Can music therapy in medical contexts ever be evidence-based?

This essay seeks to consider some of the issues around evidencethat provide an ongoing challenge to the profession of music therapyto be vigilant and critical with regards the undertaking, butalso the appropriation or application, of research in our alliedhealth discipline. It is written in response to the statement that“medical music therapists need to continue to discuss and debateour views as to what constitutes knowledge, expertise and ‘evidence’in our profession.” (Edwards, 2002, p. 33). A critical perspectiveto current demands for evidence is provided, and the useof quantitative method as the basis for trustworthy research inmusic therapy is discussed. The paediatric medical context is themain site of professional research of the author, however, some ofthe points made will have relevance for other fields of clinicalservice.

Evidence-based psychiatric practice: doctrine or trap?

Medical practice has rapidly shifted towards an 'evidence-based' approach. While there are acknowledged clear benefits to this, a number of pitfalls are frequently not appreciated. Perhaps the most important limitation is the extent to which the current body of data is inadequate for many common clinical decisions. Algorithms risk being developed, frequently by third parties, without acknowledgement of these limitations and with substantial implications for clinical independence and the quality of patient care. This paper discusses potential problems of the evidence-based approach and suggests possible guidelines for the management of clinical decisions given the limitations of data-based guidelines.

Preventing tobacco use and harm: what is evidence based policy?

The majority of tobacco users commence in early to mid-adolescence. Tobacco smoking can be characterised as a chronic, relapsing disorder. While risk increases with amount smoked, there is no safe level of use (i.e., all use is risky). Duration of use is the most important predictor of premature death with the majority of excess morbidity and mortality avoidable if people quit before middle age. Investment in initiatives that reduce smoking among pregnant women and those at risk of cardiovascular disease provide quickest returns -in reduced health care episodes and expenditure.  Measures that successfully reduce smoking among parents probably reduce smoking uptake by children, and high levels of smoking among both children and parents appear to be associated with higher levels of illicit drug use.
The evidence base for pharmcotherapies in the treatment of tobacco dependence is very strong. Population-level initiatives such as tax increases, mass media-led campaigns and smoke-free policies are all highly cost-effective in reducing population-smoking levels, including among children and young people.
Australian tobacco control initiatives have been based on "social ecology" conceptualisations of the problem, which acknowledge the pivotal role of the media in shaping social values, and public and political opinion.
Broad social change, as well as more focused prevention and cessation initiatives, has drawn heavily on research findings from the behavioural sciences. Considerable effort (mainly, in Australian, in the NGO sector) has gone into documenting policy inputs and monitoring impact and outcome measures.
This chapter discusses why conceptualising tobacco-related harm from legal, economic and social policy perspectives should also help build support for tobacco control policy among academic and practising economists and lawyers, and in the business, welfare and government sectors.

Coronary angiography observations: evidence-based or ritualistic practice?

Objective: The purposes of this study were to describe the incidence and occurrence of femoral artery bleeding during the first 6 hours after coronary angiography and to determine whether there is a relationship between  current postangiogram observation protocols and the detection of  complications.

Design: This was a prospective descriptive study.

Setting: The study was conducted in 3 university hospitals in Melbourne, Australia.

Patients: Subjects included 55 patients representing the complication rate of 1075 patients, mean age 61 years (SD, 12), 69% male.

Results: About 5.1% of patients had 1 or more incidents of bleeding  requiring manual compression. In 4.2% of patients, bleeding occurred within 6 hours of angiography. Bleeding occurred a median of 2.02 hours (Q1 = 45 minutes, Q3 = 4.31 hours) after angiography. Patients without pressure bandaging bled a median of 1.32 hours (Q1 = 36.50 minutes, Q3 = 2.59 hours) after angiography. Patients with pressure bandaging bled a median of 4.75 hours (Q1 = 2.25 hours, Q3 = 7.28 hours) after angiography. In 40.6% of cases, bleeding was detected through the patient’s call for assistance, and in 59.4% of cases nurses noted bleeding while checking the puncture site. Postcatheter observations were recorded 23.70 (SD, 14.60) minutes before the bleeding incident. There were no significant changes in vital signs, systolic blood pressure (P > .05), diastolic blood pressure (P > .05), or pulse (P > .05) before or during a bleeding episode. All were within normal parameters. No neurovascular assessment anomalies were detected.

Conclusion: The use of pressure bandaging has a significant effect on the incidence and pattern of bleeding. Routine vital sign measurement has no relevance in detecting local complications after angiography. The most significant complication is bleeding that requires manual compression. Detection is through frequent puncture site observation and patient recognition and communication.

Is it only 'what works' that 'counts' in new knowledge economies? Evidence-based practice, educational research and teacher education in Australia

Recent texts on globalisation and education policy refer to the rapid flow of education policy texts producing or responding to common trends across nation states with the emergence of new knowledge economies. These educational policies are shaping what counts as research and the dynamics between research, policy, and practice in schools, creating new types of relationships between universities, the public, the professions, government, and industry. The trend to evidence-based policy and practice in Australian schools is used to identify key issues within wider debates about the ‘usefulness’ of educational research and the role of universities and university-based research in education in new knowledge economies.

Evidence-based strategies to promote physical activity among children, adolescents and young adults: review and update

This paper updates evidence reviewed in the first edition of Getting Australia Active on effective physical activity (PA) intervention strategies among children, adolescents and young adults. Intervention studies published between 1999 and September 2003 were identified using electronic databases and hand searching. A total of 28 discrete studies were identified (31 papers). Six of nine studies reported significant effects on child or youth PA in school settings. Those that incorporated whole-of-school approaches including curriculum, policy and environmental strategies appeared to be more effective than those that incorporated curriculum-only approaches. Five of 10 studies with children and two of five studies with adolescents reported increased PA or decreased sedentary behaviour in other settings. Interventions that included contact with families generally appeared to be most effective. One study with adolescents provided some evidence of the potential effectiveness of interventions based in primary care. Two of four papers reported modest short-term results among young adults, including increased PA stage of change or a higher likelihood of being adequately physically active, but none showed any evidence of sustained increases in PA. There is an urgent need for additional studies examining interventions aimed at young adults. Across the three life stages, future studies should include objective PA measures, longer-term follow-up, larger sample sizes, a specific focus on PA (rather than weight) and culturally-specific strategies that build evidence in Australian populations. Future studies should target high risk groups and a broad range of settings and strategies focusing on reducing sedentary behaviours as well as increasing PA.

Rationale and design of the national benchmarking and evidence-based national clinical guidelines for chronic heart failure management programs study

OBJECTIVES: The National Benchmarks and Evidence-Based National Clinical Guidelines for Heart Failure Management Programs Study is a national, multicenter study designed to determine the nature, range, and effect of interventions applied by chronic heart failure management programs (CHF-MPs) throughout Australia on patient outcomes. Its primary objective is to use these data to develop national benchmarks and evidence-based clinical guidelines and optimize their cost-effective application by reducing quality and outcome variability. DATA SOURCES/STUDY SETTING: Primary data will be collected from CHF-MP coordinators and CHF patients enrolled in these programs on a national basis. Secondary outcome data will be collected from a national morbidity record and from patients' medical records. STUDY DESIGN: Stage I of the study involves a prospective clinical audit of all CHF-MPs throughout Australia (n = 45) to determine the extent of variability in programs currently. Stage II is a prospective cross-sectional survey design enrolling 1,500 patients (average of 40 patients per program) to firstly determine the typical profile of patients being managed via a CHF-MP in Australia and, secondly, the subsequent morbidity and mortality during the 6-month follow-up. Outcome data will be subject to multivariate analysis to determine the key components of care in this regard. All study data will be then examined in the final stage of the study (III) to develop national benchmarks for the application and auditing of CHF-MPs in Australia. CONCLUSION: Variability in patient outcomes is a product of heterogeneity among CHF-MPs. The development of national benchmarks will minimize such heterogeneity and will provide a greater level of evidence for their cost-effective application.

Emergency nurses' opinions regarding paediatric fever: the effect of an evidence-based education program

Introduction: The beliefs and opinions of individual nurses are key factors in clinical decisions. Emergency nurses’ clinical decisions related to paediatric fever establish emergency department norms, provide role-modelling for both peers and parents, underpin clinical management of febrile children, and influence fever management advice given to parents. Aim: This study aimed to examine: (i) the opinions of emergency nurses regarding paediatric fever, and (ii) the effect of an evidence-based education program on the opinions of emergency nurses regarding paediatric fever. Method: This study used a prospective pre-test/post-test design. The primary outcome measure was emergency nurses’ opinions measured using the ‘General Opinions about Fever Management in Children’ survey. The intervention for the study was two tutorials. Pre-test data was collected in June 2005 and post-test data was collected during August 2005. Results: Thirty-one emergency nurses participated in the study. There were a number of positive changes in emergency nurses’ opinions regarding paediatric fever as a function of an evidence-based educational intervention. Major domains of change were relationship between temperature and illness severity/risk of harm, use and effects of antipyretic medication and febrile convulsions.  Conclusion: Emergency nurses are an important source of information for parents leaving the emergency department with a febrile child. Opinions can be a major influence in nurses’ clinical decisions and many fever  management strategies used by health care professionals are reflective of individual beliefs rather than the best available evidence. The results of this study showed a number of positive changes in emergency nurses’ opinions regarding paediatric fever as a function of an evidence-based educational intervention.

Evidence-based practice and the borders of data in the global information era

This article explores the range of boundaries to negotiate the demands of evidence-based practice. Increasing demands that social work be a profession committed to evidence-based practice have coincided with innovations in information technology, which potentially give social workers unprecedented access to a plethora of sources and types of evidence. Because these innovations can enable access to evidence beyond traditional boundaries, the question of how the author establish the borders of acceptability warrants consideration. Recommendations for a critical approach to selective evidence based for social work interventions are also provided.

Evidence based practice: are critical care nurses ready for it?

In the emergence of the evidence based practice movement, critical care nurses have struggled to identify scientific evidence on which to base their clinical practice. While the lack of critical care nursing research is a major concern, other important issues have significantly stalled the implementation of evidence even when it is available. A descriptive study of 274 critical care nurses was undertaken to examine nursing research activity in Victorian critical care units. The study aimed to identify critical care nurses' research skills, the barriers encountered in participation and implementation and the current availability of resources.

Results revealed that 42 per cent of the nurses who participated in the study believed that they were not prepared adequately to evaluate research, and less than a third believed they were sufficiently skilled to conduct valid scientific studies. An association was found between nurses' ability to confidently perform research activities and higher academic qualifications. The study found that there is a lack of organisational support and management commitment for the development of evidence based nursing.

In order to facilitate the implementation of evidence based practice, clinicians must be made aware of the available resources, be educated and mentored when carrying out and using clinical research, and be supported in professional initiatives that promote evidence based practice. It is argued that this will have positive implications for patient outcomes in the critical care environment.