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Thailand's spectacular Doi Suthep Mountain provides the backdrop for Chiang Mai University, sprawled over 1400 hectares on the site of an ancient forest. There are 24,000 trees wedged among three campuses and the splendour of the Ang Kaew Reservoir, and at dusk pandemonium can be heard from afar at the Chiang Mai Zoo.
Developed 40 years ago following a royal charter granted by His Majesty King Bhumibol Adulyadej, the Chiang Mai University (CMU) is indeed a magnificent reflection of Thailand's environmental and cultural beauty.
Yet despite the idyllic surrounds, it refuses to be distracted from its mission statements, including: 'seeking excellence in the advancement and dissemination of knowledge to meet the challenges Thailand faces in a globalising world'.
In November 2002, it tied this goal with one of its corporate mission objectives - 'to provide access to an international standard of multidisciplinary education' - by welcoming the Joanna Briggs Institute's newly-formed Thailand Centre for Evidence Based Nursing and Midwifery.
Helping the Centre to achieve and promote best practice is its close professional relationship with northern Thailand's largest teaching hospital, Maharaj Nakorn Chiang Mai, which is on site at the CMU.
The Thailand Centre for EBNM has a staff of four, who are supported by an administrative committee consisting of eight members of the University's faculty of nursing, and another three from the Hospital. The Centre is led by Dr Ratanawadee Chontawan as Director, and Dr Pikul Nantachaipan as Deputy Director.
Dr Chontawan believes in the near future there will be ever-increasing implementation of evidence-based practice in nursing and different areas of clinical practice in Thailand.
"In the near future we anticipate that the Thailand EBNM Centre will have at least two systematic reviews underway," she said. "My faculty colleagues and I are working closely with hospitals in Chiang Mai, Chiang Rai, and Bangkok with regard to evidence-based practice implementation."
We are in the process developing clinical guidelines in Chiang Rai and Bangkok, and getting evidence into practice in Chiang Mai.
EBP is a relatively new concept in this country, so we need to promote its understanding and essential benefits, and the process of implementing it among nurses in academic and practice areas.
To do so, we need to teach nurses the basis of a systematic review in terms of concept, essential requirements and process. Since our Centre was formed we have organised activities, and held workshops and training programs on conducting systematic reviews and implementing EBP.
The collaborations between our Centre and hospitals were established after each training program. The key roles of academics working in the Thailand Centre, and practitioners in hospitals, were identified.
Besides being the consultants or mentors of the project, academics are taking on roles in searching for the best available evidence and practices, and helping to develop guidelines. Clinical nurses are involved with all steps of implementation, using developed guidelines, and monitoring as well as evaluating the outcomes.
"In addition, academics are also researching outcome evaluation in order to verify effectiveness of evidence-based guidelines."
The Thailand Centre for EBNM conducted a three-day comprehensive systematic review training program within the Faculty of Nursing at CMU from May 10-12 this year, in collaboration with the Joanna Briggs Institute. JBI Executive Director, Professor Alan Pearson, and Associate Director, Rick Wiechula, conducted the program.
The program aimed to promote understanding of the concept and process of systematic review of research evidence among nurses in Thailand. The participants comprised nursing faculty members from CMU, Mahidol University, and Songkhla University.
The participants have been trained in designing and conducting systematic reviews of both quantitative and qualitative evidence. By the end of the program, five systematic review protocols had been developed and 18 nurses were certified by the JBI. Based on the participants' opinion, this training program was encouraging and productive.
Until the Thailand Centre was formed evidence-based practice was virtually unknown among the country's nurses and health care professionals. In many cases, practice was based purely on 'hear say' rather than fact or evidence, and generally high standards were not achieved.
However, Thailand is now making enormous progress with its training and development programs, and introducing EBP. The trend began to change after health care took a dramatic turn in the late 1990's resulting from the collapse of Asian markets, forcing the government to introduce a significantly cheaper system the public could afford.
This coincided with a change in government strategy from supporting traditional farming to service and manufacturing industries. It meant new lifestyles, which brought unprecedented deterioration in Thailand's social ecology.
Suddenly, HIV/AIDS, traffic injuries, cancer, mental stress, and environmental hazards joined the country's top-10 causes of mortality and morbidity. And with a health system stretched to its financial limits, and consumer bases soaring, the need for evidence-based practice was of paramount importance.
Dr Chontawan said the economic breakdown drove the Thai society to rethink the holistic structuring of its societal paradigm and infrastructure.
"Today, health is stipulated as a human right, which must be protected by the state," she said. An equal entitlement to health care services was introduced for a wide range of vulnerable people including the elderly, disabled, abandoned children, and so forth. Under this paradigm, the government is responsible to efficiently provide public health services to all people at the same standard.
Disease control is also a state obligation to be pursued free of charge. Health services under the new constitution must be under the state of equity, efficiency, quality, as well as transparency and accountability to the community.
The health sector now has to re-orient its own vision and mission to meet this new demand for health and health care.
"The majority of Thais are accustomed to the conventional health system where health care is the obligation of health care institutions. With the expansion of modern delivery systems in both the public and private sector, the Thais are moving towards using more facility-based health services."
The greater demands or expectations of Thais on a health system already stretched beyond its limits has led to some services again being beyond the reach of many. The country's growing HIV/AIDS epidemic has exemplified the widening gap of inequity with the accessibility of more effective drugs to wealthier people with HIV while leaving those who are financially disadvantaged to suffer on their own.
Dr Chontawan said cancer, the leading cause of death in Thailand since 1980, was another example. "Radiotherapy is expensive, requiring complicated medical equipment to effectively cure cancer patients," she said. Not helping is the fact 54 percent of radiotherapy units are located in Bangkok, and the rest in provincial cities. Also, Thailand has a shortage of qualified health professionals to provide the treatment.
The issue of constitutional rights has raised considerable concern over health. The existing system cannot meet the increasing demand, and the country cannot afford the increasing cost of curative care within the prevailing state of infirmity.
The cabinet of the Royal Thai Government approved a national agenda for Health System Reform in May, 2000, and the main aims were for the knowledge-based social movement to support health system reform, and to enact a National Health Act within three years as the principal mechanism for future health system reform.
The government is keen to create knowledge through research. Knowledge of health is drawn on the experience and expertise of a wide range of stakeholders including professionals, relevant organisations and researchers.
There is no doubt the Thailand Centre has an important role to play in health care in this country.
The need for evidence-based practice has become so great. It can improve the total quality of health system and health care services, in terms of cost-effectiveness, clinical effectiveness, and efficiency. It can also enhance the system and mechanisms of quality assurance in the health care system including hospitals.
Evidence-based practice can also promote the key roles of APN (advanced practice nurses) in Thailand.
The Thai Nursing Council began to process credentials for APN two years ago, and the first group was approved last year. They are expected to be the leading group of nurses who implement EBP in health care services.
They need to be trained by the Thailand Centre for EBNM, because it is the first organisation to bring this concept into the nursing system in Thailand. It is something that we are all very proud of.
EBP is basically still in its infancy stages, but the trends are very positive and before long it will have a big impact in Thailand. There is a strong need to work on major health problems in this country, headed by cancer, HIV/AIDS, road accidents, cardiovascular disease, and diabetes mellitus.
I have no doubt nursing and health care students understand the importance of evidence-based practice.
The faculty of nursing in many universities in Thailand now conduct Masters programs in nursing. In the Chiang Mai School of Nursing we have 10 graduate programs that force the students to be APN. They are expected to use EBP as a tool in their daily practice.
We have teaching courses regarding research utilisation as part of the graduate study. In addition, Masters students are encouraged to use this EBP in their clinical practice.
"Knowledge management, in terms of how to generate, synthesise, and utilise existing knowledge related to health care is very much needed. Systematic reviews and EBP are both an important part of health care development in our country."
Dr Chontawan said Thailand was like most, if not all countries in terms of experiencing difficulty in attracting people to nursing.
"Work overload, low income, high risk to HIV/AIDS, and low self-image were the main reasons provided by most of the students and parents we surveyed on why they did not want to be a nurse," she said.
On the whole, nursing or health care in Thailand is really no different to other countries in terms of strengths or weaknesses. Our weaknesses may be due to financial limitations or economic issues in the country.
We need to re-manage and re-organise our social capital, human resource, natural resources and our knowledge.
"The strengths of Thailand in regard to health care may be our socio-cultural factors. I like to believe we have plenty of wisdom and natural resources that can be utilised in health care."
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