«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 ...»
Finally, in Area 4 are those interventions that have low levels of agreement but their effectiveness has been shown to be certain. Examples include prophylactic aspirin to avoid blood clotting and eating five pieces of fruit per day. Here we know that these interventions do more good than harm but yet they are not universally incorporated into our practice or lifestyle.
I suspect you are wondering how much of health care activity is in Area 2. From Baker’s estimates (1996) this would be about 15%. It is a truism, therefore, that if nurses were told that they could only use research evidence, practice would come to a standstill.
Baker argued that an increase to about 50% is the best that can be hoped for. So, the idea of practice being 100% evidence based is unrealistic and indeed undesired. The situation we should be aiming for is to increase the number of interventions in area 2 and continue to bring the interventions in Area 4 into mainstream practice.
What reasons are there for ignoring best Evidence?
If I asked you whether nurses should use the best available evidence to underpin practise you would probably say yes. Who could possibly be opposed to this? But I would argue that there are many reasons why best evidence should be ignored. I have divided these into legitimate and illegitimate reasons.
Firstly, best evidence may on occasions be ignored legitimately and the explanation for this goes back to how nurses know what they know.
SLIDE 15 (Carper) In 1978 in the first article in the first issue of the US journal, Advances in Nursing Science, Barbara Carper identified four types of knowing in nursing. The first she called 'empiric knowing', and represents knowledge that is verifiable, objective, factual, and research based. This is the type of quantifiable and objective evidence seen in area 2 above or in Levels 1 to 4 of Muir Grey’s Hierarchy. I would argue that sometimes we can ignore this type of knowledge because it is superseded by one or more of the other types of knowing.
For instance 'ethical knowing provides us with knowledge that is about what is right and wrong and what are good and bad, desirable and undesirable. For Ethical reasons, some nurses may decide not to participate in a particular treatment even though the results from clinical trails or other studies note that it is effective for some conditions. For example I know nurses who will not participate in ECT or therapeutic abortions. Ethical Evidence may also be used to make decisions about the costs of treatment (QuALYs) and rationaing of health care or whether terminally ill people should be actively resuscitated.
Carper’s third type of knowing is 'aesthetic knowing. It gives us the knowledge that focuses on the art of nursing – tacit knowledge, skill and intuition. Armed with this type of knowledge we may also ignore research evidence. For instance, there are many research-based scales that are used to assess and predict patients’ risk of pressure damage. Nonetheless, clinical judgement, based on experience and intuition is also used.
Similarly, research evidence may provide guidance on when patients can mobilise post operatively but the intuitive expertise of the nurse may justifiably override this. Rather than evidence based practice this is best referred to as practice based evidence.
Finally, there is 'personal knowing' and this represents knowledge that focus on selfconsciousness, personal awareness and empathy. It is possible that a nurse may reject textbook based evidence because of her own personal history. For example, consider the situation where a nurse is working with a patient or a family member who is going through a grief reaction. Despite empirical evidence that suggests a liner movement through a number of grieving stages, the nurse’s personal experience may indicate that not everyone has to go through all these phases.
What do I mean by Illegitimate Barriers to using best evidence SLIDE 16 I have been fortunate to lead a research team on a number of studies dealing with Barriers to Evidence Based Practice. One focused on community nurses and GPs the other on mental health nurses and their managers. Based on some of the findings from this work, I will deal briefly with what I see as the illegitimate barriers erected by practising nurses, nurse managers, nurse researchers and nurse educators.
Practising Nurses Finding from one of these studies identified the entrenched attitudes of practising nurses as being the single most significant barrier to their use of evidence. Why should this be so? Well, lets face it, nurses are no different than anyone else and research evidence is not sufficient enough reason to change practice. (How many of you smoke; eat Ulster
fries; do not take enough exercise)
Nurse Managers Modern nurse managers are concerned about evidence-based practice because they are concerned about clinical governance. But research from Sandy Funk in the US, Caroline Hicks in the UK and Cecil Deans in Australia identified lack of management commitment as one of the greatest barriers to using research evidence. Our own research here in UU has verified this (I would include Kader Parahoo’s work in this field). Our findings showed that senior health managers had other commitments and did not perceive research as a core element in the provision of nursing services. It is not surprising that in a setting with competing demands no one is really going to believe that EBP is truly important unless the boss makes it important.
SLIDE 17 (Focus-Energy Matrix) At this juncture I am going to refer to recent work by Ghoshal and Bruch from the London Business School. It was published this year in the Harvard Business Review.
(Harv Bus Rev. 2004 Mar; 82(3):41-5, 125 Reclaim your job). In essence, they state that managers’ claims of lack of time and competing commitments are little more than excuses and mask their lack of purposeful engagement in supporting improved effectiveness.
From research undertaken over a period of several years the researchers noted that all managers fitted into one of these four quadrants. It can be seen that 30% of managers had low focus and low energy causing them to procrastinate on making decisions. 40% had high energy but low focus, distracting them from the task in hand. 20% had low energy but high focus causing them to be disengaged. The best managers had high energy and high focus and as a result were purposeful in ensuring continuous improvement. They knew what mattered about their business. This research has obvious implications for managers’ support of evidence-based practice. Look at the disengaged quantrant and note particularly the denial behaviour and defensiveness – from his Phd thesis Pter Nolan
provided a nice illustration of a disengaged nurse manager:
Interestingly, in one study I compared clinical nurses’ perceptions of barriers to evidence based practice with those of managers and noted some key differences. Practising nurses tended to see lack of management commitment as a major barrier. In contrast, nurse managers identified the unwillingness of clinical nurses to change and try out new ideas as a major barrier. Here, clinical nurses were blaming nurse managers for lack of support and nurse managers were blaming clinical nurses for being unwilling to change.
SLIDE 19 (Japanese)
This tendency to pass the parcel of blame to others is endemic in health care.
SLIDE 21 (BLAME) Nurse Educators Results from our research showed that nurse educators did not always keep up to date with the latest evidence based practice or practice based evidence and this affected student’s view of using evidence. Many of you would agree that some of us are products of a nurse training system that wanted obedience, not enquiry. Traditionally, students who asked too many questions were often perceived as troublemakers and ended up being sent to the so-called ‘back wards’ I met some of you there.
Today student nurses are encouraged to ask questions and are likely to be part of a culture of critical enquiry. It is my belief that nurses are best able to appreciate and use evidence when they have been learning from the beginning in an environment where knowledge is generated, challenged and tested as well as being taught.
Nurse Researchers Our research shows that several of the obstacles to the use of evidence had to do with research and researchers. In one of our studies, nurses and GPs identified barriers such as their inability to understand statistical findings, the confusion that arises through conflicting research results, use of too much research jargon. Perhaps, unsurprisingly they complained of the overwhelming amounts of published research papers (500 nursing journals). This latter issue is not new and is illustrated wonderfully by a building metaphor used almost 40 years ago by Raulin (1963). Lets suppose that the ‘builders’, (practicing nurses) depend upon ‘brickmakers’ (nurse researchers) to produce usable bricks (research papers) so that they can make edifices (evidence based interventions).
Raulin describes this as follows:
SLIDE 22 And so it happened that the land became flooded with bricks. It became necessary to organise more and more storage places, called journals… in all of this the brick makers retained their pride and skill and the bricks were of the very best quality. But production was ahead of demand and…it became difficult for builders to find the proper bricks for a task because one had to hunt among so many…. It became difficult to complete a useful edifice because, as soon as the foundations were discernible, they were buried under an avalanche of random bricks. And, saddest of all, sometimes no effort was made to maintain the distinction between a pile of bricks and a true edifice.
Therefore, if we are not careful, practice can be choked with evidence-based guidelines, protocols and research reports. This has the potential to alienate practising nurses from nurse researchers.
Research is a skill and like all skills it must be learned through study and practice. Just as you would not approve a nurse caring for a patient if she were not competent so too we should not countenance nurses undertaking research if they are not competent to do so. In any profession worthy of the name, only a small number of the members are researchers;
the vast majority are the critical consumers of the research.
Conclusion No nurse would deny that sound evidence should be an integral part of clinical decisionmaking. Practising in this way means that many nurses are reclaiming more and more of the knowledge that the Angel took from us.
I will summarise the 10 key messages emanating from this presentation:
1. There are many instances where nurses are using evidence based practice and practice based evidence.
2. People in need of health care have a legal and moral right to be cared for and treated in the best possible way within available resources
3. Quality of evidence should not be dependent on a particular research design
4. Ethical, Aesthetic and Personal evidence can on occasions supercede empirical evidence
5. Existence of evidence is not enough – it has to be used and its impact evaluated
6. Having 100% research based practice is naïve and unrealistic
7. Practitioners, researchers, managers and educators must work together to ensure that nurses work in an environment where evidence is generated, challenged, tested and taught
8. Passing the parcel of blame is comfortable – we must occasionally endure discomfort and accept ownership of the problem
9. As Beverly Malone and Don Berwick showed, modern health care is hazardous and evidence based practice is synonymous with safe care
10. Archie Cochrane changed his views on what was an effective intervention; so too we must reinvent our knowledge, attitudes and practice regularly. Alvin Toffler wrote, SLIDE 23 "The illiterate of the 21st century will not be those who cannot read and write, but those