EBP is a “problem-solving approach to clinical decision making within a health-care organization that integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence” (Newhouse, Dearholt, Poe, Pugh, & White, 2007, p. 3). The goal of EBP is to promote effective nursing interventions, efficient care, and improved outcomes for patients The JHNEBP model was utilized for this project (see Figure 1). The Practice question, Evidence, and Translation process, which guide project development, are presented in the following sections.
The EBP practice question identifies and narrows search terms to provide evidence specific to the problem and question (Newhouse et al., 2007). The PICO process described by Richardson, Wilson, Nishikawa, and Hayward (1995) is used in the JHNEBP model to develop a narrow, well-built clinical question which frames the problem clearly and assists in the evidence search by identifying core key words. The acronym PICO is represented by: P- Patient, population or problem (age, sex, patient setting); I- Intervention (treatment, medications, education, diagnosis); C- Comparison with other treatments (may not always be applicable); and, O- Outcome (anticipated). The PICO process and its application to determine best practice related to use of an ALS in sexual assault exams is as follows:
P: adult patient who has reported sexual assault
C: other alternate light source
O: positive identification of trace biological evidence.
The resulting practice questions were: Does the Wood's lamp or other ALS positively identify trace biological evidence containing DNA in patients reporting sexual assault? and; Which light source (Wood's lamp or other ALS) identifies trace biological evidence more accurately?
Evidence, including both research and nonresearch sources, is at the core of the JHNEBP model. In this model, evidence is divided into levels according to assessed strength. Research is considered the strongest evidence with experimental studies and meta-analyses rated Level I, quasi-experimental studies rated Level II, and nonexperimental and qualitative studies and metasyntheses rated as Level III (Newhouse et al., 2007). The JHNEBP encourages use of nonresearch evidence as well. This evidence specifically informs nursing knowledge by addressing current practice related to individual patients, populations, and systems (Newhouse et al., 2007). Nonresearch evidence includes systematic reviews (level I–IV), clinical practice guidelines (Level IV), and expert opinion, case studies, literature reviews, quality improvement studies, and financial analysis reports (Level V). After the strength of evidence is evaluated, the quality is assessed as high, good, or low/major flaw.
PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), National Clearinghouse Guidelines, Google Scholar, and the National Criminal Justice Reference Service were searched for evidence regarding best practices to identify trace DNA. Keywords included Wood's lamp, ALS, forensic nursing, and trace DNA. Fourteen articles (from the United States, Australia, and Canada) were initially reviewed. Seven articles that included discussions of ALSs and their applicability to DNA evidence collection were chosen for further appraisal. Three of the articles were quasi-experimental studies and rated as level II evidence. Four of the articles were descriptive studies and rated as level III evidence. The quality of all evidence was assessed as “good” (see Table 1). Research evidence graded as “good” has the following characteristics: reasonably consistent results; sufficient sample, some control, with fairly definitive conclusions; and, reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence (Newhouse et al., 2007).
Table 1. Summary of evidence
|Substances other than semen fluoresced using wavelengths less than 450 nanometers (nm); 450nm lights almost exclusively only fluoresced when stain was semen.||Carter-Snell, C & Soltys, 2005||Level II/ Quasi-experimental|
|On all surfaces, visibility of fluorescence was increased by reduced distance of light source from surface and increased concentration of semen on surface. Visibility of fluorescence not noticeably affected by angle at which light source was held in relation to surface. ALS may be useful as screening tool to direct examiner to areas of particular interest for swabbing.||Lincoln, McBride, Turbett, Garbin, & McDonald, 2006||Level II/Quasi-experimental|
|Visible fluorescence of dried semen through goggles and through camera on live skin was successful in large number of excitation and emission filter combinations of 415 nm and above.||Marshall, S., Bennett, A., & Fraval, 2001||Level II /Quasi-experimental|
|All physicians identified semen as fluorescing and 25% successfully differentiated semen from other product using ALS with wavelength 390–500 nm. Products most commonly mistaken for semen were hand cream, Castile soap, and bacitracin. After training session, 83% of physicians successfully differentiated semen from other products.||Nelson, D. & Santucci, 2002||Level III/Descriptive|
|None of the 41 physicians were able to differentiate semen from other products using a Wood's lamp (WL). Four most common products mistaken for semen using WL were A&D ointment, surgilube, barrier cream and bacitracin ointment. None of the 29 semen sample fluoresced under the ultraviolet light provide by 2 WL's.||Santucci, Nelson, McQuillen, Duffy, & Linakis, 1999||Level III/Descriptive|
|Most useful general condition for observing fluorescence of seminal or saliva stains on various materials using the Polilight was with wavelength set to 450 nm while wearing orange goggles. Polilight was found to be poor at distinguishing between different fluids and may also pick up residual laundry detergent. Polilight's function is as a screening aid: it should be used merely to locate stains which will then require further analysis.||Vandenberg & van Oorschot, 2006||Level III/Descriptive|
|In all cases low powered light sources were unable to show visible fluorescence in semen on skin. High powered lights showed faint fluorescence of semen on skin in 3 of 8 subjects. In all cases it was easier to determine presence of something on skin by reflection of plain white light rather than by fluorescence.||Wawryk & Odell, 2005||Level III/Descriptive|
According to the evidence, semen samples did not fluoresce at wavelengths associated with the Wood's lamp. Santucci et al. (1999) report that none of 29 semen samples fluoresced when two different types of Wood's lamps were used. Wawryk and Odell (2005) reported that low powered light-emitting diode (LED) lights were unable to excite visible fluorescence in the semen. In addition, other substances were often incorrectly identified as semen when the Wood's lamp was utilized. Such substances included urine, saliva, powder, body gel, laundry detergent, hand cream, Castile soap, A&D ointment, surgilube, barrier cream, and bacitracin ointment (Carter-Snell & Soltys, 2005; Nelson & Santucci, 2002; Santucci et al., 1999; Vandenberg & van Oorschot, 2006).
Visible-range light energy ALSs with wavelengths of approximately 400–600 nm were found to be more effective in fluorescing semen particles. In one study, physicians were able to detect semen stains 100% of the time with higher wavelength ALS's (Nelson & Santucci, 2002). Carter-Snell and Soltys (2005) found that 450 nm lights almost exclusively only fluoresced when the stain was semen. A study conducted by Marshall et al. (2001) found that visualization of dried semen stains through goggles and through the camera on live skin were successful in a large number of excitation emission filter combinations of 415 nm and above. Similar to the Wood's lamp, longer wavelength ALSs demonstrated a lack of specificity when identifying stains (Carter-Snell & Soltys, 2005; Nelson & Santucci, 2002; Santucci et al., 1999; Vandenberg & van Oorschot, 2006). In one study, education improved the ability of providers to accurately identify semen using a longer wavelength ALS (Nelson & Santucci, 2002). Using a Blumaxx BM500 with a wavelength of 450 nm, physicians could differentiate semen from other stains 83% of the time after the training session.
Wawryk and Odell (2005) found that while an ALS is useful for identification of stains on clothing, its use in detecting stains on skin is limited. Using ALSs with wavelengths between 370 and 500 nm, the authors report that it was easier to detect semen on the skin by the reflection of plain white light rather than by fluorescence. Lincoln, McBride, Turbett, Garbin, and MacDonald (2006) used an ALS (excitation filter 450 nm and barrier filter goggles) to detect semen on a range of inanimate surfaces and human skin. The authors found that, on both inanimate surfaces and human skin, visibility of fluorescence was increased by reduced distance of light source from the surface and increased concentration of semen on the surface. They suggest that an ALS may be useful as an adjunct screening tool in conjunction with the routine “blind” forensic samples taken as part of sexual assault forensic exams. Vandenburg and van Oorschot (2006) found that the Polilight (wavelength 415–650 nm) had a relatively high incidence of false positives when examining casework exhibits for seminal stains. The authors reported that the Polilight ALS should function as a screening aid only, used merely to locate stains, which will then require further analysis in a laboratory.
Several recommendations were made based on the evidence. The EBP team recommended that use of the Wood's lamp be eliminated from sexual assault exams. It was also suggested that forensic teams consider use of an ALS that provides appropriate wavelengths to detect DNA. If an ALS is purchased, forensic nurses should be educated about the advantages and limitations of an ALS and proper use to improve sensitivity and specificity when identifying stains. Last, more research must be conducted related to use of an ALS including: research on the sensitivity and specificity of various long wavelength lights on various skin types and at various time frames after application of stains; the role of time and normal “wear and tear” on stains because most victims come in at least 12 to 24 hours after assault; and, the development of a system to distinguish semen from other possible contaminates.
Translation is the phase in which recommendations are evaluated for application in the clinical setting and, if appropriate, an action plan is created (Newhouse et al., 2007). This is often the most difficult phase of the EBP process. The project team has been fortunate in that several of their recommendations have been translated into practice. The forensic team has eliminated use of the Wood's lamp in their exams. The SANE team manager has successfully applied for a grant to purchase an ALS. Several vendors were contacted in an effort to find an ALS that would best meet the team's needs in terms of affordability, ease of use, and educational and technical support. After a review of various products, a new ALS with a 470 nm wavelength has been purchased. The next steps are to develop an ALS practice policy and educate forensic team members. In the future, the team hopes to conduct research to compare data from the crime lab to determine if use of the new ALS improves confirmation of trace DNA.