VOL: 103, ISSUE: 17, PAGE NO: 32-33
Jane Fitzpatrick, DEd, MSc, PGCEA, RGN, RM, RHV
Senior lecturer in the faculty of health and social care, University of the West of England.
This is the first of three articles that explore what is involved in developing effective evidence-based practice (EBP) processes. The article discusses the development of EBP, its purpose in healthcare delivery and the development of skills to identify topics of interest. The development of suitable questions about practice is also explored. The article examines in detail how to conduct a search and how to refine it, and also looks briefly at the various types of evidence that may be found. These aspects are essential preparation for developing skills for critical appraisal of evidence, examined in parts two and three of this series.
The three articles in this series aim to facilitate understanding of the following:
- Effective question identification;
- Search strategies;
- Selecting and retrieving credible sources of evidence;
- Skills required for critical evaluation of evidence sources;
- Application of research evidence to nursing practice.
In order to be credible, healthcare professionals must demonstrate effective integration of evidence, including research findings, into their clinical decision-making. In the UK, political agendas support the move towards EBP in their pursuit of improvements in the quality of healthcare. There is an expectation that care should be patient-centred and clinically effective (Department of Health, 2000). The introduction of clinical governance, designed to ensure efficient and effective healthcare, requires practitioners to demonstrate that they are using evidence-based practice in supporting service developments (DHSS, 1999). This demands that nurses base their practice on the best available evidence (NMC, 2004).
In order to develop effective strategies in implementing EBP, nurses must examine what EBP is and is not. They then need to develop a range of skills to make informed decisions about the reliability and validity of sources of evidence that they wish to integrate into their clinical practice.
Evidence-based practice has become a core requirement of contemporary nursing practice. The three articles in this series seek to explore:
- What evidence-based practice is;
- The purpose of evidence-based practice in healthcare delivery;
- How nurses can develop skills in identifying topics of interest and/or areas of concern;
- How to retrieve and discriminate between sources of evidence effectively;
- How nurses can critically evaluate source material;
- How to draw on a range of evidence to present a case to support the development of nursing practice.
The first part discusses the development of evidence-based practice and considers the skills required to develop effective EBP processes. It will explore the questions nurses might ask using the EBP process and the search strategy they might use to find source material.
The second part will review how to critically evaluate primary sources of evidence and draw the research together to make a case to inform developments in nursing practice.
The third part in this series will address in some detail hierarchies of evidence and the process of critically evaluating systematic reviews.
What is evidence-based practice?
Evidence-based practice has a range of meanings. While some authors emphasise the role of research evidence in clinical decision-making, others have a wider perspective that encompasses the views of patients and clinicians informing clinical decisions.
Sackett et al (1996) described evidence-based medicine as: ‘The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.’
In contrast, Appleby et al (1995) stressed the need to move away from clinical practice based on ritual and unsubstantiated opinion towards research as a source of evidence on which to base clinical decisions. On reflection on both views, it is apparent that it is important that nurses:
- Make considered and informed judgements about the range of evidence available; and
- Include careful consideration of experience and expert opinion in making clinical decisions.
Trinder and Reynolds (2000) argued that developments in the accessibility to a range of information sources to inform nursing practice surfaced at a time when life expectancy was increasing in the developed world. This meant that healthcare professionals had to respond to the needs of society in providing well-informed healthcare delivery. As the public have had more access to information, they have developed higher expectations of what they require from healthcare professionals (DH, 2003). As a result, nurses are increasingly challenged to justify their actions. This requires them to demonstrate that their clinical decisions are based on scientific evidence that is efficient and effective (Fig 1).
What is the purpose of evidence-based practice?
The aim of evidence-based practice is to deliver high-quality care to an individual patient or patient. To achieve this, nurses need to be able to critically evaluate ideas and experiences and apply what they have learnt to inform nursing practice.
Straus et al (2005) argued EBP is more than applying the best evidence. They stated that EBP requires healthcare practitioners to use it together with a range of clinical skills including assessment and communication. They also suggested that healthcare professionals need to consider the dynamic interaction of belief and value systems affecting the patient’s experiences of healthcare.
In contemporary healthcare settings, evidence is continually changing. As new research and technologies emerge, old ideas and opinions are subject to scrutiny. This means that evidence is constantly developing. Nurses must therefore keep up with new perspectives on care. They must also learn to adopt a process of evidence-based practice that is open to scrutiny by their peers and the public. By being open and transparent, clinical decisions can be justified and accountability demonstrated, as required by the NMC (NMC, 2004).
Box 1 illustrates the sources of evidence that nurses can draw on to inform clinical decision-making.
Box 1. Sources of evidence
Sources of evidence
Evidence can be sourced from experts and literature. The latter includes original research and compilations of research evidence used to analyse and inform choices in clinical decision-making. This is often categorised as a hierarchy of evidence. This includes:
i. Primary sources of evidence: These draw on original research findings. These sources will include reports and articles about research that has been gathered from research subjects or participants.
ii. Secondary sources of evidence: These draw on a range of sources informing the topic of concern including:
iii. Expert opinion.
The implications of hierarchies of evidence for identifying and evaluating relevant sources of evidence will be discussed in the third of these three articles.
Development of skills to identify topics of interest
In developing an evidence-based practice approach to care, nurses must develop a questioning and critical perspective to practice. This requires them to:
- Be competent in their field and have knowledge and skills to support decision-making;
- Be observant and able to identify the needs of the patient;
- Have a range of communication skills which enable them to engage with the patient and other professional groups;
- Have a questioning approach to practice and also be receptive to questions from others;
- Develop skills to source evidence and critically evaluate it in order to consider its efficacy in the practice context.
Developing the question
Questions about practice may arise from a number of sources. This could be from individuals such as patients or colleagues. They could also stem from an audit process or a management review. Questions may arise from nurses¢ evaluation of traditional or new practice or from their reading of the literature.
Questions may arise from any aspect of knowledge affecting the patient’s experience. Straus et al (2005) argued that these comprise background questions that relate to physiology, pathophysiology, epidemiology and disease or condition progression. Most EBP questions focus on aspects of care. These relate to assessment, screening, clinical diagnosis, prognosis, management options and alternative outcomes. It is crucial to ask the correct question at this point. Nurses must also take account of a range of stakeholders’ views that will reflect differing beliefs and values about care. The focus must always be on the interests of the patient (Fitzpatrick, 2002). In making clinical decisions, practitioners must therefore extrapolate evidence from a range of sources that has the potential to affect the patient’s experience.
Searching for evidence is time-consuming and requires a substantial amount of energy. It is important to become efficient and effective in management of EBP. As Cluett (2002) observed, as a novice this may involve focusing on one crucial question that is important or urgent. As nurses develop skills in managing the EBP process, they may deal with several questions simultaneously. In some clinical areas, members of the team develop a collaborative approach to evidence-based practice. This involves different members of the team searching for material on the issue concurrently.
In developing an effective EBP process, the first step is to ask a question that is answerable. It must be specific and focused. Cluett (2002) suggested that a good question comprises four components. These are:
- A clearly identified patient group or condition;
- An intervention or issue (diagnostic test, care option);
- A baseline or comparison point;
- An outcome or result.
Cluett (2002) suggested using the acronym PICO
P = patient or target population;
I = issue or intervention;
C = comparison;
O = outcome.
Box 2 gives examples of EBP questions.
Box2. Worked examples of EBP questions
Topic: Patient education and pain management following surgery
Question 1: Does patient education affect the patient’s understanding of their choices in pain relief following surgery?
P = surgical patients offered patient education about pain relief;
I = targeted patient education about choices in pain relief;
C = no specific education about choices in pain relief;
O = knowledge base.
Question 2: Does patient education reduce the patient’s requirement for analgesia post surgery?
P = patients scheduled for surgical procedures;
I = patient receives targeted patient education about analgesia available post surgery;
C = standard information given to the patient;
O = comparison between the levels of analgesia required by:
a. One group of patients who receive standard preoperative information;
b. A second group of patients who receive targeted patient information about analgesia available post surgery.
On most occasions, nurses will not be in a position to conduct a direct evaluation or research in practice. They will be looking for information about the issue from published sources.
Searching for the evidence
Once the question has been refined, the next step is to find sources that will provide relevant evidence. Evidence is located in a range of sources. These include: people with an interest in EBP and with specialist expertise; literature (including books and journals); the internet; and specialist databases.
Finding the evidence is crucial in any research process and in developing clinical guidelines. It requires nurses to develop a range of skills. These include:
- Questioning attitude;
- Focusing on and refining their area of interest;
- Networking to find support in the EBP process;
- Using electronic sources such as search engines and databases efficiently and effectively.
Many people can assist in refining the search topic and locating relevant material. Librarians, researchers, educationalists, specialist nurses and colleagues who have undertaken EBP are often willing to offer advice and help with getting started. Online networks are also a valuable source of information. For example, the Nursing Times online discussion format www.nursingtimes.net and special interest groups, such as those located at the Royal College of Nursing, are sources of ideas and support.
Key to developing an effective search strategy is asking the right question. Polit et al (2001) argued that it is crucial to adopt a competent search strategy to develop an effective EBP approach. Locating the evidence is often time consuming. It means nurses have to be strategic in:
- Locating sources, including electronic sources such as databases;
- Identifying search terms;
- Combining relevant topics;
- Selecting relevant material.
Locating electronic sources
There is a range of electronic resources for locating relevant evidence. These include electronic databases and the internet. The internet provides a credible range of electronic publication and original research (Fitzpatrick, 2004; Glassman, 2004). Internet gateways such as Google, AltaVista, Yahoo and so on are a good starting point. From here nurses can access the Department of Health, RCN, NMC and NICE websites. Some search engines such as the clinical archive on the Nursing Times website provide a free service where practitioners can develop a more focused search for reliable clinical articles.
Sites such as the National Library for Health (NLH) provide a range of sources on health issues, some of which are freely available (www.library.nhs.uk). The Cochrane library database (www.cochrane.org) holds a range of systematic reviews of research undertaken on topics relevant to clinical practice.
NHS staff and students at a UK university will have access to a range of library resources. This will include access to hard copy books and journals. NHS practitioners and students will also have access to extensive electronic resources via databases such as OVID, EBSCO or Dialogue DataStar. These require an ATHENS password, which can be obtained from the library services. OVID, EBSCO and Dialogue DataStar have extensive selections of databases. These include the British Nursing Index (BNI), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline. These databases include a range of evidence available about medical and health issues. The BNI and CINAHL focus on issues particularly pertinent to nursing.
When retrieving material, nurses may be overwhelmed by the volume of material they locate. Databases such as BNI and CINAHL allow restriction of the search field to nursing-related topics. CINAHL is an American database which allows the use of additional criteria to restrict the search to research, English, full text and the year of publication.
Identifying search terms
In commencing a search, choosing the correct terminology is crucial. Identifying search terms involves choosing keywords. This often requires lateral thinking and an awareness of the terminology that reflects the topic of interest. For example, if you are interested in pressure ulcer prevention you may find further relevant evidence by using the terms ‘wound management’ or ‘tissue viability’.
James Boole is credited with the development of the logical sequencing of searching on library catalogues. The words ‘and’ and ‘or’ are inserted between the key words. ‘And’ reduces the number of hits since this requires both of the search terms to be present. Inserting ‘or’ means any article with either term or both will be located. For example, ‘wound management¢ would locate every reference with ‘wound’ in the title or abstract and every article mentioning ‘management’, which provides an enormous number of hits. Using ‘wound’ AND ‘management’ would only retrieve those with both terms. In contrast, using OR would increase the number of hits.
In using a database a truncation can also be used. This is when an asterisk (*) or sometimes a dollar sign ($) is used to facilitate a search for plurals and other endings. For example, nurs* would include nurse, nurses and nursing.
The BNI database allows practitioners to conduct several searches and then combine them to narrow the focus. For example, searching for ‘wounds’, ‘tissue viability’ and ‘pressure ulcer’ allows nurses to find articles with all three terms.
Imagine that you are working on a ward. You are looking after a patient requiring ongoing support following a course of chemotherapy when he is discharged from hospital. You know that he is to be discharged to the care of the district nurse. You have two minutes to spare and decide to do a quick search.
You enter the BNI and CINAHLusing databases such asEBSCO, OVID or DataStar
1. Type in ‘cancer’ -55,055 hits - too many to read;
2. Type in ‘discharge’ -15,896 hits;
3. Combine ‘cancer and discharge’ - 414 combined, still too many to scan;
4. Type in ‘district nurse’ - 375 hits;
5. Now combine sets 3 and 4 and also use the drop down menus to limit your search to English articles only, research and years 2001-2007 to obtain recent articles. Two articles which are:
CINAHL - Cumulative Index to Nursing & Allied Health Literature: Luker, K.A. et al (2003) The role of district nursing: perspectives of cancer patients and their carers before and after hospital discharge.[Journal Article, Research, Tables/Charts]European Journal ofCancer Care; 12: 4, 308-16. (38 ref) and CINAHL - Cumulative Index to Nursing & Allied Health Literature:Wilson, K. et al (2002) Patient and carer needs following a cancer-related hospital admission: the importance of referral to the district nursing service.[Journal Article, Forms, Research]Journal of Advanced Nursing; 38: 3, 245-53. (31 ref).
6. You can scan the abstract briefly and then save the search or e-mail it to yourself to find the articles again.
7. You could also download the article in PDF format if the full text is available. This enables you to read it again as it was originally shown on the screen.
Searching methodically should produce a manageable list of references. The number you need to find will depend on the purpose for the search, for example if the articles are to be used to develop a care plan for an individual patient or a clinical guideline, or for an assignment.
To locate documents such as clinical guidelines, national service frameworks or systematic reviews a similar search strategy could be used, but they would be located in different databases.
Clinical guidelines and national service frameworks
Clinical guidelines and national service frameworks are developed by teams who are specialists in their field. For example, the RCN guidelines on the management of venous leg ulcers have been compiled by a range of experts from backgrounds in research and practice including nurses, tissue viability nurses, doctors, pharmacists and physiotherapists (RCN, 2006). These sources of evidence may be located on the websites of national organisations such as the Department of Health or Royal College of Nursing. NHS trusts may have incorporated these into local policies, protocols or procedures. These are located in local trust websites or, alternatively, nurses could use the NLH guidelines finder.
Systematic reviews are compilations of a range of primary research that meets a range of specific criteria. The review outlines the aspects that match the criteria and the authors draw together the strands of the arguments from a range of primary research papers to develop an opinion about the relevance to clinical practice.
Many NHS trusts have consultant and specialist nurses such as diabetes nurse specialists and mental health consultant nurses. These nurses are appointed for their specialist knowledge and leadership skills. Many are accessible via local NHS trust networks. Specialist and consultant nurses also publish articles in journals such as Nursing Times that are based on research evidence and offer advice about the implications for nursing practice.
This first article in a series of three has introduced the processes involved in developing an evidence-based approach to nursing practice. It has offered an overview of the history of EBP and introduced the idea of identifying a problem or issue readers wish to explore in depth. It has encouraged nurses to work through the process of identifying keywords and combining these to identify relevant sources of evidence. In addition, the article has suggested ways of deciding on sources of evidence that are relevant for practice and ways to save these so they can be retrieved later. The development of these skills will enable preparation for the next stage of critiquing sources and considering the implications they might have for nursing practice.
The development of the skills outlined in these articles is essential for those wishing to develop an evidence-based culture in the workplace. They will enable nurses to consider what issues they can address and how to conduct their enquiry by drawing on credible resources.
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Bandolier: Monthly e-journal that summarises evidence- based practice. www.jr2.ox.ac.uk/bandolier/
EBM toolkit: Canadian-based collection of resources to support practice of evidence-based medicine. Contains appraisal checklists, methodological filters and other ¢user guide¢ resources. www.med.ualberta.ca/ebm/ebm.htm
National Library for Health (NLH): Covers research, systematic reviews and clinical guidelines.
NICE (National Institute for Health and Clinical Excellence) produces guidelines. www.nice.org.uk
RCN site www.rcn.org.uk
Research and Development Co-ordinating Centre: RCN site. www.man.ac.uk/rcn