Evidence-Based Practice in Nursing - Essay Example

Evidence Based Nursing (EBN) Table of Content I. Introduction II. Policy context of research and EBP III. Appraisal of research paradigms IV. Evaluation of aspects of the research process V. Ethical frameworks VI. Data collection VII. Analysis VIII. Conclusion IX. Bibliography/References I. Introduction Evidence-based practice is relatively new in nursing. The objectives of this type of practice are to continually develop and strengthen the quality of nursing interventions. It is introduced on in the context of the movement for evidence-based medicine (EBM) and evidence-based practice (EBP). For last two decades it has focused on the identification and consideration of strategies to overcome barriers to EBP. These barriers include substantive variations in nursing practice and nursing results; lack of guidelines for nursing practice; time constraints; limited access to the research literature; lack of skills in clinical appraisal; lack of coordination between the different health care sectors; and lack of skills in information seeking. On top of this, nurses claim that the prevailing professional ideology emphasises practical skills rather than intellectual knowledge, and that their work environment does not encourage information seeking. Such barriers resulted in different initiatives such as national and international conferences, journals, books, teaching programmes and centres. These activities often share a positive but largely uncritical approach, stating directly or indirectly that EBN is something we must have, and that it is something we must have now. While the interest among nurses in nursing practice, in education and in research - nationally and internationally - has increased, at the same time many nurses do not embrace EBN with enthusiasm, probably because it appears to hold such limited relevance for their everyday practice needs. Some of the underlying assumptions in EBN and their implications in a selected research issue in the context of evidence based practice (EBP) will be discussed in this paper. (Law, 2002) II. Policy context of research and EBP Government agencies and institutes are actively supporting this new phenomenon. The international journal Evidence-Based Nursing in UK and The Centre for Evidence-Based Nursing (CEBN) in US are proof active support of policy makers for the cause of this new practice. The international journal Evidence-Based Nursing began in January 1998 'as a direct response to a dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. The journal is published quarterly with the support of the United Kingdom's Royal College of Nursing. It has the aim 'to select from the health related literature those articles reporting studies and reviews that warrant immediate attention by nurses attempting to keep pace with important advances in their profession. (Law, 2002) The Centre for Evidence-Based Nursing (CEBN), part of the Department of Health Sciences at the University of York, is concerned with furthering EBN through education, research and development. Its research activities are listed on the Centre's home page. Its aims are to generate reliable research evidence for clinical nursing through primary research and systematic reviews of the efficacy of caring methods and nursing interventions; its staff are researching into how nurses in practice use their clinical expertise alongside both research evidence and patient preferences in making decisions; they are also evaluating the impact of teaching EBN on nursing practice and organisations. III. Appraisal of research paradigms In EBM and EBN, the documents are attributed with different degrees of evidence, depending on the kind of research methods used. It is not surprising that EBM is strongly connected to RCTs and meta-analyses. Medical research has a long and strong tradition in the natural sciences, where the only kind of valid inference is deductive, and where repeated experiments are the only solid ground for reaching 'the truth'. At the same time, it is surprising and yet not surprising that EBN follows the EBM line. (Law, 2002) It is surprising because at least within the past 20 years there has been a movement in nursing practice and in nursing theories away from instrumental reasoning in nursing to caring (the individual patient in the centre) reasoning. Furthermore, a part of nursing research nationally and internationally has moved away from the ideals of natural science to more interpretative research ideals, based on the social and humanistic sciences. (Silverman, 1998) It is not surprising because a great part of nursing research is derived from medical research (the ideals of natural science) and because the nursing profession seeks to achieve the same academic level as the medical profession. In a Danish text about EBN, the author claims that EBN will change nursing practice from 'think and feel' to 'knowledge and documentation'. This claim is based on an optimism that surrounds natural science and on the comforting view that natural science is progressing towards the correct description of reality. The belief is that experts can find solutions to major health care problems through instrumental reasoning and that natural science still offers the best sources of long-term security. Furthermore, nurses in general are not educated in examining epistemological assumptions, for instance about truth and context. Evidence based nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences, in the context of available resources. Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and nursing practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicament, rights and preferences in making clinical decisions about their care. It is clearly indicated in the under review article. Within the underlying scientific paradigm, reasoning is instrumental. This means that scientific procedures such as protocols fulfilling basic criteria such as the random allocation of participants to comparison groups, outcome measures of known or probable clinical importance, reproducibility of results. This builds, however, on a narrow epistemology that gives precedence to instrumental reasoning and to establishing true knowledge about the patient. The survival of this frequently used trusted idea 'is further promoted by the fact that habit formation tends to remove the idea from the field of critical inspection. The weight placed on instrumental reasoning is, however, problematical. As we tend to identify seeking 'objective truth' with 'using reason', and so we think of the natural sciences as paradigms of rationality. We also think of rationality as a matter of following procedures laid down in advance, of being 'methodical'. So we tend to use 'methodical', 'rational', 'scientific' and 'objective' as synonyms. IV. Evaluation of aspects of the search process including issues The evaluation of nursing interventions and the understanding of patients' experiences have to be investigated by different research methods. Randomised Controlled Trials RCTs, meta-analyses and systematic reviews are the best designs for evaluating nursing interventions, while qualitative studies (interviews) are to be preferred to gain a better understanding of patients' experiences. The latter are particularly useful in exploring and explaining the barriers to patient compliance, how a treatment affects patients' everyday life, the meaning of illness to the patient, etc. The idea of RCTs, meta-analyses and systematic reviews as the 'gold standard' methods of assessing the effectiveness of treatment methods and nursing interventions is based on the assumption that rigorous systematic reviews provide nurses with a summary of all the methodologically sound studies related to a specific topic. The reason that the RCT is the most appropriate design is that through random assignment of patients to comparison groups, known and unknown confounders are distributed evenly between the groups ensuring that any difference in outcome is due to the intervention. This picture of EBN is based on the assumptions that knowledge is autonomous and cumulative; that words can be taken at face value; and that nursing interventions are fixed in time and space; that is, they can be considered context free. V. Ethical frameworks We use our clinical skill and intuition—the art of clinical practice—to develop a unique treatment approach that is tailored to the client's needs. This means we are unethical for not employing strictly evidence based treatment approaches. The implications that well-established, widely used, and individualized treatments are necessarily good, and that evidence-based treatments are either not well established, not widely used, not individualized. (Paauw, 1999) Even before all possible knowledge has been gathered, however, EBP means that the researchers will begin with the information that is available, combine it with their own clinical experience and their own clinical data, and use the entire package to the benefit of every client. At the risk of alienating those who already believe in the central importance of empirical evidence. VI. Data collection EBP is “partly a philosophy, partly a skill and partly the knowledge about, and application of, a set of tools” (Dawes, 1999). Those tools are usually summarized in relation to the following steps. (Law, 2002) Step 1. The clinician formulates a specific question about the approach to be used in caring for a particular client (e.g., which diagnostic test will be most sensitive for this case, or which treatment will be most effective and efficient with this client). Step 2. The clinician finds the available published evidence on point. Step 3. The clinician evaluates the quality of the evidence obtained at Step 2. Step 4. The clinician makes a reasonable decision about the approach to be used in caring for this client, based in large part on the high-quality evidence identified at Step 3. Step 5. The clinician evaluates the impacts and outcomes of the care provided to the client. It is especially important to note that EBP includes, by definition, all of these steps. First, practitioners must recognize the need to ask a pointed question: Would my default, favourite, or standard treatment be the best choice for this client, or is there an approach that has a better chance of meeting this client's goals more easily, more completely, more inexpensively, more quickly, or more permanently? Such a question is unnerving; it requires the “humble attitude” (Law, 2002b, p. 5) that one's default, favourite, or standard treatment might not be the best choice for one's clients. Practitioners must then take the large and equally unnerving step of acknowledging that they do not have all the information necessary to answer such a question, followed by the larger and possibly even more unnerving step of turning to the research literature for possible information. Equally, practitioners must approach that research literature with a healthy scepticism. They must have the skills and take the time to evaluate not only whether each potentially relevant study or review was done well, and therefore has drawn a valid conclusion as to the impact of the treatment for the study's participants, but also whether any of the potentially relevant studies or reviews do in fact have any relevance for a particular clinical case. At this point, practitioners must take the time to combine the new knowledge they have gained from well conducted and validly interpreted research studies with their own expertise and with a particular client's idiosyncratic beliefs and desires, in order to make and implement a well-reasoned clinical decision; some critics omit this step from their straw-person versions of EBP (Trinder, 2000), but it is crucial and it exists by definition. Finally, EBP explicitly includes a phase of evaluating the results of the decision and of the selected procedure; there is clinical evidence to be gained from each client, too. VII. Analysis Detailed instructions To give precedence to instrumental reasoning and to objective truth means those questions about time, space and contexts are left behind. This is problematical because patients and nurses are living, thinking, feeling and acting individuals, relating to one another in different ways and situations, where communication 4 in a broad sense always take place in time and space. The trusted idea about truth as correspondence to objective reality does not take into account that acting is contextual, that interpretation always is at stake and that it is difficult (impossible) to produce generalisability from one group of nurses or patients to another (external validity). External validity would, for example, be less of a problem when studying pharmaceuticals, where the effect is more constant across patients whatever the place and time of the intervention. The RCT is born of a mechanical natural science view, where cause-effect relationships form the agenda, where time ideally can be fixed and where contextual factors are understood as biases. It follows that it is not an appropriate research method with which to evaluate nursing interventions, because such interventions involve social relations and take place in time. Although the advocates of EBN indicate that patients' preferences and experiences are important components of most clinical decisions and that the best design to gain knowledge of this is qualitative, too often their good intentions fail. The qualitative design 5 within EBN shares, in a more blurred and therefore in a potentially more dangerous form, the same problems as the RCT. Of course, one can get other kinds of answers from patients using a semi structured or an open-ended questionnaire instead of a closed questionnaire. This, however, does not solve the main problem, which is that within EBN, patients' preferences and experiences are viewed as something static, independent and unchanging over time, space, contexts and nursing intervention. As long as the design is not separated from the mechanical natural science paradigm, where cause-effect relationships form the agenda, interpretations will have shortcomings. (Silverman, 1998) VIII Criticism on EPB Despite all its benefits of EBP, EBP also has its critics. A frequent criticism of EBP, one with special relevance if we begin to consider applying these principles to stuttering treatment, is that EBP has limited itself and its applicability by requiring high-quality research evidence is necessary This criticism is accurate, as far as it goes, but it also reflects a limited view of EBP. Most EBP authors and textbooks do describe RCTs as the gold standard, or the best evidence that a single study can provide of a treatment's effects; some even suggest that busy practitioners can cull less relevant or less important articles from the never-ending stream of new publications by focusing primarily on RCTs or on systematic reviews or meta-analyses of RCTs. Based on such a recommendation, EBP leaves itself open to the standard clinical criticism that group averages represent no single client, or that no individual client is well served by conclusions drawn only from groups. More importantly, the EBP process fails if the research literature does not include sufficient relevant RCTs for the practitioner to evaluate and potentially apply with an individual client. (Silverman, 1998) The notion, that individual clinical decisions should be based on the research literature, as evaluated and interpreted by individual practitioners, represented a radical step for the practice and teaching of medicine. Some 17th- to 20th-century authors recognized that many common prescriptions or remedies did little good, but it is probably fair to claim that most practitioners, and most members of most communities, generally accepted the available remedies and accepted that the reason they were used was that they had previously been used or were part of a recognized tradition. This trust was most likely encouraged by what a behavioural psychologist would call the power of intermittent reinforcement and a logician would call the fallacy of confirming evidence. (Paauw, 1999) VIII. Conclusion EBP has been widely accepted by many scholars and many practitioners, and descriptions of its strengths and its advantages abound. Among the most important of these is, clearly, that evaluating the available research literature, and then basing treatment decisions on relevant, high-quality studies, should allow practitioners to provide each client with the best possible individualized and research-based treatment. This client-focused aspect of EBP cannot be underestimated: Regardless of the extent or the quality of research support for any particular treatment, the goal of EBP is not to impose that treatment on all practitioners or any individual client. Indeed, despite substantial overlap in many of the issues, EBP is very different from attempts to designate certain treatment approaches as empirically supported (Chambless & Hollon, 1998) in an abstract sense unrelated to a specific client; EBP emphasizes a manner of practice, not an academic classification exercise. Thus, EBP specifies that practitioners should actively formulate questions about the needs and desires of each client, seek high-quality empirical evidence that bears on those questions, and use that evidence to serve that client in the best possible manner. If these procedures are followed, then the widespread adoption of the principles of EBP will lead to the widespread adoption of well-researched and empirically supported treatments—this adoption will occur, however, not because those treatments have been imposed or so labelled, but because those treatments have been supported in the research literature and are then purposefully selected by individual clinicians who have an individual client's best interests in mind. (Word Count 2797) Bibliography/References Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7–18. Cooper, E. B. (1987). The chronic perseverative stuttering syndrome—incurable stuttering. 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How to get started. The Evidence-Based Medicine Working Group. Journal of the American Medical Association, 270, 2093–2095. Paauw, D. S. (1999). Did we learn evidence-based medicine in medical school? Some common medical mythology. Journal of American Board of Family Practice, 12, 143–149. Sackett, D. L., Haynes, R. B., Guyatt, G. H., & Tugwell, P. (1991). Clinical epidemiology: A basic science for clinical medicine (2nd ed. ). Boston, MA: Little Brown. Silverman, W. A. (1998). Where's the evidence? Debates in modern medicine. Oxford: Oxford University Press. Trinder, L. (2000). A critical appraisal of evidence-based practice. Read More