Title: Evidence Based Nursing is developing in primary health care . Critically discuss the applications to your practice. (District Nursing)
Undergraduate Degree Level Essay
The evolution of the nursing profession has witnessed a great many changes of both emphasis and direction in both the delivery and the content of patient care as well as accompanying changes in both the philosophy and the theory of that care. Arguably the nursing profession has historically based its activities and also its philosophies, on tradition and the perpetuation of currently accepted practices which have not been firmly rooted in a general scientifically tested framework.(Roper N 1977). This can be verified by the fact that the nursing literature of the 1970s and 80s has many references from writers and commentators who were arguing for nursing to evolve into a research based profession and highlighting the fact that there was a demonstrable absence of a significant amount of good quality research-based fact which dictated the current practices throughout the profession in general. (Gortner SR 1976).
An impartial observer, considering this situation over the intervening years, would probably agree that there has been a clear and marked swing in both the published literature and the actual practice of nursing, towards the underpinning of practice with strong scientific research. Evidence based nursing has emerged as being one of the dominant driving forces in nursing evolution and the advent of evidence based practice has become apparent to the point where it is now and this could be considered to be the “gold standard” and essential basis for the majority of professional nursing care (Yura H et al 1998)
If we look at the issues and considerations that could support this statement, we could point to Hunt’s tour de force on the subject in his seminal paper of 1981 (Hunt J 1981), in which he sums up his belief that “each nurse must care enough about her own practice to want to make sure it is based on the best possible information”. This plea seemed to strike a chord in the nursing profession to the extent that, over the following few years, there was a noticeable increase in the published papers that both echoed these sentiments and also defined the various barriers to progress in this respect. These were largely quantified as including time constraints, limited access to the literature, a lack of training in critical skills of appraisal and, most fundamentally, a professional ethos and ideology that placed a great emphasis on the practical rather than the intellectual component of knowledge, together with a work environment that did not actively encourage the seeking out, researching and recording of new information (after Royle J et al 1996). One could be forgiven for observing that such comments are still relevant to a degree today.
In order to present a balanced argument, we can observe that there is not a blind and uniform acceptance of evidence based nursing procedures. There are some who actively criticise evidence base procedures. Haynes (R B et al 1996) points to the fact that a blind following of evidence based practice can promote a concept of a “cookbook” of procedures that have to be dogmatically followed and it can stifle the holistic consideration of what may be best for each individual patient. We shall return to this point later. White (S 1997) counters this argument with the suggestion that a nurses’ professional training includes both learning the basic pathophysiology and anatomy and acquiring experience. She suggests that it is actually the “effective application of this experience that requires a sound evidence base.” Research evidence can aid the professional decision making process, but cannot either do the clinical examination or collate the vast amount of snippets of information that pass between patient and nurse. White suggests that it is this clinical expertise (derived from learning and experience), that is the crucial element in the application of the evidence based knowledge which separates true evidence based nursing practice from the “cookbook” approach with Haynes’ vision of the mindless and unquestioning application of “both guidelines and rules” (White S 1997).
Before we leave the general issues relating to evidence based nursing, we shall also cite the analytical work of Pearson (A 2000) who produced an influential treatise on the role of the nurse and nursing in evidence based research. In his paper Pearson makes a fundamental and significant delineation between lay nursing and professional nursing which is defined by the application of research based practices and procedures. He suggests that the evolution of evidence based nursing had its origins in the days of the reforms pushed through by Florence Nightingale, became commonly accepted practice in the 70s and 80s when the “theoretical constructs of practice began to evolve and be adopted”, and has currently culminated in the advent and emergence of the nurse practitioner and nurse specialist whose professional structure, training and practice is essentially evidence based.
This essay is primarily about how evidence based nursing is developing in primary healthcare team with specific reference to personal practice. This is a potentially a vast topic and therefore we will use illustrative examples of specific areas of development.
A great deal of a primary healthcare team’s time (particularly that of the nurse) is taken up with the treatment of pressure sores and ulcers. It is instructive to consider the evolution of the evidence base for the treatment of this condition and then to extrapolate the process to other conditions frequently seen in primary care.
We can cite the work of Sir James Paget who made the observation in 1862:-
Elderly patients with femoral neck fractures and other high risk groups develop them (pressure sores) early, “chiefly in the first week,” and then made the observation “They often appear on the day of operation. It is not just the patient, but every part of his or her body, that must survive the operation”. (Bliss MR 1992).
The rationale for citing this statement is that it illustrates a comment and observation that may be factually correct, but has no evidence based weight whatsoever other than being a reflection of the author’s opinion. It has no foundation in statistically verifiable fact and may be subject to all forms of objective bias. It obviously was never produced as a result of a randomised controlled trial but, like many other “pronouncements” by prominent practitioners, it has both influenced and been accepted by generations of healthcare professionals over the years. This exemplifies Roper’s point, cited earlier, relating to the tradition of previous practice being perpetuated by successive generations.
The point can be tracked further still by considering a more recent paper by Vohra (Vohra R K et al. 1986). On the face of it, this paper gives a comprehensive overview of the (then) current practices in the treatment of ulceration and pressure sores. It goes into great detail relating to the aetiology, pathophysiology and trends in management of the ulcer patient and has an extensive and current reference section in the paper. The problem form the perspective of this essay is that, although the paper is undoubtedly comprehensive in its approach, virtually the entire paper together with virtually all of the cited references, is opinion based with not a single reference to a good quality randomised controlled trial. (MacLean DS 2003). The paper does make use of comparative studies where one treatment is compared with another, but this in turn exemplifies yet another shortcoming and that is that such trials are good if a healthcare professional has only these two options at their disposal for treatment, (which is seldom the case). Modern philosophy would dictate that in good evidence based practice, the nurse would need to be able to cite evidence that one treatment is demonstrably superior to all others for a given set of clinical circumstances and that this evidence is from a repeatable and unbiased source.
To give an illustration of this point, MacLean makes the comment:-
It is clearly of minimal value to a patient to be able to say to them that a comparison of rubbing a pressure sore with honey has been found more beneficial than rubbing it with butter when the use of a ripple mattress is clearly superior to both of them.
If we contrast this paper with another, more recent paper (Bliss et al. 1999), there are a number of very significant differences. This paper is also an overview of the current trends in treatment of ulcers and pressure sores. Firstly the author is a nurse. Secondly, it only cites 12 references (as opposed to over 70 in the Vohra paper) but each is a randomised controlled trial selected to support the various statements made in the paper. This represents a major and fundamental change in presentation, philosophy and practice. It could be suggested by the cynic that such observations are a chance finding in two randomly selected papers. We would suggest that an examination of the literature of the periods involved would support the view that they represent a true reflection of the genuine change in both style and expectation that now pervades the nursing professions and more fundamentally, it also reflects the criteria by which papers are now judged and accepted for publication in the major peer reviewed journals. It is not appropriate to discuss the content of the paper in detail other than to observe the fact that the paper concludes with a description of the classic Gebhardt trial (Gebhardt KS et al 1994) which compared the results of bed rest with intermittent chair nursing on the development of ulceration and in the words of Morris (A 2002):-
In many respects, the Gebhardt trial is a reflection of both the calls noted in the previous paper for proper scientific scrutiny to be brought to bear on the subject and the evolution of the expectation of the healthcare professions into the requirement for a firm evidence base for their continued work.
In terms of direct impingement on the practical aspects of primary healthcare nursing, the move towards evidence based procedures can be illustrated in the development of scales such as the Waterlow scale (PN 1991). This was developed as a direct recognition of the need for an evidence based tool which would both directly help the nurse assess and quantify the degree of risk together with helping them predict just which was the most effective treatment modality for any individual patient. This was accomplished by allowing a reproducible measurement of ulceration and thereby rendering this area of clinical practice amenable to proper scientific scrutiny and testing. The result of this scale development is that the nurse can identify a treatment that has not only been suggested by previous practice or experience, but one that can be shown to be the most appropriate for a given set of clinical circumstances with the most likely clinical benefit (NT 1996).
It is a logical step from this position to the situation where new scales are developed based on evidence based assessments and treatments, to predict the likelihood of healing of ulcers. Such a situation has resulted in the development of tools such as the PUSH scale (Gardener S et al 2005).
This represents the currently accepted end-point of a logical progression that we have traced and quantified from the type of opinion based pronouncements of Sir James Paget, past the experience based observations and comparative trials such as those of Vohra, through to the completely evidence based practices of today where a clinically defined situation is identified, a solution is hypothesised and then subjected to validation by appropriate double blinded and unbiased scientific techniques in a randomly controlled clinical setting. It allows the authors (Gardener S et al 2005) to conclude their paper with the comment
The PUSH tool provides a valid measure of pressure ulcer healing over time and accurately differentiates a healing from a non-healing ulcer. It is a clinically practical, evidence-based tool for tracking changes in pressure ulcer status when applied at weekly intervals.
Such a comment is virtually unchallengeable because of the weight of valid recorded evidence behind it.
If we consider new and current moves to examine the evidence base of activities in the primary healthcare team, we can also consider the advent of screening clinics which are commonly nurse-led. (Califf R M et al. 2002). We could consider the current trend for hypertension screening. It is commonly accepted that treating hypertension is of value in preventing both morbidity and mortality, (Cooper R et al. 2000), but a less frequently asked question is “What is the rationale and the evidence base for providing a screening programme for patients?“ (HTT 2005). Curiously, the evidence base for the screening programmes that have been run has been rather insecure. The main reason for this has been the comparative paucity of definitive information relating to the levels of effective treatment and, as the treatment can realistically only be assessed as effective over a long time span, such studies take many years to yield substantive information. It therefore follows that the evidence base for screening can only realistically be determined once a rational an proven evidence base for treatment has been established. (Brotons C et al. 2003). This is the position set out in the comprehensive paper by The National Heart, Lung, and Blood Institute Working Group (HTT 2005).
A pragmatic view would also have to observe that the position is further complicated by the constant evolution of new drugs and methods of measuring blood pressure which render previous data on the subject out of date by the time that it is assimilated. (Appel L J et al. 2003). This paper is very detailed in its assessment of the situation and it is not practical to consider all of its findings in any depth, but it provides a comprehensive overview of the evidence base for the promotion of hypertensive screening together with the evidence to support the use of different levels of hypertension as the endpoint of the screening process.
Perhaps we can conclude this essay about the relevance of evidence base nursing practice to primary health care with the excellent and though-provoking article by Frances Griffiths. (Griffiths F et al. 2005). Although we have been arguing for the use of evidence based practice in modern nursing care, there is one commonly overlooked aspect of this practice which is the subject of the Griffiths paper. As the wealth of good quality information relating to the effectiveness of many clinical interventions and practices increases, this fact alone presents healthcare professionals in general with the increasing dilemma of how to apply the information obtained to the individual patient. The evidence base for a procedure will generally inform clinicians of the likelihood of it being successful in the general population. It will not give any indication, other than a probability, of its chance of success in the individual patient. This is a problem for the nurse (and other healthcare professionals), as the bulk of current medical practice is on a face-to-face basis with individual patients, rather than dealing with populations. (Fox R C 2002)
To illustrate this point, Griffiths points to the fact that it is commonly accepted that epidemiology tells us that smoking is an independent risk factor in the population for myocardial infarction, yet there is no evidence base to tell us which particular individuals will be affected. Similarly there are a multitude of good quality trials which show that there is an increased risk of breast cancer that is linked with hormone replacement therapy but there is nothing that will tell us which individuals are at specific risk. (Willis J 1995)
This dilemma is central to the proper understanding of the place of evidence based practice as the balance between good practice based on proper evidence and individual patient care is central to the history of nursing and will not disappear however good the evidence base for a particular treatment becomes. In the words of Haynes (R B et al. 2002):-
Diseases always manifest themselves in patients’ bodies and minds, and in seeking to understand, treat, and predict the outcome of disease, clinicians need to move their focus from the individual to more generalised research.
To this end, the nurse would do well to reflect on the fact that assimilation of evidence is central to her practice, but communicating that evidence to patients is a key part of clinical consultations, with a growing evidence base of how it is best achieved.
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