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The nursing contribution to evidence based practice. Brendan Docherty MSc PGCE RN Abstract: An overview of evidence-based practice including structures that support it, examples of peer audit, patient involvement and research. Diagram and 15 references. Contents Back to Nursing Progress contents The NHS Plan (1) has signaled many forward thinking changes and challenges in nursing (used in the context of this article to be inclusive of midwives and health visitors) and healthcare generally. This includes the delivery of a service, the evaluation of that service and the involvement of the patient as central to all service delivery components.
Making a Difference (2) has identified areas of development that will help nurses reach the goals of the modern NHS fit for the 21st Century - advanced practice skills, more nurse-led initiatives, modern career frameworks and leadership development to mention a few. This paper hopes to identify some areas where nurses have to consider their professional development and life long learning needs in order to meet these challenges and to help improve the patient experience of care received within an organisation.A note to the wise however - the advent of the Nurse Consultant does not mean, that the nursing contribution is recognised and solid. It means that higher levels of practice, responsibility and autonomy have to be justified and shown to be effective before the real effect of these advanced roles will be valued by the other healthcare team members. Therefore, investing in mechanisms (such as audit and clinical indicators) that clearly demonstrate the effectiveness of the nursing strand towards the overall healthcare delivery picture is useful. Back to contentsFrom the inception of the NHS in 1948 we have undergone four main changes in governing arrangements within healthcare settings. We have moved from medical governance, to financial and managerial governance, to our current position of patient (or clinical) governance (3). It could be said that it has taken us some time to reach the point and that the patient focused care theme should have been the lynchpin for the NHS from the onset.However, as much as we all wish to involve the patient at every point in service delivery it is not always possible or sought. It is certainly, in my own clinical experience, challenging to be told the opposing views of a patient when you believe you have the patient's best interest at heart. It does, however, embrace the feeling of patients as individuals that nurses have supported for so long, and we have to meet the patient at the point where they want to work in collaboration with us, rather than passive recipients of healthcare. However, evidence-based practice and evidence-based nursing have very strong positions in the Clinical Governance agenda of quality improvement. (4) The main components include developing an evidence-based culture within an organisation, agreeing the strategic direction for evidence-based practice, developing skills, applying skills and the evaluation of skills in practice. (5)Evidence-based practice can be defined as using contemporaneous best evidence when making patient care decisions, but somehow does not always address the gap that exists between research and practice. The evidence can vary from high level research (for example systematic reviews of randomised controlled trials) to descriptive studies or evidence based on clinical evidence and expert advice and then everything in between the two extremes. (6) Therefore, each healthcare team member has to critique evidence, assess its reliability and application before combining it with their own clinical expertise before the research practice gap can be bridged.Organisational systems are fundamental to this process, and an organisation that encourages active thinking and critique of evidence-sources may be more likely to develop a quality driven practice development culture that enhances patient care. Back to contentsThe main structures that support evidence based practice are:
How many of you are confident and competent at collecting audit, research or clinical effectiveness data? I am sure some of you have some of the skills to some degree. Previous to the new NHS agenda, audit was the work of some secluded department within a Trust, and the audit skill base and techniques, more often than not, were not shared or demonstrated to aid learning outside that department. Audit work is not complex, but the mere word may start off a fear of panic in many as it infers sub-optimal practice and correction of practice deficits. However, the skill base is easily picked-up and there has to be a greater emphasis in healthcare generally of audit and clinical effectiveness data collection. This activity is not necessarily as a separate entity to nursing, but hand in hand as we nurse, realigning out current methods of working to incorporate the investigation of our practice continually to ensure that we are achieving excellence in patient care. Back to contentsThere are already pockets of good practice happening. At the Homerton Hospital, for example, when a midwife hands over care of a mother to the next midwife, the accepting midwife immediately and systematically audits the previous midwife's work. The care and evaluation of that care for effectiveness - peer audit and clinical effectiveness - ensures that standards are high and meeting the needs of the individual patient. Midwives at the Homerton, therefore, have found a mechanism where audit and clinical effectiveness is part and parcel of everyday practice. Defining nursing has been problematic over the years - mainly because of three factors. Nursing is an art, nursing is a science and nursing is also changing. Answering nursing research questions, therefore, means that no particular research method can be employed categorically. This means that we cannot be prescriptive about what and how to best answer nursing questions - but this is a great opportunity rather than a harness. A unique richness can be gained from the study of patients and the nursing process using a mixed research method to obtain a pertinent array of answers to one clinical question, for example triangulation. (8) Back to contentsIf evidence for practice already exists, then critique and peer review of the information must assess the robustness, validity and reliability of the evidence prior to applying it to your patient population. (9).Transferring this research or evidence into clinical practice at a patient-nurse interaction level may be complex and difficult. Who wants to wade through the action and rationale sections of a clinical guideline from a dusty book that may have been on the shelf for years? The secret is to capture the pertinent elements of the evidence and transpose it into something that is quick, easy to use and that patients can understand - and in a language that is familiar. I am, of course, talking about integrated care pathways, algorithms and other abbreviated forms of evidence that aids quicker and patient focused decision making processes. (10) Back to contentsHow do we achieve meaningful feedback from patients on the care we deliver? This may not be answered by a simple questionnaire or audit tool at ward level, but may involve patient consultation groups, national consultation processes, patient advocacy services, citizen panels and thinking 'out of the box' and seeing services from the patients perspective. (1) To gain a real and meaningful picture of how those who we care for see and value us, it has to be a mixed model of evaluative processes to ensure that patients can access and feed into the process with ease and in a seamless manner. More work has to be undertaken involving patients - and given the multi-cultural and socio-economic variances of our Trust - this requires careful consideration and preparation. We must ensure that the right care is delivered at the right time, in the correct manner by the practitioner with the appropriate skills to do so. (7)It is imperative that we involve our patients to ensure that the care we provide is meeting their expectations as well as our own. (11) Back to contentsThere is a dilemma currently. Do we teach nurses to undertake research or how to utilise research to improve practice? - compounded by the very complex nature of nursing as a profession. (12) Nursing has certainly contributed greatly to the development of qualitative research methods, but what may be much more important is that these methods are now being used by other professional groups as well as the Department of Health as robust tools of the enquiry process. Also, with a national strategic move towards research being focused on health care clinical priorities we are seeing the emergence of healthcare research as opposed to uni-professional research. (13) It will be difficult (as it has been in the past) to secure funding for nursing research unless we can be confident that the nursing contribution is worthy of investigation. We must also work closely with our professional colleagues to ensure that the nursing voice is heard in healthcare research planning and execution.A recent review of nursing research identified that mental health and education were the top two areas being investigated by nurses in nursing. (14) This paper also identified, however; that there were less nursing research projects being funded appropriately and that multi-authorship in nursing was not common, and certainly not comparable to most medical research papers. Why is this? Why are nurses working in isolation and possibly not seeking support for their research endeavours? Back to contentsThere is no doubt that nursing research has a valuable place in healthcare delivery and patient focused care. However, research efforts should be focused on how nursing and healthcare teams work to deliver quality driven care. Nurses investigating "nursing" may find that this work will not attract interest from the R & D funds. However; if a clinical question relating to patient care needs answering by looking at the art and science of the nursing discipline, then that may be more likely to attract attention as long as the end point is patient care orientated. A nursing research strategy that is housed within an interdisciplinary framework will be important in the move towards achieving the goal of evidence-based healthcare delivery. This strategy may include education, the identification of local priorities and the development of existing evidence into patient care (15). For some nurses undertaking research projects as part of the first degree, masters or PhD level studies, there has been ambiguity about what to investigate. For some, choosing the path of least resistance happens -resulting in a literature review and conclusions that may duplicate existing work. However; if nurses were to be commissioned by the organisation, that is, given a clinical problem, to answer a clinical question of interest to the person undertaking the research and worthy of the nurses valuable clinical expertise and research efforts, then the following happens:
Nurses and nursing is in a very valuable position to influence healthcare policy, service developments and to improve the quality of the patient experience. Unlike other established professional groups, nursing as a profession is continuing to emerge and develop with both the NHS and the patient's needs. Our strength, therefore, is to ensure that not only are we proactively involving ourselves in these developments, but that we are leading on and sharing good practice examples with others within our organisation, London and the wider NHS nationally. Back to contentsNursing Progress: 2001. Copyright: Nursing Progress, Royal Hospitals NHS Trust Also published in Professional Nurse 1. Department of Health. The NHS Plan: a plan for investment, a pan for reform. London: The Stationary Office, 2000.2. Department of Health Making a Diference. The nursing, midwifery and health visiting contribution to health and healthcare. London: The Stationary Office.1999. 3. Scott I. Clinical Governance: An opportunity for nurses to influence the future of healthcare development. NT Research 1999: 4.3; 170-6. 4. Elcoat D. Clinical Governance in action: key issues in clinical effectiveness. Professional Nurse 2000: 18.10; 822-3. 5. McSherry R, Haddock J. Evidence-based health care: its place in clinical effectiveness. British Journal of Nursing 1999:8.2; 113-7. 7. National Health Service Executive. Achieving effective practice. London: The Stationary Office 1998. 8. Docherty B. Using triangulation in health-care research. Professional Nurse 2000: 16. 2; 926-7. 9. Cormack D. ed The research process in nursing (4th edition). Oxford: Blackwell Science, 2000. 10. Thompson P, Angus NJ, Scott J. Building a framework for getting evidence into critical care education and practice. Intensive and critical care Nursing2000: 16; 164-74. 11. O'Neill S. Clinical Governance in Action: Patient experience. Professonal Nurse 2000: 15.12; 746-7. 12. Reed J. Using a group project to teach research methods. Nurse Education Today 1995: 15; 56-60. 13. Department of Health. Research governance framework for heath and social care. London: The Stationary Office, 2001. 14. Traynor M, Rafferty AM. (2000). Research revealed. Nursing Standard 2000: 14.45; 35. 15. Baker M, Kirk S. eds. (2nd edition). Research and development for the NHS: evidence, evaluation and effectiveness. Oxon: Radcliffe Medical Press Ltd, 1998. Back to Top Nursing Progress: Issue 10: June 2001.Copyright: Nursing Progress, Royal Hospitals NHS Trust Back to Nursing Progress contentsBack to Issue 10 contents list Page last updated by DEB on 1/7/02 |
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