Evidence-Based Practice And Health Visiting - Essay Example

Running Head: Identificatin and discussin Identificatin and discussin f different levels f evidence relating t ne extract frm the prfessinal prtfli [Name f the writer] [Name f the institutin] Identificatin and discussin f different levels f evidence relating t ne extract frm the prfessinal prtfli The questins f where, hw and why evidence-based nursing has emerged and what it is, has practical significance fr three reasns. The first is that beliefs abut the cncept determine actin. The secnd is that misunderstanding can bring abut a lss f cnfidence in thse wh are expected t develp practice. The third is that cnceptual cmpartmentalizatin in science ften leads t a dissciatin with the previus wrk in the field. These things are cnsidered f scientific relevance t the develpment f high quality nursing service. The impetus fr this paper was the idea that the cncept f evidence-based nursing represents smething f a paradx. The paradx is that there seems t be very little evidence t supprt the ntin that the term is a slid enugh cnstruct fr scientific r practical purpses. In fact the cncept itself hlds within it the seeds f its wn destructin. In the same way that a persn speaking abut elcutin r lecturing abut gd teaching can betray the very principles they are extlling by their behaviur, current advcates f evidence-based practice (EBP) seem t betray the whle ratinale fr EBP by having n scientific cnstruct t supprt its emergence. thers have cmmented n similar scenaris in health care. 'The emphasis n enlarging the EBM 'textbk' als runs the risk f re-creating the intense enthusiasm fllwed by the sad disenchantment that ccurred abut 25 years ag when the 'Prblem riented Medical Recrd' was intrduced (Feinstein & Hrwitz 1997). The same culd be said f previus vgues the 'Nursing Prcess', 'Primary Nursing' and in mre recent times the 'the Reflective Practitiner'. This is a paradx that has resunding implicatins fr evidence-based nursing nt just because it limits its utility, but because there may be inherent ntlgical issues which preserve certain superficiality in the prcess f prmting better nursing practice. It is prpsed here that the epistemlgical status f evidence-based nursing shuld be cnsidered further in rder t refine a mdel which has sme utility in imprving nursing practice. An epistemlgical perspective 'Epistemlgy, r the thery f knwledge, is cncerned with hw we knw what we knw, what justifies us in believing what we d, and what standards f evidence we shuld use in seeking truths abut the wrld and human experience' (Audi 1998, p. 1). The current persuasive pwer f EBP appears t be based n a belief that it is a viable cnstruct. Belief has been described as a 'dispsitinal mental prperty in that it tends t be accepting' (Audi 1998, p. 276). Audi argues that thinking as an ccurrent mental prperty aims t change that which is knwn. A basic tenet f this paper is that there is mre belief assciated with the cncept f EBP than actual thught based n scientific evidence. In what ways can the belief in EBP be said t be a justified Accrding t ne philsphical view the epistemic status r justificatin fr believing in a cncept such as EBP is a functin f three different things (Chishlm 1989): * The bject f a belief may be self-presenting. In such a case, the belief may be called a basic apprehensin. * Sme beliefs have a kind f prima facie prbability. If I accept a prpsitin and if the prpsitin is nt discnfirmed by my ttal evidence, then it is that prpsitin which is pssible t me. * A belief may derive its epistemic status frm the way in which it lgically cncurs with the ther things ne believes. It is cnsidered that EBP, as a cncept, is nt a self-evident cnstruct, s (a) is nt the case. The prpsitin that EBP is a viable cncept is generally accepted n face value, and (b) seems t be the cmmn basis f belief in the cncept. What is f cnsiderable cncern here is hw des EBP lgically cncur with ther beliefs r knwledge that we have. This analysis therefre will be guided by the fllwing questins. Hw has the cncept f evidence based nursing cme int being What justifies its existence What evidence exists t supprt the fact that it is a cnstruct that cncurs with ther knwledge that we have Symblic interactinism In this paper the thery f symblic interactinism will be adpted as a justificatin fr analysing the utility f the phenmenn f 'evidence-based nursing' frm an epistemlgical pint f view. There are many facets f the thery f symblic interactinism and they are mre fully described elsewhere (Benzies & Allen 2001) Fr the purpses f this paper symblic interactinism (SI) has a certain utility in analysing cncepts and evaluating their status as cnstructs. The reasn fr this arises mainly frm the tw cmpnent wrds 'symbl' and 'actin'. In this perspective human behaviur is gverned by internal prcesses that give meaning t the envirnment (Haralambs & Hlbrn 2000). The mst crucial element fr this epistemlgical analysis is the prcess f symblism determined by Gerge Herbert Mead (1863-1931) and succinctly described by Haralambs and Hlbrn (2000) in the fllwing way: 'Human beings interact in terms f symbls, the mst imprtant f which are cntained in language. A symbl des nt simply stand fr an bject r event: it defines them in a particular way and indicates a respnse t them. Thus the symbl "chair" nt nly represents a class f bjects and defines them as similar, it als indicates a line f actin that is the actin f sitting. Symbls impse particular meanings n bjects and events and in ding s largely exclude ther pssible meanings.' (Haralambs & Hlbrn 2000, p. 1056) This cnstructin f symblism applies t tangible as well as ur less tangible cncepts such as lve, human rights and indeed evidence-based nursing. Three pints can be made abut Meads' cncept f 'symbl'. The first is that wrds (language) are transfrmatins f persnal cncepts. These cncepts have particular actin rientatins fr each individual. The degree f cnsensus abut the critical attributes f these cnstructs and the assciated actin amngst individuals may be great r small amngst any given ppulatin. It is this last pint that is at issue in the current debate n the epistemlgical status f evidence-based nursing. Lewis Carrll seems t exemplify this cncern when relating ne fictinal cnversatin in 'Thrugh the lking glass': 'When I use a wrd', Humpty Dumpty said in rather a scrnful tne, 'it means just what I chse it t mean -- neither mre nr less.' 'The questin is', said Alice, 'whether yu can make wrds mean s many different things.' 'The questin is', said Humpty Dumpty, 'which is t be master -- that's all.' (Carrll 1872, p. 54) Cncept r cnstruct in evidence-based symblism It has been argued that the prcess f science invlves the transfrmatin f thery int prpsitins and then t fact (Seaman 1987). This represents a transfrmatin f cncepts int cnstructs. As used here the term cncept is taken t mean that there is lse cnsensus in the way that a symbl is defined r clarified in every day usage. In cntrast a cnstruct reflects the specific, ptentially bservable cnfirmed characteristics f a cncept (Bckpp & Hastings-Tlsma 1995). Usually a cnstruct in scientific terms is built up n the basis f the degree t which ne r mre parameters f the cnstruct can be demnstrated as cnstant. Essentially there needs t be evidence t supprt the permanent existence f a parameter as a distinguishing characteristic. Indeed research is largely abut cnfirming the differentiating characteristics f bjects r phenmena. Thus a cnstruct exists s that cmmn meaning is maximized and this is achieved by its validatin by the existing evidence. S what evidence exists abut the clearly differentiating characteristics f evidence-based symblism. It is pssible t begin by examining the rigins f evidence-based symblism. 'Evidence-based' symblism The beginning f 'evidence-based' symblism seems t be mst cmmnly attributed t the physician and epidemilgist Archie Cchrane wh called fr the preparatin, maintenance and disseminatin f systematic reviews in all fields f health care (Cchrane 1979). The actual symblism that was cined was 'evidence-based medicine' (Sackett et al. 1997). After the emergence f evidence-based medicine varius authrs have preferred t use terms such as EBP r evidence-based health care (Gray 1997). Nursing by assciatin has becme invlved in this evidence-based medicine mvement and the term evidence-based nursing has been cined (Cullum et al. 1997, Pearsn et al. 1997, Smith 1997). In the case f evidence-based nursing it culd be said that many f the aspects f the cncept are linked t the idea f research-based practice and its relatinship with EBP is f relevance. In the United Kingdm (UK) an upsurge f interest in nursing research can be traced back t the recmmendatins f the Briggs Reprt (Briggs 1972). This reprt recmmended that British nursing must be a research-based prfessin. There has been an almst lgarithmic increase in the number f nursing research papers published since 1970 (Table 1). This as been accmpanied by a relatively cnstant stream f papers lamenting the lack f uptake f research findings in nursing practice (fr example Hunt 1981, Walsh & Frd 1989, MacGuire 1990, Luker 1992, Rlfe 1998). A MEDLINE search cnducted n 12 July 2001 utilized a number f key wrds assciated with 'evidence-based' and 'research' symblism during a time perid frm 1960 t the present. The results shw that the keywrds 'evidence-based medicine' revealed 5612 papers, EBP 432 papers, evidence-based nursing 47 papers, evidence-based health care 60 papers, and evidence-based decisin making 43. Almst all f these papers have been published since 1995 and the earliest use f the symbl 'evidence-based' is 1992 (Table 2). These data indicate sme variatin in evidence-based symblism the centre being the mst prlific cncept f evidence-based medicine. The data n Table 2 als demnstrates an increase in papers adpting 'evidence-based' symblism alng with a cmmensurate decrease in the use f the term 'research' in the nursing cntext. If this publicatin recrd is anything t g by there has indeed been an increased adptin f 'evidence-based' symblism. The previus rhetric f research-based nursing seems t be increasingly replaced by evidence-based nursing (r EBP). This may suggest that the symbls are smetimes used euphemistically and that the meaning fr many nurses may be the same. What then is the evidence fr an actin rientated distinctin Have we merely prduced a system f human cncepts that have meaning t individuals, with little cnsensus in the health prfessinal ppulatin and d we have a scientifically separable new cnstruct that will guide prfessinal actin The meanings attached t evidence-based symblism In rder t begin t evaluate evidence-based symblism as a unified cncept it seems sensible t bserve the semantic aspects f the language used by majr prpnents f the phenmenn at the superficial level making inferences abut the deeper meaning. It has been suggested that 'evidence-based' symblism in the health care dmain demnstrate quite a number f incnsistencies (Stetler et al. 1998). A selective review f definitins f EBP will nw be presented in chrnlgical rder fr the reader t reflect upn befre inferences are drawn. * 'evidence-based medicine is the prcess f systematically finding, appraising and using cntempraneus research findings as the basis fr clinical decisins (Rsenberg & Dnald 1995, p. 1122). * 'A shift in the culture f health care prvisin away frm basing decisins n pinin, past practice and precedent tward making mre use f science, research and evidence t guide clinical decisin making (Appleby et al. 1995, p. 3) * 'the cnscientius, explicit and judicius use f current best evidence abut the care f individual patients. The practice f evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence frm systematic research' (Sackett et al. 1996, p. 71) * 'Practitiners need t make better use f nursing research t establish a mre EBP. Evidence-based practice enables nursing t prvide and justify high-quality, cst-effective care' (Simpsn 1996, p. 22) * 'Prviding care t clients fr which there is evidence f clinical effectiveness is the crnerstne f EBP. Evidence may cme frm research, audit, feedback frm clients and expertise'. (RCN 1996) * 'Making decisins abut grups f patients and/r ppulatins and basing such decisins n a careful appraisal f the best evidence available' (Gray 1997, p. xi) * 'Evidence-based nursing is ne apprach that may enable future health care prviders t manage the explsin f new literature and technlgy and ultimately may imprve patient utcmes' (Kessenich et al. 1997, p. 25) * 'Evidence-based practice is a methd f prblem slving which invlves identifying the clinical prblem, searching the literature, evaluating the research evidence and deciding n the interventin. (White 1997, p. 175) * 'Evidence-based health care invlves using a cmbinatin f clinical expertise and the best available research evidence, tgether with patient preferences, t infrm decisin-making' (Flemming & Cullum 1997, p. 28) * 'This emphasis n EBP implies that relevant research has been r is being dne (therwise there wuld be n findings t utilize), that the findings frm such research are available and accessible, that there are mechanisms fr putting such findings int practice and last but nt least that research findings are put int practice' (Hunt 1997, p. 14) * 'With the emphasis nw being placed n scientifically validated r EBP, it has becme mre imperative that clinical guidelines be based in credible infrmatin in ur text bks and research literature.' (Gunn 1998, p. 178) * 'Evidence-based medicine calls fr the integratin f ur clinical expertise with the best available external evidence and patients' values by translating ur need fr infrmatin int an answerable questin and then tracking dwn the best infrmatin with which t answer that questin.' (Sackett & Straus 1998, p. 1336) * 'The systematic intercnnecting f scientifically generated evidence with the tacit knwledge f the expert practitiner t achieve a change in a particular practice fr the benefit f a well defined client/patient grup' (French 1999, p. 74) * The thrust f evidence-based medicine is arund identifying mre clearly thse health care interventins that can be shwn t be effective n scientific grunds (Elkan et al. 2000, p. 1316). In the earliest definitins it is cmmn t see sme essential elements; 'best evidence' 'individual patients' 'individual clinical expertise' and 'external clinical evidence' as 'primary' r 'systematic research'. These incnsistencies, hwever, are further exacerbated by tw separate issues. They can be represented by the questins; what is the meaning f the wrd 'evidence' and what is the prcess f EBP These tw questins will nw be cnsidered separately. The meaning f 'evidence' It is apparent that the mst cmmn, but by n means exclusive, meaning f the wrd 'evidence' is primary research findings. There are, hwever, many variatins n this theme. Just ne example is a natinal reprt which indicates that there are numerus ways in which the term 'evidence' can be perceived (Tranmer et al. 1998). In this reprt evidence was defined as infrmatin based n histrical r scientific evaluatin f a practice that was accessible t decisin makers in the health care system. The types f evidence cnsidered acceptable included: * experimental (randmized clinical trials, meta-analyses and analytic studies); * nn-experimental (quasi-experimental, bservatinal); * expert pinin (cnsensus, based n published literature and cnsensus prcess, cmmissined reprts); * histrical r experiential (Tranmer et al. 1998). After examining ther literature the variatins in the meaning f the term 'evidence' can be summarized as: * Evidence as truth. * Evidence as knwledge (including, tacit, expert pinin and experiential). * Evidence as any relevant infrmatin that cnfirms r refutes a belief. * Evidence as primary research findings. * Evidence as meta-analyses and systematic reviews. Because f this variatin there is a strng argument fr restricting the use f the term 'evidence' in EBP symblism t research findings. Even then there is a debate n which frmulatins f research findings are mst valuable. There have been suggestins f a hierarchy f levels f evidence. ne such classificatin f levels has been suggested as fllws: * Findings based n a systematic review which has been packaged and cllated, frming recmmendatins fr practice, as in the case f clinical guidelines. * Systematic reviews and verviews f appraised research. * Sund research that has been identified by individuals searching surces themselves. * Expert pinin r the results f quality imprvement prgrammes'. (McClarey & Duff 1997, Mrgan 1997). This classificatin seems t be based n the systematic review as its majr fcus. There is, hwever, n cnsistent rientatin t the definitin r quality f systematic reviews. Fr instance the Cchrane library prefers the inclusin f papers that are either randmized cntrlled trails r clinical trials. Cchrane review grups are reluctant t accept studies based n qualitative data when in essence there is n reasn t believe that systematic reviews cannt be cnducted using phenmenlgical data. There are many examples in the literature f reviews that have included studies using qualitative data (fr example Grtenhuis & Last 1997). Accepting the pre-eminence f quantitative data and taking accunt f this criticism anther frmulatin f these levels can be suggested: * Meta-analysis f tw r mre studies using identical frms f data. * Externally mnitred large-scale research prjects (fr example gvernment/industry cmmissined). * Authritative published judgement f studies adpting the same research questin r similar data. (systematic review). * Student-cnducted and supervised literature critiques (PhD theses). * Expert and research infrmed pinin (textbks, pinin papers). These suggestins, hwever, are still cntrversial and a lack f cnsensus abut the meaning f the term 'evidence' amngst health care prfessinals can lead t mre variatin in meaning. It is pssible t dismiss this cncern by saying that if the symblism imprves perfrmance then des it really matter. This then begs the questin f what is the human perfrmance that is being described The meaning f evidence-based practice After cnsidering the status f the term 'evidence' it is nw pssible t cnsider the actin element f the symblism, that is evidence-based practice. ther terms are used in this symblism such as evidence-based health care, evidence-based medicine, evidence-based nursing and evidence-based decisin-making. Evidence-based practice will be adpted fr the fllwing discussin simply because it is believed t be the mstly widely used generic term fr the phenmenn in questin. An examinatin f the definitins previusly cited and the assciated papers indicates a plarizatin f belief abut many elements f the EBP prcess. The fllwing dimensins can be bserved and varius prpnents adpt different psitins n each f them. * The Datum dimensin -- hypthetic-deductive research findings vs. any relevant infrmatin. * The Scientific dimensin -- include interpretive appraches vs. exclude interpretative appraches (i.e. use f qualitative r hermeneutic data). * The Scial dimensin -- the individual client vs. client grup fcus. * The rganizatinal dimensin -- practitiner vs. rganizatinal decisin-making. In fact the different criteria adpted n each f these dimensin ften give the impressin that the term EBP is ften used as a euphemism fr ther lng standing traditins. The fllwing euphemisms are plausible: * EBP as research-based practice; * EBP as an infrmatin management prcess; * EBP as prfessinal practice develpment; * EBP as clinical judgement/prblem slving; * EBP as managed care. These cncmitants have been laid ut in Figure 1. ne interpretatin f this figure is that EBP is in fact a prduct f the cnceptual verlapping f already existing traditins. If this is the case then EBP symblism may be merely a replacement fr failed systems f quality assurance! Culd the symbl EPB be replaced by QA in the mdel described in Figure 1 If this is nt plausible then ne can suggest that it may be just an expansin f research based-practice (applied research). Is it simply an adjunct that attempts t slve the issues f research uptake by facilitating the disseminatin and cmprehensin f research findings during an infrmatin explsin (fr example Rbinsn 1995, Silagy & Lancaster 1995, McArthur 1997, Guld et al. 1998). Then it culd be cncluded that it is merely an artefact f infrmatin technlgy. In the final analysis it is seems that EBP symblism lacks cnsensus and that there is very little evidence t supprt the cntentin that a new cnstruct r prcess exists. Cnclusin This paper has raised as many questins as answers. The majr challenge f this paper is still the questin, what is the evidence that EBP in nursing is a viable cnstruct r prcess The defence f the cncept has taken many frms since 1995 and ne paper in particular takes issue with many f the ratinales frwarded by the prpnents f evidence-based medicine (Feinstein & Hrwitz 1997). ne additinal cncern is that mst f what is being said abut evidence based practice (and this paper included) is based n subjective, albeit expert r infrmed, pinin. Authrs are largely expressing persnal pinins abut the nature f the cnstruct and the prcess. It is difficult t find any empirical evidence (research) t supprt the ntin that the term 'evidence' is a stable cnstruct r that EBP is a distinct prcess which ffers mre than a nvelty effect in a basically plitical scenari (Feinstein & Hrwitz 1997). References Appleby J., Walshe K. & Ham C. (1995) Acting n the Evidence. Research Paper 17. NAHAT, Birmingham. 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