Evidence Based Care
Volume:6 Issue: 1, Spring 2016

Studies suggest that family caregivers of hemodialysis patients experience a high level of burden, which could lead to numerous physical and psychological problems. Despite the need for adequate training and support, these caregivers are mostly neglected, and few studies have been performed in this regard.
Aim: to evaluate the effect of educational programs on the home care of hemodialysis patients and burden of their family caregivers.
This randomized controlled clinical trial was conducted on 76 caregivers of hemodialysis patients referred to Shahid Hasheminejad Hemodialysis Center of Tehran, Iran in 2015.­ Subjects were divided into two groups of intervention and control (n=38). The intervention group received four training sessions on the home care of hemodialysis patients for two weeks, and the control group received routine care. Data were collected using the Caregiver Burden Inventory (CBI) at the beginning and six weeks after the intervention­. Data analysis was performed in SPSS V.21 using Chi-square, Fisher’s exact test, independent and paired T-test, and Mann-Whitney U test.
In this study, no significant difference was observed between the two groups in terms of demographic characteristics. At the baseline, mean score of caregiver burden in the intervention and control groups was 88.5±11.7 and 84.9±15.1, respectively, and no significant difference was observed between the groups in this regard (P=0.30). Six weeks after the intervention, the results of independent T-test revealed a significant difference between the mean scores of caregiver burden in the intervention (58.7±6.6) and control groups (87.8±11.7) ­(PImplications for Practice: According to the results of this study, use of an educational program for family caregivers­ could be effective in reducing their burden and other problems associated with the home care of hemodialysis patients. Therefore, it is suggested that educational managers of medical centers encourage the healthcare personnel to apply such programs in order to improve the health of caregivers.

Pregnant women with insecure attachment style are at high risk of psychiatric disorders. Since emotions are the first coordinators of attachment behavior, emotion regulation training can alter maternal attachment style. In this study, we aimed to evaluate the effects of emotion regulation training on the attachment styles of primiparous pregnant women with insecure attachment style.
Aim: This study aimed to evaluate the effects of training programs on the headache of patients after spinal anesthesia.
This randomized, clinical trial on 40 primiparous pregnant women with age range of 30-34 years, who were referred to healthcare centers of Mashhad, Iran, during 2014. The data collection instrument was Revised Adult Attachment Scale (RAAS). The participants were assigned to intervention and control groups. A training program was implemented on emotion regulation based on dialectical behavior therapy (DBT) for the intervention group. After delivery, RAAS was completed by the mothers again. The control group only received the routine care. To analyze the data, Chi-square and independent t-test were run using SPSS, version 15.
Mean ages of the mothers in the intervention and control groups were 26.9±4.04 and 27.5±3.5 years, respectively. According to the results of independent t-test, the difference between the groups was non-significant (P=0.77). The groups were analogous in terms of attachment style pre-intervention. After the intervention, independent t-test did not reflect any significant differences between the groups regarding avoidant (P=0.37) and anxious (P=0.11) attachment styles. However, mean score for secure attachment style was significantly enhanced (P=0.01).
Implications for Practice: Our findings revealed that implementation of emotion regulation training increased secure attachment scores. Thus, implementing emotion regulation training program is recommended as part of a program for pre-natal care in healthcare centers.

Premature birth is a major cause of infant mortality in developed countries. Newborns confined to neonatal intensive care units (NICUs) are in a rapid stage of brain development. As such, sleep plays a pivotal role in the proper brain development of newborns. However, this developmental aspect is often disregarded due to the lack of information.
Aim: This study aimed to evaluate the effect of nest posture on the sleep-wake state of premature infants.
This cross-over clinical trial was conducted on 60 premature infants admitted in the NICU of Ghaem Hospital in Mashhad, Iran in 2015. Infants were divided into two groups of experimental and control. Data were collected using the Assessment of Premature Infant's Behavior (APIB). Neonates in the control group were placed in an incubator, and neonates in the experimental group were positioned in a nest. Between-group comparison was performed using paired-samples T-test for normal variables and Wilcoxon test for non-normal variables.
In this study, no statistically significant differences were observed between the two groups in terms of the scores of deep sleep state before (P=0.50) and after the intervention (P=0.59). However, during the intervention, mean score of deep sleep was higher in the experimental group (P=0.08). Moreover, mean score of slow wake state had no significant difference between the study groups before (P=0.67), after (P=0.86), and during the intervention (P=0.81).
Implications for Practice: According to the results of this study, nest posture increased the deep sleep hours of premature infants as the most imperative state of brain development. Therefore, it is recommended that nest posture be used to improve the deep sleep state of premature infants.

Given the importance of anger controlling on addicts aggression at withdrawal beginning and their specific conditions, it is essential that different educational methods tailored to the content anger management to reduce aggression and control anger in the addicted people.
Aim: This study aimed to compare the effect of anger management training using workshop and training package methods on the aggression of patients with addiction.
In this randomized clinical trial, 60 Clients referred to the addiction withdrawal clinic of psychiatric hospitals of Mashhad in 2014-2015, were allocated into three groups, educational workshops)n=20) (4 sessions over 2 days of anger management training) and training package (n = 20)(trained as a manual and CD) and control (n = 20)(no intervention). Bass & Perry Aggression Questionnaire was implemented immediately before and one month after the intervention. For data analysis, ANOVA, Kruskal-Wallis and paired t-test were performed, using SPSS version 11.5.
Results Based on the results of One-way ANOVA, there was a significant difference between the three groups of workshop (14.7±9.4), training package (10.3±5.3), and control (-2.8±3.6); (PImplications for Practice: Holding workshops on anger management can be highly effective in lowering aggression in drug addicts, due to its interactive nature.

Stress and anxiety in cancer patients are caused by disease diagnosis, unfamiliar experiences, and therapy-related problems. In addition to the short duration of radiotherapy, receiving and understanding of the information about this treatment could be difficult for patients due to anxiety, fatigue, and mental pressure. Training of cancer patients about radiotherapy via educational programs could reduce pre-treatment anxiety.
Aim: This systematic review aimed to integrate the information regarding the effects of pre-treatment educational training on the level of anxiety and distress symptoms of cancer patients receiving RT.
This systematic review was conducted to identify the studies comparing different methods of pre-treatment patient education before radiotherapy via searching in databases such as MEDLINE, PsycINFO, Web of Science, ClinicalKey, ProQuest, and PubMed. Selected studies included clinical reports on the effects of educational interventions on the anxiety of patients receiving radiotherapy. Excluded samples were commentaries and studies without intervention.
In total, we reviewed eight articles assessing the effect of educational interventions before radiotherapy on the anxiety of cancer patients. Educational interventions used in these studies included face-to-face consultation with a radiotherapist, group instructions with routine individual training using visual materials (e.g., brochures, booklets, videotapes, and PowerPoint presentations), group discussions, electronic instructions, written materials, and phone contact with a nurse.
Implications for Practice: According our findings, pre-treatment education could reduce the anxiety of cancer patients before radiotherapy. These educational programs could be performed using written, visual, electronic, or face-to-face instructions. However, considering the condition of cancer patients and their treatment, selection of the appropriate training method requires further investigation through comparing different approaches.

There has been a dramatic increase over the past few decades in the use of modern fertility technologies and the demand by infertile couples for using these techniques have increased as well. Studies exploring the experiences of women fertilized with egg donation technique in their treatment process have been rare.
Aim: This study aimed to explore and explain the treatment experiences of women fertilized with egg donation.
This is a Qualitative study. Data were analyzed simultaneously as they were being collected and according to the conventional content analysis method. The study began in July 2013 and continued until September 2014. Fourteen unstructured, in-depth interviews were carried out with 12 infertile women who had been fertilized or had given birth to children through egg donation. One of Tehran’s referral centers for infertility was used as the study setting. All participants submitted their written consent prior to the start of the study.
Analysis of the findings showed "difficult and stressful treatment" as the final theme with 6 subthemes, including: 1) religious barriers, 2) treatment difficulties, 3) treatment frustration (including the following subcategories: fatigue and despair, and the experience of frequent failures), 4) dissatisfaction with the services provided, 5) confusions in treatment, and 6) Perception of relative peace.
Implications for Practice: Exposure to various assisted reproductive technologies, including egg donation, is a stressful process, and providing emotional support to patients is one of the most essential care services they require from treatment centers. The results of the present study can assist in planning future strategies for meeting the specific needs of these distinguished patients.

Regarding nurse's significant role in improving quality of marital life in mastectomy patients and their families, implication of the adaptation model can help nurses reaching this goal.
Aim: This study aimed to determine Effect of an educational-supportive program based on Roy This quasi-experimental study was performed on 69 mastectomy patients receiving chemotherapy in 2013 in clinical services in Tehran, Iran. The samples were randomly allocated to two groups. The data collection instrument was ENRICH Marital Satisfaction scale (2011). In the experimental group, maladaptive behaviors and their stimuli were determined by the questionnaire, and then adaptive strategies were implemented in 45 days. The program was based on support (patients instruction), peer group, weblog, meeting with the participants’ spouses, and three-month follow-up using behaviors checklist. Control group patients received the regular treatment sessions. T-test, Pearson’s correlation coefficient, Spearman's rank correlation coefficient, and Chi-square tests were run, using SPSS version 19.
In experimental group, paired sample t-test reflected an increase in marital satisfaction from 24.7±2.6 before to 32.9±3.5 after the intervention (P=0.03). However, no significant differences were observed in the control group from 26/7±4/6 before to 26/5±4/8 after the intervention in this regard (P=0/63).
Implications for Practice: Roy Adaptation Model can be used as a framework for designing educational-supportive programs to improve quality of marital life in mastectomy patients receiving chemotherapy.

Recently, use of research, theory, evidence-based practice (EBP), and quality improvement (QI) has increased dramatically in the professional manuscripts and discourses of the health related literature. However, inadequate knowledge and inability to recognize the differences between these processes have led to uncertainty in some of these practices.
Elucidation of such processes is of paramount importance for students of different branches of health sciences, registered nurses, and even scholars. As such, certain distinctions have to be outlined in the methodologies and goals of these scientific processes.
The principal objective of research, around which all the other goals revolve, is to produce new knowledge and/or add to the existing body of knowledge in a specific area of science. This could be the knowledge that is directly applicable for practice or the knowledge that needs further verification before application. The process of research has been well illuminated in the literature. Scientific research methods are based on a research problem definition, which is used to formalize a research protocol in order to answer the research question (1). One example of a research question is as follows:“Does the use of sitters prevent hospitalized elderly patients from falling?”
Research is defined as the systematic inquiry to generate new knowledge and refine or validate the existing knowledge regarding a specific subject.
Theorizing aims at the formulation and systematization of research findings and knowledge in order to define a certain phenomenon or problem methodically (2). In this process, logical and interconnected concepts, statements, and propositions are manipulated to describe, explain, predict or control the phenomenon. Therefore, research findings should be presented in the form of theories (scientific and systematic description of knowledge) and asserted hypotheses in qualitative and quantitative research approaches, respectively (3). In other words, research knowledge and findings resemble the effective substances of a medicine, which must turn into different forms in order to be used in medical practice effectually. Accordingly, theory and theorizing are considered the cornerstones of every scientific discipline. In the positivist approach towards science, theory comes before research in all academic achievements.
On the other hand, the most recent paradigms have recognized and substantially emphasized the significance of EBP as an inherent and definitive index to assess the quality of professional healthcare practice.
EBP is an attempt to answer clinical questions through evaluating the existing evidence (1). Using EBP, the clinician applies the most credible evidence available in order to deliver the necessary care procedures under all circumstances. While scientific evidence is considered a main component of the overall structure of EBP, other sources should be taken into account as well.
1. Professor of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
* Corresponding author, Email: mohamade@modares.ac.ir
The fundamental components of EBP methodology are embedded in the PICO model, which is used to frame the EBP question. PICO is a leading technique in EBP and is defined as follows: P (identification of patient or population problem to specify the main concern, complaint, disease or health status of the patient), I (identification of the intervention used to address the problem), C (comparison of the main alternatives of the intervention), and O (recognition of the expected outcome). Systematic search strategy is known as the root of the evidence obtained from research, theories, and clinical literature, as well as the clinical knowledge that is based on the opinion of experts.
Therefore, the foremost sources of evidence are research, theory, and theory-based research findings. If EBP is separated from research and theory, it has been disconnected from its origin and is devoid of meaning and scientific value. Nevertheless, some health care researchers tend to neglect this intrinsic and essential relationship, insisting on EBP without considering the significance of conducting accurate research and devising a proper theory as the foundations of the evidence, outcomes, and products of qualitative research. This is an outright diversion from the subject of accurate research, which is against the principles of EBP.
An important distinction between research/theory and EBP is that EBP accounts for the preferences of patients with respect to the type of intervention. In this regard, an example of a PICO question is as follows:“In hospitalized elderly patients (P), how does a bed alarm (I) compared to the use of sitters (C) affect the rate of falling (O)?”
EBP adopts a problem solving approach based on the most reliable evidence, clinical expertise, and patient preferences to answer the question above.
In the field of health care, QI is applied to improve the quality of delivering care locally. In QI, the first step is to recognize the care delivery problem and address it at a local level, which is followed by efforts to resolve the problem. Some of the most common approaches used in QI include Plan-Do-Study-Act (PDSA) cycles, Six Sigma, and lean methodologies. An example of a QI question is as follows:“What are the causes of the high patient fall rates? How could we reduce the percentage of patient falls in our hospital unit?”
Overall, the QI method uses relevant data to monitor the outcomes of care processes in order to design and examine the changes via improving the applied methods, which increases the quality and safety of healthcare systems constantly.
While each process is associated with its unique characteristics, overlaps are likely to appear between each of the two processes. For instance, in the EBP process, if one discovers (theory) that evidence is inadequate to implement a certain intervention, it highlights the need for research on that specific subject. Similarly, QI may lead to the identification of new questions, which could be used for research purposes. All the discussed processes, as well as their scientific and professional dimensions, are essential to nursing disciplines in healthcare systems.