Sources of Information to Develop an Evidence Base in Nursing - Essay Example

There has been a growing international interest in the development of measures to help ensure that public policy and practice decision-making is better informed by the relevant and reliable researches. This interest has been fuelled by evidence that some health and social interventions which have been commonly applied in the belief that they are doing good are actually harmful, that others are largely ineffective, and thus wasteful of public resources. Furthermore, some interventions which reliable researches showed to have significant benefits have been largely ignored. By bringing together the results of research in a systematic way, appraising its quality in the light of question being asked synthesizing the results in an explicit way and making the knowledge base more accessible, it is hoped to foster a greater sensitivity to the evidence by researchers, policy makers, health practitioners and the public. It is assumed by most of the public and patients that the activities of health care professionals is "scientific", based firmly on the results of scientific research and subject to resource constraints of high quality. However, when practice patterns are studied, it is often found that health care interventions have not been evaluated, and even when they have, the evidence on effectiveness is not evenly applied (Hewitt-Taylor, 2002). Over the last decade the themes of evidence-based health care have become a widely discussed. The main thrust is provided with the impetus of evidence based practice movement, which stresses the "conscientious, explicit and judicious use of current best practice in making decisions about care of individual patients" (Sackett, 1996). Evidence based approach is applicable for the various fields of health care and nursing is not an exclusion. There are several information sources, which are reliable for supporting clinical decision-making in clinical/nursing practice (see Fig. 1 at the Appendix). The highest level of evidence is presented by systematic reviews and meta-analyses of randomised controlled trials (RCTs). RCTs play the central role in the system of evidence-based practice; their results are "gold standard" of evidence-based practice. Other types of the researches, e.g. cohort studies, case - control and case-report studies, have only limited value for decision-making process. But in some conditions, for example, when the use of randomised controlled trials is restricted by ethical or technological considerations cohort studies and series of case reports can be very important for developing clinical standards and practical guidelines (Brown, Crawford & Hicks, 2003). In the United Kingdom there is a call for evidence-based health care (DOH, 1996) and for a focus on evaluating and improving clinical effectiveness (Gray, 1997). Evidence came from researches (mainly quantitative), which should inform practice in the order that the effectiveness and efficacy, acceptability and responsiveness of health care could be optimised. In other words, there is widely introduced research-based practice in nursing. Two articles published by the British researchers in two prominent nursing journals (Coulling, 2005 & Maclellan) are dedicated to the problem of nursing care providing to the patients with the post-operative pain syndrome. Using template we will examine these two research articles and identify how these articles reflect the key principles of the research process in nursing. The titles of both articles clearly and explicitly indicate the content and research approach taken. The abstracts of these articles contain all necessary details about the study design, used methods of research as well as about key findings. Both articles include the section of literature review, which contains relevant discussion on previous research and provides a summary of the key findings emerging from the literature. The selection of articles in the literature review allows identifying the necessity of proposed research. Thus McLellan's study (2005) was aimed "to introduce a nurse-led intervention to improve pain management after surgery and evaluate its effectiveness by measuring patients' pain scores" (p. 180), whereas Coulling's research was more focused on examining doctors' and nurses' knowledge, education and confidence about pain after surgery. These aims are generated directly from clearly stated research hypotheses substantiated by the appropriate reviewing of existing evidence. There are some similarities in the selection of research methods in the articles provided for critical appraising. Authors used interviewing focus groups for disclosing important issues of the problem of post-operative pain. Nevertheless there were some distinct in the approaches to research methodology, which could be explained by the differences between stated goals and objectives of these studies. Thus, McLellan used instruments and study design to assess rates of postoperative pain in the patients receiving different nursing interventions while Coulling have applied questionnaires for studying awareness among medical staff. The sample selection in the both studies was not probabilistic. The references that number of the participants in the study was selected "following statistical advice" seem to be not enough reliable. Nevertheless the sample size was congruent with used methods. Data were collected by direct interviewing (Coulling's study) and by questionnaire design (McLellan, 2005) relatively. These methods are valid and reliable to stated goals and objectives. The section of ethical consideration is included in the both studies. Because Couling's research was not applied to any vulnerable subjects than ethics approval was not sought. Nevertheless, the formal approval of the trust's research and development) department was obtained and all stages of the research were conducted under the supervision of this agency. Another author got approval for her studies from the Joint Research Ethics Committee. There were received written consents from patients selected for participating in the study and assurances of confidentiality and anonymity were given for them. Authors did not describe procedure of statistical analysis in the details but the approaches used for analysing obtained data are relevant to the aimed statements. Correspondingly, the findings have been reviewed in relation to the original research hypothesis and stated goals and objectives of studies. Thus, there was approved that the introduction of the nurse-led interventions reduces patients' postoperative pain scores (McLellan, 2005). Alternatively, Coulling (2005) showed that the involvement and collaboration of staff is fundamental to the achievements in acute pain management in the hospital settings and that this progress is not only a result of education. Both authors paid attention to the implementation of research findings into the practice. The most important of them are presented by the necessity of developing new standards of education and training in acute pain management and that the role of nurse practitioners in postoperative pain management should be expanded. Authors made casual mention of the barriers for implementing their key findings into the practice and considered that cultural misconceptions could influence on the effectiveness of postoperative pain management. We can see that by the developing high quality researches nurses participate in the establishment of the standards of evidence based practice within nursing. Both mentioned articles were designed as cohort studies than they could be source of B level of evidence, but there is important that if nurses are not participating in developing evidence based care that other professional groups will offer guidelines for nursing. In this way nurses could lose their autonomy and authority (Bonell C., 1999). There are following sources of information, which can be used to develop an evidence base in nursing: systematic reviews (medical community has deficiency of such publications), meta-analyses, results of randomised controlled trials, results of cohort studies and case-control studies. After critical appraising of research findings many of them are included accordingly to their evidence level into the clinical standards and guidelines (e.g. NMAC (1996) or RCOA (2003)). For example recently developed standard of the Best Practice Statement on Postoperative Pain Management (2004) was developed after reviewing more than 90 references. This statement is an official guideline of NHS Quality Improvement Scotland and it was developed by a working group of clinical nurse specialists working in acute pain services across Scotland. This group worked in the close contact with experienced multidisciplinary team provided advisory counselling for the principal working group. The Best Practice Statement is called upon helping to infuse research into practice. The fourth section of this guideline is dedicated to the algorithms of postoperative pain assessment. Because McLellan study was conducted in the Ireland there are no direct referencing between her article and Scottish guideline, otherwise many statements of the guideline were reflected in her work. This fact could be explained by the universality of the principles of evidence-based care. The Best Practice Statement offers to use patient-controlled analgesia for pain relief. Nevertheless this document has not specified the role of nurses in the provision of such services. There is only assumed that all nursing staff, including clinical nurse specialists in acute pain management, should maintain individual professional knowledge and competence appropriate to the level at which they are practising accordingly to NMC Code of Professional Conduct (2002). Thus findings of the cohort study conducted by McLellan could be very important for updating existing standards of care. Because the information support of the implementation of new official guidelines is the issue of current importance than results obtained by Ms. Coulling could be also useful. The successful application of the Best Practice Statements as well as other clinical standards could require involving the multidisciplinary team and introducing new research programs into the clinical practice. References 1. Sackett D (1996) Evidence based medicine: what it is and isn't. British Medical Journal 321 (7023) pp. 71-77 2. Hewitt-Taylor J. (2002) Evidence based practice. Nursing Standard Vol. 17 pp. 47-52. 3. Brown B., Crawford P. and Hicks C. (2003) Evidence-Based Research Open University Press; 1 edition 320 p. 4. Coulling S (2005) Nurses' and doctors' knowledge of pain after surgery. Nursing Standard Vol 19 No. 34 pp. 41-49. 5. MacLellan K (2004) Postoperative pain: strategy for imporving patients experiences. Journal of Advance Nursing Vol. 46 No. 2 pp. 179-185. 6. Nursing & Midwifery Council. (2002). Code of Professional Conduct 2002. London: NMC. Accessed at the web-site on 20/06/05. 7. National Medical Advisory Committee. (1996). The Provision of services for Acute Postoperative Pain in Scotland. A Report by the National Medical Advisory Committee. Edinburgh: 8. The Royal College of Anaesthetists and The Pain Society. (2003). Pain Management Services Good Practice. London: Accessed at the web-site on 21/06/05. Appendix Figure 1. Levels of clinical evidence (the top - is the highest) Read More