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Оглавление8 Evidence‐based practice
Ben Bowers, QN
Figure 8.1 Evidence‐based practice as a continuous cycle.
Figure 8.2 Hierarchy of evidence.
Box 8.1 Useful evidence‐based resources to access.
Systematic evidence review websites
NICE clinical knowledge summaries http://cks.nice.org.uk/#?char=A
Cochrane library http://www.cochranelibrary.com
Bandolier http://www.bandolier.org.uk
University of York Centre for Reviews and Dissemination http://www.crd.york.ac.uk/CRDWeb/
Journals and books
Journals where papers are ‘peer reviewed’
Open access journals which are ‘peer reviewed’
Text books, e.g. District Nursing Manual of Clinical Procedures
Online database searches
NICE evidence search http://www.evidence.nhs.uk
OpenAthens account (giving free access to NHS staff to multiple health and nursing databases) http://www.openathens.net/nhs_users.php
Google scholar (not as comprehensive as health/nursing‐specific databases) https://scholar.google.co.uk
Royal College of Nursing library resources (free access to a range of health and nursing databases for members) https://www.rcn.org.uk/development/library_and_heritage_services
Evidence‐based guidance
NICE http://www.nice.org.uk/Guidance
Department of Health and Social Care https://www.gov.uk/government/publications
Queen’s Nursing Institute http://www.qni.org.uk/for_nurses/publications
Royal College of Nursing http://www.rcn.org.uk/development/publications
Evidence‐based mobile apps
Source: Bowers, B. (2018). Evidence‐based practice in community nursing. British Journal of Community Nursing 23(7): 336–337.
There is an expectation that nurses use the most up‐to‐date and relevant evidence to inform decisions about their patients’ care. Scientific and well‐reasoned decisions improve patient care and make the best use of limited resources, and the application of evidence‐based practice has always been a major driving force in district nursing. However, what is valued as evidence has changed to reflect societal and healthcare priorities. We currently prioritise empirical evidence demonstrating an intervention’s clinical effectiveness (particularly its impact on patient outcomes); cost effectiveness; patient acceptability; safety, and acceptability to healthcare professionals (Figure 8.1). However, it is rare that the available evidence examines and demonstrates all these values.
Applying evidence in practice consists of five key consecutive steps:
1 Recognising there is a need for new information to answer a particular clinical question.
2 Searching and selecting a suitable range of evidence to answer the question.
3 Critically appraising this evidence.
4 Using the most applicable and best evidence, together with patient preferences, to inform clinical practice.
5 Evaluating the effectiveness of the intervention. This often leads to new clinical questions being formed and the process starts again.
Limitations in practice
Clinical decisions are not always based on the most up‐to‐date and valid available evidence. In a study of 82 primary care nurses, participants recalled using 67 different sources of information to inform their clinical decision‐making (Thompson et al., 2005). However, participants were observed seeking information as a result of just 23% of their consultations. This almost always involved obtaining advice from colleagues.
A perception of lack of time to access information, and lack of knowledge in how to access it are key challenges in applying evidence‐based practice (Thompson et al., 2005; Hanafin et al., 2014). For district nurses needing to make prompt clinical decisions with patients in the home, limited real‐time access to evidence resources can be a substantial barrier to delivering evidence‐based care. Phoning experienced peers or sourcing local policies and guidance is relatively quick. Conversely, these approaches narrow knowledge about what constitutes good evidence to certain perspectives and assumes that local policies and guidance are up‐to‐date.
Accessing resources
District nurses need answers to practical treatment decisions. Knowing where to access a robust range of evidence‐based resources in community nursing is crucial. There is an array of useful resources including printed journals, books, online databases and evidence reviews (Box 8.1). In reality, the range and choice of evidence can be confusing in itself. Mobile phone apps offering easy‐to‐access and up‐to‐date evidence‐based guidance are likely to play an increasingly important role in community practice.
For now, easily consumable and frequently updated online resources such as NICE Clinical Knowledge Summaries, NICE Pathways and Bandolier evidence reviews offer good starting points for gathering comprehensive evidence. The Cochrane database and University of York Centre for Reviews and Dissemination database provide systematic evidence‐based reviews on key subjects. Well‐written and informative peer‐reviewed articles can prove a good way to identify key evidence on a subject.
The nature of under‐identified community care clinical situations means it is often necessary to undertake literature searches (e.g. through CINAHL or BNI databases) and then critically review individual papers to inform evidence‐based decision making. These can be accessed online through the likes of OpenAthens and Royal College of Nursing (RCN) membership library services. It is also feasible to use Google Scholar, though undertaking a search on this alone is not recommended, as it will give limited results and article access. Local NHS librarians are experts in undertaking literature searches (a specialist area in itself) and can provide invaluable help and guidance. NHS libraries often offer to help design and undertake literature searches, making the process much more efficient.
What constitutes good evidence?
Contemporary evidence‐based reviews have an established hierarchy, valuing studies with objective reliability (Figure 8.2). Randomised controlled trials or evidence from large‐scale clinical trials are prized well above descriptive studies, qualitative research or expert opinion. Yet in district nursing care, there is a scarcity of randomised controlled trial data for a multitude of reasons. These include the difficulties inherent in controlling variables in patients’ own homes, limited research interest and funding, and the prevailing focus on studying the impact of interventions in hospital environments.
The evidence base is frequently drawn from a mixture of qualitative and small‐scale quantitative studies, expert opinion and translating the results of hospital‐based studies, each providing partial insights into what constitutes best practice. Using a multitude of different evidence sources has benefits for patient care because it does not overvalue the importance of randomised controlled trials (Mantzoukas, 2008). Although useful, evidence from randomised controlled trials does not lend itself readily to providing care in patients’ homes where variable psychosocial factors play a crucial role. Well‐designed qualitative studies can provide meaningful insights into patient preferences and complex processes of care.
Evidence‐based practice must centre around patient preferences, desires and clinical judgements in individual situations (Jacobs et al., 2012). This is where communication and therapeutic relationship‐building skills (the art of nursing) interplay profoundly with knowing what clinical intervention will be most effective (the science of nursing). In practice there are often several ways to undertake care, each with their advantages and limitations. Providing the patient is making an informed choice, and where care is evidence‐based and regularly evaluated in partnership with the patient, care is likely to be clinically effective.
