practice treatment of febrile illness treatment in children on evidence-based research is encouraged
6. Decreased unnecessary use of antibiotics and other medication
7. Decreased health care cost
8. The body's physiological response to infection is supported
The literature review provides best practice guidelines for managing a child with febrile illness. The lack of consistency of nursing interventions directly affects patient outcomes, parental knowledge, anxiety, and lack of appropriate interventions. The primary focus is to provide interventions to increase the child's comfort while decreasing the febrile illness. Education is focused on the decision to treat a febrile illness, sponging, advice aimed at parents, as well as the appropriate use and dosage of antipyretics in managing a child with febrile illness.
Section II: Discussion of Best Evidence
For more than two decades there has been strong evidence-based support for the beneficial effects of mild febrile illness (e.g., Kluger, 1986, Kluger, 1992, Lorin, 1999 and Sarrell et al., 2002). Despite this, reports of febrile illness and fears of febrile seizures remain unchanged (May and Bauchner, 1992, Poirier et al., 2000 and Sarrell et al., 2002). Nurses continue to reduce low grade febrile illness without other symptoms, wake sleeping febrile children for antipyretics and administer a different antipyretic to children still febrile 1 h following initial treatment (Poirier et al., 2000 and Sarrell et al., 2002). Inconsistent febrile illness treatment practices, the impetus for this study, have been reported for nearly two decades and highlight the need for exploration of this integral aspect of pediatric nursing (e.g., Younger and Brown, 1985, Reeves-Swift, 1990 and Harrison, 1998). This paper examines whether pediatric experience and education influence nurses’ knowledge of and beliefs about febrile illness treatment.
Febrile illness treatment literature is inconsistent and could influence nurses’ practices. For example, advice on the temperature at which to treat febrile illness varies from 38.3 °C (Thomas, 1995), 38.9 °C (Cunha et al., 1984), 39.4 °C (McCarthy, 1999) to only treating febrile illness greater than 40 °C when the physiological benefits of febrile illness diminish (Connell, 1997, Lorin, 1994 and Luria et al., 1996). Rationales for reducing temperatures, to prevent febrile seizures, are no longer applicable. Febrile seizures are benign, common events in young children (D’Auria, 1997) associated with rectal temperatures above 38 °C (Kudsen et al., 1996). They are precipitated by a number of factors including a lower seizure threshold of the developing cortex (normal seizure threshold is higher than 41.5 °C (Kudsen et al., 1996)), susceptibility to infections, tendency to have high febrile illness and a genetic component affecting the seizure threshold (Baumann, 2001, Freeman, 1992 and Nelson and Ellenberg, 1981). Nursing management of febrile children should be scientifically based focusing on energy conservation, promoting comfort and maximizing the immunological benefits of febrile illness (Connell, 1997).
Reports of nurses’ management of febrile illness remain static (e.g., Poirier et al., 2000 and Sarrell et al., 2002). Do these reports reflect experienced or novice nurses’ management? Literature reflects negative beliefs about febrile illness and febrile seizures (May and Bauchner, 1992, Poirier et al., 2000 and Sarrell et al., 2002) and the lack of nursing documentation of febrile illness treatment (Edwards et al., 2003 and Grossman et al., 1995). However, there is a dearth of literature describing the influences of nursing experience, education and level of practice on nurses’ knowledge of and beliefs about febrile illness and febrile illness treatment. This study attempted to address these deficits and to identify ongoing education needs for practicing pediatric nurses. This paper refers to the second phase of a three phased study. The first phase involved audits of 67 charts, of children admitted to hospital for a febrile illness, to explore nurses’ febrile illness treatment practices the second phase was a survey for which a general description of nurses’ knowledge, beliefs and the influences on their febrile illness treatment practices can be found in Walsh et al. (2005) and the third phase involved focus group discussions to explore the contradictions found in the data (Edwards et al., 2001). This paper reports the influences of specific nurse characteristics on their knowledge of and beliefs about febrile illness and febrile illness treatment. In particular it explores the influences of:
The level at which nurses are practicing. Level 1 registered nurses provide direct patient care. Level 2 nurses provide direct patient care and have additional responsibilities in the unit, such as the orientation and preceptorship of new staff, staff development, providing continuing education and research as part of their responsibilities (ANRAC, 1990).
Completion of a pediatric certificate from either a hospital based program or tertiary certificate. This was included to determine nurses’ interest in and commitment to pediatric nursing.
Length of pediatric experience.
Length of time in current position (current experience).
On their knowledge of and beliefs about febrile illness and febrile illness treatment.
The complexities of health care can confound any practitioner’s choice of clinical actions. Deficits in current knowledge or the occurrence of problem triggers provide the basis for posing an answerable question. Posing the right question is critical in directing the clinician in the search for best outcomes. Most nurses find a special interest niche somewhere in their practice, and this interest can spark an investigation of recent research findings.
· Patient population of interest: defining the target patient population by specifying age, sex, ethnicity, and specific health problem of interest. Example: children who are 13 years and younger with acute otitis media.
· Intervention: defining the nurse practitioner action including assessment techniques, procedures, and treatments. Example: use of first-generation antibiotics (amoxicillin, trimethoprim plus sulfamethoxazole, or erythromycin plus sulfisoxazole) to treat acute otitis media.
· Comparison: assess the differences between current practices, procedures, and health information compared with EBPs. Example: what is the effectiveness of first-generation antibiotics compared with second- and third-generation antibiotics (e.g., cefaclor, amoxicillin plus clavulanate, or cefixime)?
· Outcome: a nursing action that results in patient effects; specifying the results may narrow the focus of the question. Example: in one randomized clinical trial, first-generation antibiotics were more effective than second- and third-generation antibiotics.
Febrile illness treatment as per evidence-based practice has become an integral aspect of pediatric nursing practice. Findings strongly suggest the pediatric nurses studied were not expert febrile illness managers. Although those practicing at a higher level and with between one and four year’s pediatric or current experience had more accurate knowledge than their co-workers, they were not experts, their knowledge was mediocre. Discovering that knowledge did not influence these nurses’ beliefs is important for clinical practice as many educational interventions target knowledge. Nurses with negative beliefs about febrile illness who support the use of antipyretics to reduce temperatures in the belief they are preventing febrile seizures might be responsible for the febrile illness phobia they report in their peers. The nurses studied had not incorporated the latest clear evidence for ‘best practice’ in febrile illness treatment as per evidence-based practice, available in the literature, into their practice (e.g., Connell, 1997, McCarthy, 1999 and Robertson, 2002).
Limited knowledge and inappropriate beliefs about antipyretic effectiveness, for example, administering antipyretics to prevent febrile convulsions and reducing temperatures as low as 38.3 °C, raises concerns about the quality of care children hospitalised for a febrile illness receive. Nurses, in this study, with poor knowledge of and negative beliefs about febrile illness and febrile illness treatment as per evidence-based practice might care for febrile children ritualistically, and/or inconsistently, rather than rationally, reinforcing febrile illness phobias in themselves, their colleagues and the parents of children in their care (e.g., Impicciatore et al., 1998, Weiss and Herskowitz, 1983, May and Bauchner, 1992, Thomas et al., 1994 and Poirier et al., 2000). Current practices may be the interaction between nurses’ indecisiveness about the effectiveness of aggressive antipyretic therapy in preventing febrile convulsions and a strong desire to prevent harm. The nurses studied were employed in a major metropolitan pediatric hospital, how do children in provincial and rural hospitals fare?
Febrile illness treatment as per evidence-based practice must be grounded in a thorough knowledge of febrile illness and the febrile response, based on a thorough assessment of the individual child and their response to febrile illness at each time point (Connell, 1997). Findings highlight the need to improve nurses’ febrile illness treatment as per evidence-based practice practices, irrespective of recommendations from a recent systematic review that an endeavour to alter practice in the absence of obvious harm from antipyretics was unjustifiable (Meremikwu and Oyo-Ita, 2002). Parent education in febrile illness treatment as per evidence-based practice by nurses has been recommended for the past 20 years (Casey et al., 1984 and Purssell, 2000), however, if the nurses studied do educate parents then poor knowledge and negative beliefs are being reinforced.
Pediatrics is a relatively small speciality area so undergraduate nursing students usually have limited pediatric placements. As attainment of a pediatric certificate appears to have made little difference to knowledge or beliefs it is possible that pediatric febrile illness treatment as per evidence-based practice is learnt ‘on the job’ through informal education. Informal education is a tool used by experts to guide workplace learning by addressing learning needs as they arise (Gillam, 1997). Informal education has been successfully used by experienced pediatric nurses to educate novices about pediatric pain assessment (Fuller and Conner, 1997). Although the informal educators in this study, Level 2 and experienced nurses, were more knowledgeable, they reported similar beliefs to novices. Findings suggest the informal educators might reinforce negative beliefs and practices through their teachings and behaviours, identifying a need to investigate how novice pediatric nurses learn to manage febrile illness. It could, therefore, be argued that informal febrile illness treatment as per evidence-based practice education had been effective. Many of the informal educators, those with more pediatric and current experience, demonstrated levels of knowledge and negative beliefs similar to newer nurses.
Findings highlight the need for Level 2 and experienced nurses to continually upgrade their knowledge and attend available inservice and continuing education programs about febrile illness treatment as per evidence-based practice. Experienced nurses are perceived as experts by new and current nursing and medical staff; they have been there longer and are presumed to ‘know it all’. This lack of knowledge by experienced pediatric nurses is of utmost importance and in particular for nurse educators responsible for planning and conducting postgraduate, continuing education and inservice programs. Additionally, focused investigations are necessary to determine causes for low knowledge levels and negative beliefs. Areas for investigation include: application of knowledge to practice; interest in continued education; opportunity for both novice and experienced nurses to attend inservice on fundamental nursing issues; influence of reductions in permanent staffing and the associated increased workload of experienced staff to continually educate casual, pool and agency nurses and nursing students; and disinterest in continued learning due to ‘burn-out’.
Traditional knowledge enhancing programs targeting nurses’ pain management, a similarly interdependent nursing activity, have not always influenced either practice or beliefs in practice settings (Camp-Sorrell and O’Sullivan, 1991 and Francke et al., 1997) or been enduring (Howell et al., 2000). To promote consistent, rational febrile illness treatment as per evidence-based practice educational programs must target all nurses, both experienced and novice, and challenge nurses’ negative beliefs, not simply give information. Febrile illness treatment as per evidence-based practice practices are influenced by normative beliefs that parents, peers and doctors expect nurses to administer antipyretics to febrile children (Walsh et al., 2005). Therefore, barriers to changing practice following febrile illness treatment as per evidence-based practice education will possibly be similar to those in pain management, that is, colleagues and the setting (Czurylo et al., 1999). This highlights the need to ensure all nurses attend continuing education programs to facilitate the removal of normative barriers to evidence-based febrile illness treatment as per evidence-based practice.
Why were expert nurses not knowledgeable about this common pediatric practice? As an everyday occurrence for pediatric nurses, febrile illness treatment as per evidence-based practice might not be included in further pediatric education, or could be considered unimportant thereby receiving minimal coverage. The scarcity of nursing documentation of febrile illness treatment as per evidence-based practice practices and rationales for antipyretic administration highlight this (Edwards et al., 2003 and Grossman et al., 1995). If so, then experienced pediatric nurses as well as nurse educators and managers might consider febrile illness treatment as per evidence-based practice education relevant only for novices, limiting experienced nurses’ interest in and attendance at inservice about basic pediatric nursing practices.
Clinical signs are very important in children with febrile illness because they guide the diagnostic procedures. Febrile illness has to be characterized precisely; for example, the age and time at onset, the height of the febrile illness, the pattern and number of daily peaks, and recurrence. Parents should be encouraged to measure the temperature regularly to establish a febrile illness chart. In infants and toddlers, it may be difficult to distinguish recurrent viral infections from recurrent febrile illness of another origin. Febrile illness may be accompanied by several different symptoms. Cutaneous signs, e.g. evanescent rash during febrile illness peaks, urticaria, purpura, etc., are important for the differential diagnosis and also require a good description from the parents or other physicians, as they may change or disappear during the course of the illness. Other important associated signs include mucosal involvement (aphteous ulceration), bone and joint involvement (pain, inflammation), and signs of eye, lung or gastrointestinal tract problems.
The study identified that Level 2 nurses and nurses with between one and four years pediatric or current experiences were most knowledgeable about febrile illness and febrile illness treatment as per evidence-based practice. However, this knowledge did not positively influence their beliefs; their beliefs were similar to novice pediatric nurses. Of concern for practicing pediatric nurses is that nurses with the greatest length of pediatric and current experience were not the most knowledgeable. Additionally, neither greatest length of pediatric experience nor completion of additional pediatric education made minimal difference to level of knowledge or beliefs.
Implications for nursing education include determining how novice pediatric nurses learn to manage febrile illness and educating the educators, Level 2 nurses and experienced nurses. It is essential that ‘on the job’ learning is evidence-based. Educational programs should be ward based with all staff members encouraged to attend. Programs need to target beliefs as well as knowledge as higher knowledge levels in febrile illness treatment as per evidence-based practice did not positively influence nurses’ beliefs.
Section III: Recommendations
Nursing research has developed immensely during the last few decades and in my view nursing research is now firmly established in many countries, worldwide and rapidly developing in other countries. However we do need to discuss and reflect upon how we can develop it further to really make a case in practice, and to do so it is my firm believe that we need to move away from too much descriptive research into research designs that really have something to say to practice, that translates the findings from these descriptions into practice. We also need to build programs rather than carrying on with projects, and in these programs we need a healthy composition of highly experienced researchers and junior researchers as well as doctoral students, and say ‘no thank you’ to those wanting to do other things. We need to strengthen collaboration within countries as well as across countries. Doing so, I believe we will make a difference when it comes to health-care delivery as well as the interventions used in the care of people. We need to take the next step and contribute to a new generation of nursing research with great impact on practice, providing knowledge that our consumers, patients as well as providers cannot resist. The science of health care is always evolving, challenging us to be progressive. Florence Nightingale reminds us that “Nursing is a progressive art in which to stand still is to have gone back.” Practice routines should be examined to determine if practitioners are offering nursing care based on tradition, intuition, and authority or evidence. The emphasis on evidence-based practice needs to be part of an individual practitioner’s motivation and collective organizational practice culture. Evidence-based practice is the bridge between research and practice. However, it is well known that the gap between research findings and implementation is far too long. A memorable example of delayed implementation of evidence is that of the British Navy. The benefits of limes and sauerkraut to prevent scurvy were discovered in 1601, yet rations containing vitamin C were not required until 1795. In fact, the British Board of Trade took an additional 70 years to order that citrus be provided on merchant ships, a total of 264 years between evidence and practice!
References:
Australasian Nurse Registering Authorities Conference, 1990 Australasian Nurse Registering Authorities Conference, 1990. ANRAC Nursing Competencies Assessment Project. University of Queensland, Brisbane.
Baumann, 2001 R. Baumann, Prevention and management of febrile seizures, Pediatric Drugs 3 (2001) (8), pp. 585–592.
Camp-Sorrell and O’Sullivan, 1991 D. Camp-Sorrell and P. O’Sullivan, Effects of continuing education: pain assessment and documentation, Cancer Nursing 14 (1991) (1), pp. 49–54.
Casey et al., 1984 R. Casey, F. McMahon, M. McCormick, P. Pasquariello, W. Zavod and F. King, Fever therapy: an educational intervention for parents, Pediatrics 73 (1984) (5), pp. 600–605.
Connell, 1997 F. Connell, The causes and treatment of fever: a literature review, Nursing Standard 12 (1997) (11), pp. 40–43.
Cunha et al., 1984 B. Cunha, M. Bigamon-Beltran and P. Gobbo, Implications of fever in a critical care setting, Heart and Lung 13 (1984) (5), pp. 460–465.
Czurylo et al., 1999 K. Czurylo, M. Gattuso, R. Epsom and B. Stark, Continuing education outcomes related to pain management practice, Journal of Continuing Education in Nursing 30 (1999) (2), pp. 84–87.
D’Auria, 1997 J. D’Auria, Fever. In: J. Fox, Editor, In Primary Health Care of Children, Mosby, New York (1997).
Edwards et al., 2001 H. Edwards, M. Courtney, J. Wilson, S. Monaghan and A. Walsh, Fever management practices: what pediatric nurses say, Nursing and Health Sciences 3 (2001) (3), pp. 119–130.
Edwards et al., 2003 H. Edwards, M. Courtney, J. Wilson, S. Monaghan and A. Walsh, Fever management audit: Australian nurses antipyretic usage, Pediatric Nursing 29 (2003) (1), pp. 31–37.
Francke et al., 1997 A. Francke, J. Luiken, A. de Schepper, H. Abu-Saad and M. Grypdonck, Effects of a continuing education program on nurses’ pain assessment practices, Journal of Pain & Symptom Management 13 (1997) (2), pp. 90–97.
Freeman, 1992 J. Freeman, The best medicine for febrile seizures, The New England Journal of Medicine 327 (1992) (16), pp. 1161–1163.
|
