Evidence Based Nursing
Evidence based health care relates to all the health professions – medicine, nursing and allied health - as well as health policy makers, planners and executives. The Joanna Briggs Institute provides extensive, free-access information about evidence based health care on its website at <click here to go to the JBI Website> and provides easily accessible evidence databases and tools to appraise, embed, utilise and evaluate evidence in practice to its Members through JBICOnNECT – the Clinical Online Network of Evidence for Care and Therapeutics <click here to go to the JBICOnNECT> |
Evidence-based nursing is closely aligned to the development of evidence based medicine. The origins of contemporary evidence based medicine can be traced to the work of A.L. Cochrane, Ian Chalmers and David Sackett. Cochrane drew attention to the lack of information about the effects of health care, with particular reference to medicine, and suggested that:
"[it] is surely a great criticism of our profession that we have not organised a critical summary by specialty or subspecialty adapted periodically of all relevant randomised controlled trials"1
He argued that, as resources for health care are limited, they should be used effectively to provide care that has been shown, in valid evaluations, to result in desirable outcomes. He emphasised the importance of randomised controlled trials in providing reliable information on the effectiveness of medical interventions
Evidence based medicine
Evidence-based medicine focuses on the need for medical practitioners to base their interventions and activities on the most up-to-date evidence or knowledge available. The evidence-based approach acknowledges the difficulties faced by busy practitioners in keeping up to date with an ever-growing literature in health care and emphasises the importance of providing them with condensed information gathered through the systematic review of the international literature on a given topic.
Although there is an international focus on a multidisciplinary approach to reviews and dissemination, until 1996 most activity focused on medicine and even now, evidence-based practice is used as an acronym for evidence-based medicine.
The development of evidence-based medicine has been rapid over the past 15 years, and has been led by Professor Ian Chalmers and Professor David Sackett. Evidence-based medicine (EBM) has been defined by Sackett as:
"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"2
Sackett and Rosenberg3 argue for the need to base medical practice on the best possible evidence; to critically appraise research reports for validity and usefulness; and to incorporate the rapidly growing body of evidence into medical practice. They suggest that EBM is concerned with five linked ideas:
1. that clinical and other health care decisions should be based on the best patient-, population- and laboratory-based evidence
2. the nature and source of the evidence to be sought depends on the particular clinical question
3. the identification of the best available evidence requires the application of epidemiological, economic and biostatistical principles plus pathophysiology and personal experience
4. this identification and appraisal of the evidence must be acted upon; and
5. there should be continuous evaluation of performance.
This evidence-based approach to medicine draws on the activities of numerous specialist groups from across the world, linked together to form the Cochrane Collaboration.
The Cochrane Collaboration
The Cochrane Collaboration has played a leading role in developing and promoting evidence-based health care and continues to be pre-eminent in developing methodology related to the systematic review of evidence of effectiveness. The Cochrane Collaboration focuses on the systematic review of randomised controlled trials for specific medical conditions, client groups or specific health professional interventions. The collaboration links review groups internationally and offers training and support to such groups. Review groups commit to an ongoing process of systematic review in a specific area, and this involves:
• determining the objectives and eligibility criteria for including trials;
• identifying studies that are likely to meet the eligibility criteria;
• tabulating the characteristics and assessing the methodological quality of each study identified;
• excluding studies that do not meet the eligibility criteria;
• compiling the most complete set of data feasible, involving the investigators if possible;
• analysing the results of eligible studies, using a meta-analysis or statistical synthesis of data if appropriate and possible;
• performing sensitivity analyses if appropriate and possible; and
• preparing a structured report of the review that states the aims of the review, describes the materials and methods used and reports the results.
Review groups also engage in a continual process of updating reviews. The Cochrane Collaboration caters for other interests (including non-medical groups) such as certain categories of health service users, groups of health professionals, settings for health care, or classes of intervention.
The Joanna Briggs Institute promotes the involvement of nurses and allied health professionals in Cochrane Reviews and JBI reviews of evidence of effectiveness are often carried out through JBI reviewers registering their reviews with a Cochrane Review Group. JBI staff are members of a number of Cochrane Review Groups and Cochrane Methods Groups.
The Cochrane Library
Reviews conducted by Cochrane Review Groups are published in The Cochrane Library, which is published quarterly basis by John Wiley and Sons, and made available on the Internet and on CD-ROM, The Cochrane Library consists of a regularly updated collection of evidence-based medicine resources, including The Cochrane Database of Systematic Reviews (CDSR).
This contains the full text of evidence based systematic reviews of health care interventions, prepared by The Cochrane Collaboration. The Cochrane reviews are updated in the light of new evidence and there are more than 3000 Cochrane reviews in CDSR, more than half of which already contain key findings and conclusions.
The Cochrane Library also includes:
• The Database of Abstracts of Reviews of Effects
• The Cochrane Central Register of Controlled Trials (Central Cochrane Database of Methodology Reviews)
• NHS Economic Evaluation Database
• Health Technology Assessment reports available within The Cochrane Library.
The Cochrane Library supports free text searching of all its content, as well as keyword searching and the sophisticated software allows users to edit and save search strategies, download records and print easily.
Evidence based nursing
Basing practice on the best available evidence has become a highly valued aspiration for nurses and nursing leaders have been exhorting nurses to engage in “research based practice” for at least 50 years. There is considerable evidence, however, that nurses do not apply research findings in their practice. Pearson et al4 have cited quite a number of examples of this (p.4). As to why this is so, Lathlean5 suggests the following:
• a nurse may be unaware of the research findings
• a nurse may not understand the findings
• a nurse may not believe the findings
• a nurse may not know how to apply them, and finally
• a nurse may not be permitted to apply the findings.
The evidence-based practice movement offers considerable assistance to nurses to improve research utilisation in practice. It recognises that it is unrealistic to expect busy health professionals to have the time to stay abreast of all the latest research. Hence, one of its key strategies is the development of condensed information that summarises the results of a systematic review of evidence on a topic that includes the meta analysis or meta synthesis of research results. This involves a trained researcher or a team of researchers gathering all the available research papers on a given question and systematically reviewing it for reliability and validity; that is, assessing its quality. Systematic reviews can provide the raw materials for establishing clinical guidelines and assist in identifying gaps in existing research, often discovering that there has been no research (or none of sufficient quality) on a given question. There is a rapidly expanding literature on evidence-based practice in nursing and Cullum et al5 and Manton6 see much potential in the evidence-based approach for nursing. Much of the work has originated in the United Kingdom, but there is a growing awareness in the United States too. In Australia, New Zealand and a number of other countries, there has been considerable development of infrastructure underpinning evidence-based health care generally and nursing in particular.
Simply defined, evidence-based nursing is the combination of individual clinical or professional expertise with the best available external evidence to produce practice that is most likely to lead to a positive outcome for a client or patient. Although medicine and nursing are the health care occupations most advanced in the evidence-based practice movement, the ideas and arguments are common to all professionals who work in health care. Sackett et al7 contend that evidence-based medicine had its philosophical origins in the mid-nineteenth century in Paris. They define it as being ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (p.71). These concepts are not without controversy, however. The most controversial issue relates to the current focus on evidence of effectiveness. The dominant approach to the systematic review of evidence favours the meta-analysis of the results of Randomised Controlled Trials (RCTs); indeed, the RCT is conceptualised as the “gold standard” in evidence of effectiveness, with other quantitative methods ranked as lower in quality in terms of evidence, and the results of interpretive and critical research are not regarded as high quality evidence. Critics of the prevailing privileging of the RCT and quantitative research cite the arguments inherent critiques of traditional science and the emergence of new paradigms for knowledge. Whilst the RCT is probably the “best” approach to generating evidence of effectiveness, are concerned with more than cause and effect questions, and this is reflected in the wide range of research approaches utilised in nursing to generate knowledge for practice.
The core of evidence based practice is the systematic review of the literature on a particular condition, intervention or issue. The systematic review is essentially an analysis of all of the available literature (that is, evidence) and a judgement of the effectiveness or otherwise of a practice. Currently, the systematic review involves the following steps:
1. The development of a rigorous proposal or protocol. The review protocol provides a predetermined plan to ensure scientific rigour and minimise potential bias. It also allows for periodic updating of the review if necessary. All of the stages of the review (as listed below) are described fully in the protocol, and it is usually subjected to peer review before the review commences.
2. Stating the questions or hypotheses which will be pursued in the review. Questions should be specific regarding the patients, setting, interventions and outcomes to be investigated.
3. Identifying the criteria that will be used to select the literature. The inclusion criteria should address the participants of the primary studies, the intervention and the outcomes. In addition to this, it should also specify what research methodologies will be considered for inclusion in the review (eg randomised controlled trials, clinical trials, case studies etc).
4. Detailing a strategy that will be used to identify all relevant literature within an agreed time frame. This should include databases and bibliographies that will be searched, and the search terms that will be used.
5. Establishing how the quality of primary studies will be assessed or critically appraised and any exclusion criteria based on quality considerations.
6. Detailing how data will be extracted from the primary research regarding the participants, the intervention, the outcome measures and the results.
7. Setting out a plan of how the data extracted will be pooled. Statistical analysis (meta analysis) may or may not be used in pooling numerical data and this will depend on the nature and quality of studies included in the review. Where possible, odds ratio (for categorical outcome data) or standardised mean differences (for continuous data) and their 95% confidence intervals are calculated for each included study. If appropriate with available data, results from comparable groups of studies are then pooled in a statistical meta-analysis using Review Manager software from the Cochrane Collaboration, which also tests the heterogeneity between the combined results using standard chi-square test. For textual data, the current convention is to develop a narrative summary. With the emergence of QARI, it is anticipated that textual analysis (meta synthesis) will become the convention in reviews of this nature. While it may not be possible to state exactly what analysis will be undertaken, the general approach should be included in the protocol.
Systematic reviews are conducted by teams of researchers over long periods of time.
JBI and EBN
The Joanna Briggs Institute is an interdisciplinary, not-for-profit, international research and development agency linked to an international collaboration of autonomous specialty, country or state based collaborating centres – The Joanna Briggs Collaboration. There are 26 collaborating centres incorporating the disciplines of nursing, medicine, midwifery, physiotherapy, rural health, multi-professional practice, nutrition and dietetics, podiatry, occupational therapy, complementary therapies, aged care and medical radiation. Since its establishment, the Joanna Briggs Institute has sought to impact on health improvement internationally through advancing evidence-based practice in health care.
The role of the Joanna Briggs Institute is too improve the feasibility, appropriateness, meaningfulness and effectiveness of health care practices and health care outcomes by facilitating international collaboration between collaborating centres, groups, expert researchers and clinicians through:
• Developing methods to appraise and synthesise evidence and conducting systematic reviews and analyses of the research literature (evidence translation);
• Globally disseminating information in diverse formats to inform health systems, health professionals and consumers (evidence transfer);
• Facilitating the effective implementation of evidence and the evaluation of its impact on health care practice (evidence utilisation)
• Contributing to clinical cost effective health care through the promotion of evidence based health care practice (evidence utilisation).
More Resources:
Websites:
Bandolier
www.jr2.ox.ac.uk/Bandolier/
Clinical Evidence
www.clinicalevidence.org
Cochrane Collaboration
www.cochrane.org/index.htm
Evidence-Based Practice Centers
www.ahrq.gov
McMaster Health Information Research Unit
hiru.mcmaster.ca/
Netting the Evidence
www.shef.ac.uk/~scharr/ir/netting/
NHS Centre for Reviews and Dissemination
agatha.york.ac.uk/darehp.htm
Trip Database
www.tripdatabase.com
Centre for Health Evidence (Canada)
www.cche.net/
Centre for Evidence Based Nursing
www.york.ac.uk/healthsciences/centres/evidence/cebn.htm
Academic Center for Evidence-based Nursing (ACE)
www.acestar.uthscsa.edu/
Journals:
Evidence Based Nursing
ebn.bmj.com/
Bandolier Journal
www.jr2.ox.ac.uk/Bandolier/
Effective Health Care Bulletin
www.york.ac.uk/inst/crd/ehcb.htm
BMJ Clinical Evidence
www.clinicalevidence.org/ceweb/index.jsp
Evidence Based Health Care and Public Health
www.sciencedirect.com/science/journal/17442249
International Journal of Evidence-Based Healthcare
www.blackwellpublishing.com/journal
Worldviews on Evidence-Based Nursing
www.blackwellpublishing.com/wvn
Books:
Dawes M.(2005) Evidence-Based Practice: A Primer for Health Care Professionals. 2nd ed. Edinburgh: Churchill Livingstone.
Dicenso, A, Guyatt, G, Ciliska, D. (2005) Evidence-Based Nursing: A Guide to Clinical Practice. Elesvierhealth
Levin, R, Feldman, H.R.(2006) Teaching Evidence-Based Practice in Nursing: A Guide for Academic and Clinical Settings. Springer.
Malloch, K., Porter-O’Grady, T. (2005) Introduction to Evidence-Based Practice in Nursing And Health Care. Jones and Bartlett
Pearson, A., Field, J. and Jordan, Z. (2007) Evidence-based Clinical Practice in Nursing and Healthcare: Assimilating Research, Experience and Expertise. Blackwell, Oxford.
Simmons, M, Abbott, P, McSherry, R (2001) Evidence-Informed Nursing: Guide for Clinical Nurses. Routledge
References
1. Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972
2. Sackett, D.L., Rosenberg, W.M.C., Gray, J.A.M., Haynes, R.B. and Richardson, W.S. (1996) Evidence-based medicine: what it is and what it is not. British Medical Journal 312: 71-72.
3. Sackett, D.L. and Rosenberg, W.M.C. (1995) On the need for evidence-based medicine. Health Economics 1995; 4:249-254.
4. Pearson A, Borbasi S, Fitzgerald M, Kowanko I, Walsh K. (1997) Evidence Based Nursing: An Examination of Nursing Within the International Evidence Based Health Care Practice Movement. Nursing Review:1-4
5. Lathlean, J. (1989). Research in Action: Developing the Role of the Ward Sister. London: King’s Fund Centre.
6. Cullum, N., DiCenso, A. & Ciliska, D. (1997). Evidence-based nursing: an introduction. Nursing Standard. (11)28: 30–33.
7. Manton, A. (1998). Validating what we do: a word about evidence-based practice. Journal of Emergency Nursing. (24)1: 1–2
8. Sackett, D.L., Rosenberg, W.M., Muir Gray, J.A., Haynes, R.B. & Richardson, W.S. (1996). Evidence-based medicine: what it is and what it isn’t. British Medical Journal. 312: 71–72
