«SLIDE 1 (INTRO) I could spend this time extolling the many virtues of nurses and nursing, patting ourselves on the back. While I will take the ...»
SLIDE 1 (INTRO)
I could spend this time extolling the many virtues of nurses and nursing, patting ourselves
on the back. While I will take the opportunity to do some of this, I also want to challenge
nursing with some home truths. By the way, throughout the presentation I will use the
word nurses as shorthand for nurses, midwives and health visitors:
SLIDE 2 (Talmud)
“The child in the womb of his mother looks from one end of the world to the other
and knows all the teaching, but the instant he comes in contact with the air of earth, an angel strikes him on the mouth and he forgets everything”.
This extract from the Jewish Talmud seems to indicate that at one stage we had all the evidence we needed to solve all our human problems but on being born, we lost it. We still have the mark of the angel above our top lip! My presentation will attempt to explore how we reclaim and use some of what the Angel took from us. In so doing I will try to answer the following questions.
SLIDE 3 (Questions)
1. What stimulated the Evidence Based Practice movement?
2. Why should we want it and what is and is not evidence?
3. What are certainty and agreement in Evidence Based Practice?
4. What legitimate and illegitimate reasons are there for ignoring the best Evidence?
I will begin by relating a scenario:
Scenario 1: A nurse goes out to lunch with some friends who are not nurses. They ask her what is new in the field of nursing. She mentions that evidence based practice is currently a popular phenomenon. When they ask her what this means she says that it involves providing people with care and treatment that is informed by the most up to date knowledge. They look surprised and ask her if this is not something that nurses have always done!
Why should they be surprised – well today, in the UK someone somewhere is receiving care or treatment that is out of date or that is not underpinned by sound evidence. Nurses should be very concerned about this. People who need health care have clear legal and moral rights. One such right is to be cared for and treated in the best possible way within available resources. In many cases and for reasons I will explore later, nurses are always respecting these rights – the very foundations of our profession.
Some Background It is generally agreed that as a movement, evidence-based practice was `kick started' by a lecture given by Archie Cochrane in 1972. He was a doctor and epidemiologist and he aroused a lot of interest by pointing out that many decisions about health care are made without up-to-date evidence about the care and treatments used.
However, his 1972 lecture was a culmination of concerns he had expressed over many years. It was stimulated originally by his POW experiences during World War Two where he noted that people were d
“I would gladly have sacrificed my freedom for a little knowledge. I had never heard then of 'Randomised Controlled Trials', but I knew there was no real evidence that anything we had to offer had any effect … and I was afraid that I shortened the lives of some of my friends by unnecessary intervention.” Several of you may have noted that in 1972 as Cochrane was complaining of how medical research results were was not being used, UK nursing was being chastised by the Briggs’ Report for not having enough research in the first place. Briggs recommended that nursing become a research-based profession. Since then the situation has improved beyond recognition but the profusion of nursing research in the interim has the potential to confuse rather than enlighten.
There is also confusion over terminology. In 1992, twenty years after Cochrane’s lecture, David Sackett coined the term Evidence Based Medicine. Two years later the expression Evidence Based Practice reared its head and in 1996 the phrase Evidence Based Nursing was first used in print. At this juncture, I should add that I am troubled by these terms.
Evidence Based Practice and Evidence Based Nursing give the impression that clinical nurses are non-thinking automatons who follow unquestionably the directives of nurse researchers. Nursing Research results should be used to inform practice not to dictate it.
This is why I prefer the terms Evidence Based Decision Making or Evidence Informed Practice. I also acknowledge the presence of Practice Based Evidence. But, regardless of what terminology we use, it is a good idea to explore why we want it!
Beverly Malone in the April 2004 editorial in Quality and Safety in Health Care stated that there was a need to invest in evidence based methods that can determine and monitor safe nurse staffing levels, taking into account skill mix, case mix and good working practice. Here she was emphasising the use of evidence for SAFE care.
Borrowing from Dante’s Inferno, Florence Nightingale asserted that due to the Hazardous nature of care and treatment in the Barrack Hospital in Scutari, the words ‘Abandon Hope All ye who enter here’ should be written over the entrance. Today, Health Care is still Hazardous.
SLIDE 5 (Berwick) In London in 2003 Don Berwick used Leape’s research to compare the lives lost each year with the number of encounters needed for each lost life. You can see that compared to ultra safe activities like schedule airline trips or train trips the number of deaths from health related interventions puts it in the dangerous category of 1 death per 1000 encounters. This makes health care related deaths much higher than road traffic deaths.
This is a disaster and to help reduce this death toll there has been the promotion of Evidence Based Practice within government policy in the UK, Europe, USA and Australia.
Appleby stated that evidence based practice was “A shift in the culture of health care provision away from basing decisions on opinion, past practice and precedent toward making more use of research evidence to guide clinical decision making”.
DiCenso et al (1998) put forward a less rigid and almost contradictory definition.
“A 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”.
Look at these definitions carefully; I am not going to ask you which one you prefer;
rather I want you to note that neither of them refers specifically to patient outcomes – a familiar pattern in definitions of evidence-based practice. Rather, each concentrates on the ‘thinking and doing’ aspects of care, suggesting that the term evidence based practice relates specifically to the processes of care and treatment. The fact that these processes should be linked with outcomes is not a matter for explicit consideration by any of these authors. Therefore, each of you could be basing your clinical and managerial decisions on the best evidence available and you would be employing evidence-based practice. But this evidence could be having no impact or even a negative impact on patient outcomes.
So to use evidence to underpin practice and not evaluate its effectiveness is short sighted (1st key message).
Another thing to notice about these definitions is that what DiCenso would identify as evidence, would not be perceived as such by Appleby. From Appleby et al’s perspective, evidence is reliant on the existence of research findings. In contrast, DiCenso states that clinical expertise and patient preferences are also sources of evidence. This apparent contradiction may be explained by what Muir Gray 1997) called the Hierarchy of Evidence. This is really a hierarchy of cause and effect rather than one for general evidence, but it has been propagated as the latter.
SLIDE 8 (Hierarchy) Level I Meta analysis of a series of randomised controlled trials Level II At least one well designed randomised controlled trial Level III At least one controlled study without randomisation Level IV Well-designed non-experimental studies Level V Case reports, clinical examples, opinion of experts.
Figure 1. The Hierarchy of Evidence Regardless of this, you will notice that the top four levels are really about counting and this predilection has its roots as far back at the in the middle ages.
For instance, Galileo wrote Count what is countable, measure what is measurable and what is not measurable –make measurable.
But many of the issues of importance to nursing defy quantification: how do you calibrate compassion, how do you quantify a presence, how do you measure empathy?
It is not unusual to hear the mantra that RCTs are the Gold standard, the most highly prized source of evidence. This is a false assumption as it depends on what the research question is. If I wanted to study possible causes of diabetes, then yes the RCT may well be the Gold Standard. However, if I wanted to study people’s fears of the effect of diabetes on them and their families, then the gold standard may to listen to and record their experiences.
But according to this hierarchy, word of mouth is not regarded as good evidence. This is not the case in all professions. In the legal profession such evidence is highly valued and word of mouth is sufficient to put a person in jail for a long time, or in some countries be executed. In contrast, such sources are denigrated in most textbooks and articles about evidence in nursing. Perhaps it might be more useful for a new hierarchy to be proposed.
SLIDE 9 (new hierarchy) Level I Opinion and views of experts Level II Patient preferences and narrative accounts Level III Nurses’ experiences Level IV Results of qualitative studies and quality Improvement/audit activities.
Level V The results of quantitative research.
As with the previous hierarchy, this one also has inherent problems. How can you decide whether a patient’s preference comes above or below the experience of nurses? It depends on circumstances; hierarchies belong to the world of quantification and the quality of evidence should not be tied to a research design!
To return to Archie Cochrane for a moment; he was to a large extent the instigator of the Gold Standard RCT. But, in an almost in a Road to Damascus conversion, he too realised
that other approaches were needed for human problems:
SLIDE 10 (Archie -Damascus) “… The Germans dumped a young Soviet prisoner in my ward late one night. The ward was full, so I put him in my room as he was moribund and screaming and I did not want to wake the ward … He had obvious gross bilateral cavitation and a severe pleural rub. I thought the latter was the cause of the pain and the screaming. I had no morphia, just aspirin, which had no effect … I felt desperate … I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming but loneliness. It was a wonderful education about the care of the dying. I was ashamed of my misdiagnosis and kept the story secret.” Cochrane, A. (1989). One Man's Medicine. London: BMJ (Memoir Club). p. 82 So over time Archie Cochrane had other views about what may or may not be an effective intervention. Therefore, evidence is a victim of time (2nd key Message). What was evidence last year may not be evidence this year. Perhaps at one time there was evidence that boring holes in people’s skulls or using leeches were perceived as good ways of controlling some symptoms or that extracting teeth was the best way to deal with dental caries. Today, such interventions are perceived as barbaric. I have no doubt that in fifty years time, interventions currently used as best evidence will be denigrated by society. No crystal ball gazing but I doubt if ECT, some major surgery and many types of cancer chemotherapy (all currently underpinned by sound research) will exist.
What is certainty and agreement in Evidence Based Practice?
In health care we reach out continually for the holy grail of certainty. However, the world of health care, as with life in general, is full of uncertainties.
SLIDE 12 (photo School) Uncertainty brings anxiety and confusion and this means that during times of uncertainty nurses fall back on familiar practices.
In Area 1 are those interventions that have high levels of agreement but their effectiveness is far from certain. Knowing the vintage of some of my colleagues here this evening, I know they will remember Savlon baths, Salt Baths, 4-hour back round, unnecessary 4 hourly observations. However, today in many wards in the province nurses still weigh all patients on a weekly basis regardless of their health problem and patients still starve for longer than the recommended 4 hours prior to operation. Most of these interventions do no real harm but they also do no real good.
Ignoring evidence and basing practice on tradition has immense benefits for some nurses:
they feel comfortable with routines, which are often a mechanism for keeping control in a busy clinical area where there are unpredictable and ever changing conditions and where staff are forever altering in numbers and qualifications. Also, routines are sometimes legitimised because they were learned from the actions of an authority figure or a trusted colleague. But it is not always wise to place too much trust in the actions of a colleague!
SLIDE 14 (Polar Bear)
In Area 2 are those interventions that nurses undertake that have high levels of agreement and certainty. They are mostly informed by good research evidence. Examples include pre op visits to reduce post op complications, nurse-led smoking cessation clinics and cognitive behavioural therapy to improve functioning in inpatients with acute psychosis.
Here, undoubtedly, the interventions do more good than harm.
In Area 3 are those interventions that nurses undertake that have low levels of agreement among the profession and their effectiveness is far from certain. For example, there have been a plethora of literature concerning theories and models of nursing, most of which are not research based – yet they have been used in practice to provide a systematic approach to nursing care. These interventions do no real harm but it is uncertain whether or not they do any good.