Nursing

Authors

Alba DiCenso, RN, PhD
Donna Ciliska, RN, PhD
Susan Marks, BA, BEd
Ann McKibbon, MLS
Nicky Cullum, RN, PhD
Carl Thompson, RN, PhD

Contact

Alba DiCenso
McMaster University
Faculty of Health Sciences
1200 Main Street West, Rm. 3N25B
Hamilton, Ontario, Canada
L8N 3Z5

Phone: 905-525-9140 ext 22277
Fax: 905-524-5199
Email: dicensoa@mcmaster.ca

Introduction to evidence-based nursing

“No man, not even a doctor, ever gives any other definition of what a nurse should be than this-‘devoted and obedient’. This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.”

Florence Nightingale, 18601

Florence Nightingale would probably not recognise the nurse of today. As we move into the next millennium, we expect nurses to care with their hearts and minds; identify patients’ actual and potential health problems; and develop research-based strategies to prevent, ameliorate, and comfort. We increasingly expect them to undertake work historically done by doctors; we also expect them to be empathic communicators who are highly educated, critical thinkers, and abreast of all the important research findings.

Research makes a difference. In a meta-analysis designed to determine the contribution of research-based practice to patient outcomes, Heater and colleagues reported that patients who receive research-based nursing care make “sizeable gains” in behavioural knowledge, and physiological and psychosocial outcomes compared with those receiving routine nursing care.2

The process of incorporating good quality research findings into nursing practice is, however, not straightforward. Bostrom and Suter found that only 21% of 1200 practising nurses had implemented a new research finding in the previous six months.3 Luker and Kenrick used qualitative techniques in an exploratory study of community nurse decision-making in the United Kingdom and determined that the nurses had an awareness of research but did not perceive it as informing their practice.4 This work also supported previous reports that nurses have difficulty in accessing and appraising published research, either because they do not have access to journals and libraries, or because they have not been taught how to find and appraise research.5, 6, 7

Estabrooks asked staff nurses about the frequency with which they used various sources of knowledge. Most frequently used knowledge sources were found to be experiential, nursing school (even though the average length of time since completing their basic nursing education program was 18 years), workplace sources, physician sources, intuitions, and what has worked for years. Literature (whether in textbook or journal form) was rated in the bottom 5 for frequency. She also asked them to identify the one most common source from which they learned about research findings. While 38.7% identified nursing journals, additional analyses revealed that the primary journals the nurses were reading were not research journals, but rather trade magazines published by nursing professional organisations.8

More than 400 nursing journals are listed in Ulrich’s International Periodicals Directory,9 many of which publish original research, and in a range of languages. Nurses working individually cannot hope to find and read even the highest quality research published each year, particularly when much of the research relevant to nursing is published in non-nursing journals.

When clinical nurses have been taught how to identify and appraise research critically they have responded with enthusiasm, but they have had difficulty in learning and applying these skills in practice, partly because of shifting patterns and workloads.10 Nurses who were interviewed in a qualitative study of their information needs said that they needed reference sources to be accurate and concise. This is consistent with a survey of midwives working in the northwest of England, who reported great difficulty in assessing the quality of journal articles. These midwives asked for research reports to be more concise, free from jargon, and self-explanatory.11

Research utilisation has been defined as the use of research findings in any or all aspects of one’s work as a registered nurse or at its simplest, the use of research.8 More recently, the term ‘evidence-based nursing’ (EBN) has emerged. This term has evolved from the initial work done in ‘evidence-based medicine’ defined 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.12 If we use this same definition for ‘evidence-based nursing’, its meaning is broader than that of ‘research utilisation’. The practice of evidence-based nursing involves the following steps: formulation of an answerable question to address a specific patient problem or situation;13 systematic searching for the research evidence that could be used to answer the question;14, 15 appraisal of the validity, relevance and applicability of the research evidence; integration of the research evidence with other information that might influence the management of the patient’s problems: clinical expertise, patient preference for alternative forms of care, and available resources;16 implementation of the evidence-based practice decision; and finally, evaluation of the outcome of the decision.

Resources to facilitate evidence-based nursing

During the last decade, major initiatives have been introduced to help clinicians become evidence-based practitioners. The following is a brief description of some of these efforts:

Evidence-Based Journals

Rather than publishing original research, the objective of these journals is to summarise those studies that are valid and clinically useful. Currently, these journals consist of ACP Journal Club, Evidence-Based Medicine, Evidence-Based Cardiovascular Medicine, Evidence-Based Health Policy and Management, Evidence-Based Mental Health, and Evidence-Based Nursing. While they are all similar in format, we will provide a brief description of Evidence-Based Nursing. The specific purposes of this journal are: to identify, using predefined criteria, the best quantitative and qualitative original and review articles on the meaning, cause, course, assessment, prevention, treatment, or economics of health problems managed by nurses and on quality assurance; to summarise this literature in the form of “structured abstracts” that describe the question, methods, results, and evidence-based conclusions of studies in a reproducible and accurate fashion; and to provide brief commentaries written by practising nurses on the context of each article, its methods, and clinical applications that its findings warrant.

The authors of this module are all involved in the production of Evidence-Based Nursing. Alba DiCenso, Nicky Cullum, and Donna Ciliska are co-editors; Susan Marks and Ann McKibbon are research associates and Carl Thomson is an associate editor. In addition to the abstracts, Evidence-Based Nursing includes an “EBN Notebook” in which we publish short papers about the research process. We have included copies of some of these published to date in this module. Topics include: asking answerable questions; searching for the best evidence, and identifying the best research design to fit the question (Part 1: quantitative designs and Part 2: qualitative designs).

Systematic reviews

We are now at the point in health care research where important questions have often been addressed by more than one study. A systematic review is a method of summarising the findings of all methodologically sound studies addressing the same research question. In a systematic review, eligible research studies are viewed as a population to be systematically sampled and surveyed. Individual study characteristics and results are then abstracted, quantified, coded, and assembled into a database that, if appropriate, is statistically analysed much like other quantitative data. The statistical combination of the results of more than one study, or meta-analysis, effectively increases the sample size and results in a more precise estimate of effect than can be obtained from any of the individual studies used in the meta-analysis.

The Cochrane Collaboration is an international organisation that aims to help people make informed decisions about health by preparing, maintaining, and ensuring the accessibility of rigorous, systematic, and up-to-date reviews (including meta-analyses where appropriate) of the benefits and risks of health care interventions.17 The Cochrane Library is the product of the Collaboration’s work and includes reports and protocols of over 1000 systematic reviews produced within the Collaboration, abstracts of over 1800 reviews summarised and critically appraised by the Centre for Reviews and Dissemination at the University of York, UK, and citations for over 200,000 randomized controlled trials.

Centres for Evidence-Based Nursing

In the past few years, a number of countries, including the UK, Canada, Germany, New Zealand, Australia and others, have created Centres for Evidence-Based Nursing. While the specific goals of these centres vary, most seek to educate nurses through workshops or through formal courses to be evidence-based nurses in practice, education and research; to conduct original research and systematic reviews; and to design and evaluate strategies for disseminating research findings to nurses.

Evidence-based practice guidelines

Clinical practice guidelines are “systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances”18 Guidelines can be used to reduce inappropriate variations in practice and to promote the delivery of high quality, evidence-based health care. Guidelines should be based on the best available research evidence, should be developed with representation from as many interested parties as possible, should be tested by professionals uninvolved in their development and in the healthcare setting for feasibility, and should be reviewed regularly and modified to incorporate new knowledge.19

These are exciting times in nursing. With the increased emphasis on graduate education for nurses, many important research questions related to the practice of nursing are being addressed using rigorous research methods. There is a strong motivation among nurses to apply the findings of research to their practice through evidence-based nursing. To complement these developments, a variety of resources have emerged to help nurses become evidence-based practitioners.

Other resources for evidence-based nursing

We’ve enclosed 2 notes that have appeared in Evidence-Based Nursing and also provide a list of some others that you may find useful.

  • DiCenso A, Cullum N, Ciliska D. Implementing evidence-based nursing: some misconceptions [editorial]. Evidence-Based Nursing 1998 Apr;1:38-40.
  • Anne Mulhall, Nursing, research, and the evidence [editorial]. Evidence-Based Nursing 1998 Jan;1:4-6.
  • Flemming K. Asking answerable questions [editorial]. Evidence-Based Nursing 1998 Apr;1:36-7.
  • McKibbon KA, Marks S. Searching for the best evidence. Part 1: where to look [editorial]. Evidence-Based Nursing 1998 Jul;1:68-70.
  • McKibbon KA, Marks S. Searching for the best evidence. Part 2: searching CINAHL and Medline [editorial] Evidence-Based Nursing 1998 Oct;1:105-7.
  • Roberts J, DiCenso A. Identifying the best research design to fit the question. Part 1: quantitative designs [editorial]. Evidence-Based Nursing 1999 Jan;2:4-6.
  • Ploeg J. Identifying the best research design to fit the question. Part 2: qualitative designs [editorial]. Evidence-Based Nursing 1999 Apr;2:36-7.

DiCenso A, Cullum N, Ciliska D. Implementing evidence-based nursing: some misconceptions [editorial]. Evidence-Based Nursing 1998 Apr;1:38-40.

During the brief time that we have been engaged in developing Evidence-Based Nursing we have been fascinated by the reactions of friends, professional colleagues, and the media. The overwhelming majority of responses to the concepts of evidence-based nursing and the creation of this journal have been positive. But there have also been misgivings, sometimes generated by misunderstandings. This editorial addresses the following criticisms which we have encountered in person and in print: (1) evidence-based practice isn’t new: it’s what we have been doing for years, (2) evidence-based nursing leads to ‘cookbook’ nursing and a disregard for individualised patient care and, (3) there is an over-emphasis on randomised controlled trials and systematic reviews in evidence-based health care. We intend the paper to generate, rather than close the debate!

Evidence-based practice isn’t new; it’s what we have been doing for years

The plea that ‘each nurse must care enough about her own practice to want to make sure it is based on the best possible information’ is not new. It was written more than 15 years ago. In the same article, Hunt noted that the phrase ‘nursing should become a research-based profession’ had already become a cliche!20 Over 20 years ago, Gortner et al lamented the lack of research evidence in many areas of nursing practice,21 and the year after, Roper spoke of nursing performing ‘far too many of its tasks on a traditional base and not within a framework of scientific verifications’. 22

While the recognition of the importance of evidence-based practice is not new, much of the past 20 years has focused on the identification of the barriers to evidence-based practice and the consideration of strategies to overcome these barriers. These barriers include time constraints, limited access to the literature, lack of training in information seeking and critical appraisal skills, a professional ideology that emphasises practical rather than intellectual knowledge, and a work environment that does not encourage information seeking. 23

We have learned that it is not sufficient to give nursing students a few lectures on the process of doing research and then expect them to use that knowledge throughout their careers in an ongoing process of gathering and interpreting research evidence and implementing findings. Nurses and midwives have been telling researchers for years that they want to deliver research based care, but that they find it difficult to access the research. In a study of health agencies in Ontario, Canada, Mitchell et al found that only 35% of small hospitals (< 250) beds had nursing research journals in their libraries; 38% of health agencies based change in nursing practice on the research process; 15% implemented research utilisation programmes for staff nurses; and 97% wanted assistance in teaching their nursing staff about research utilisation. 24

Although we have advocated evidence-based nursing for many years, we have struggled with how to make it happen. This struggle is not unique to nursing but common to all health professions, including medicine. Challenged to address this important issue, an international commitment to evidence-based health care has resulted in a number of initiatives to improve access to research findings such as the Cochrane Collaboration, the Evidence-Based Medicine Working Group, critical appraisal skills teaching programmes, centres for evidence-based practice, research utilisation conferences, and evidence-based journals.

Evidence-based nursing leads to ‘cookbook’ nursing and a disregard for individualised patient care

In practising evidence-based nursing, a nurse has to decide whether the evidence is relevant for the particular patient. The incorporation of clinical expertise should be balanced with the risks and benefits of alternative treatments for each patient and should take into account the patient’s unique clinical circumstances including comorbid conditions and preferences. Those who judge evidence-based nursing as cookbook nursing are ignoring this important component.

The figure shows a simple model for clinical decisions with 4 components that might influence the management of the patient’s problems: clinical expertise, patient preference for alternative forms of care, clinical research evidence, and available resources. It is important to note that clinical expertise and patient preference may override the other components of the model for a given decision. For example, clinical expertise must prevail if the nurse decides that the patient is too frail for a specific intervention that is otherwise ‘best’ for his condition, and the patient’s preference will dominate when he declines a treatment that clinical circumstances and research evidence indicate is best for his condition. All of these factors, however, have to be considered in the light of the fact that resources for health care are limited. Most decisions in health care have resource implications; there are likely to be occasions when the potential benefit of an intervention is judged to be outweighed by the potential costs. While individual clinical nurses may not make this judgment, they need to be aware of this important dimension.

In professional training and beyond, we learn the basic mechanisms of disease and pathophysiology and acquire skills in assessment, planning, intervention, and evaluation. We refine these skills by accumulating clinical expertise through observing the correlates and consequences of our actions in dealing with many patients. Many elements of clinical assessment and management require the advanced knowledge that nursing education provides and the expertise that comes with experience.

Evidence from research can help to perfect the expertise but cannot do the examination or sort through the myriad of quantitative and qualitative information that nurses collect during the clinical encounter. Clinical expertise is the crucial element that separates evidence-based nursing from cookbook nursing and the mindless application of rules and guidelines.

Patients have always exercised their preferences for care by choosing alternative treatments, refusing treatment, preparing advance directives (‘living wills’), and seeking second opinions. Today’s patients have greater access to clinical information than ever before, and some become more knowledgeable about their conditions than their care providers; particularly those with chronic conditions. Although the patient’s role in clinical decisions is usually not formalised and is sometimes ignored by care providers, it is an important component of most clinical decisions. Clearly, the best possible scenario is one in which the patient is able to play a full part in making decisions about his or her own health care, having been given an accurate assessment of the current state of knowledge.

Imagine the older person in hospital after a stroke. The nurse caring for this person uses highly developed communication skills, intuition, and clinical experience to get to know the patient and his family. The nurse begins to understand how the patient feels about what is happening to him, and what his goals for rehabilitation might be. As she establishes this rapport, she is in a position to determine if the patient is depressed, anxious, and/or eager to learn about his condition. The relationship that a nurse builds with her patients is important to patients, as shown by Kralik et al in this issue (p63). However, these relationships are enhanced if the nurse is also able to ensure that the caring practices and interventions she uses are safe and effective. Knowing which exercises are effective for patients with hemiplegia, knowing how to prevent their pressure sores, and how to teach them to transfer from a bed to a chair will contribute to high quality patient care.

There is an over-emphasis on randomised controlled trials and systematic reviews in evidence-based health care

Evidence-based health care is about applying the best available evidence to a specific clinical question. The randomised controlled trial (RCT) is the most appropriate design for evaluating the effectiveness of a nursing intervention, for example the effectiveness of nicotine inhalers in helping patients quit smoking (see Hjalmarson et al in this issue, p45), or the effectiveness of different pressure relieving aids in preventing pressure sores (Vyhlidal et al in this issue, p51)25. The reason that the RCT is the most appropriate design is that through random assignment of patients to comparison groups, known and unknown confounders are distributed evenly between the groups ensuring that any difference in outcome is due to the intervention.

In a 1997 issue of the British Journal of Nursing, White stated that: Perhaps the most obviously flawed assumption is that examining research using RCTs is the best way to evaluate the effectiveness of interventions and a better basis for clinical decision-making than the clinical experience of the practitioner.26

We strongly disagree with White’s assertion. History has shown numerous examples of healthcare interventions which, on a patient by patient basis, might appear to be beneficial, but when evaluated using randomised trials have been shown to be of doubtful value, or even harmful. Examples include the use of cover gowns by nurses when caring for normal newborns in the nursery,27 and shaving before surgery.28 Few of us would want to begin a drug regimen that has not been proved to be safe and effective in a RCT.

More recently, there has been an emphasis on systematic overviews of the research literature. In an overview, eligible research studies are viewed as a population to be systematically sampled and surveyed. Individual study characteristics and results are then abstracted, quantified, coded, and assembled into a database that, if appropriate, is statistically analysed much like other quantitative data. The statistical combination of the results of more than one study, or meta-analysis, effectively increases the sample size and results in a more precise estimate of treatment effect than can be obtained from any of the individual studies used in the meta-analysis. There are 3 overviews in this issue of Evidence-Based Nursing which address the effectiveness of distance medicine technology (Balas et al, p58), compression treatment for venous leg ulcers (Fletcher et al, p50), and psychosocial interventions for children with chronic illnesses (Bauman et al, p43). Through rigorous systematic overviews, nurses are provided with a summary of all the methodologically sound studies related to a specific topic. In most cases, this is much more powerful than the results of any one single study.

Just as randomised trials and systematic overviews are the best designs for evaluating nursing interventions, qualitative studies are the best designs to better understand patients’ experiences, attitudes, and beliefs. Results of intervention studies may inform nurses about the optimal effects of an intervention in a sample of patients, but they do not explore and explain the barriers to patient compliance with the intervention, nor how the treatment affects the patient’s everyday life, the meaning of illness for the patient, or the adjustment required to accommodate a lifelong treatment regimen. Rigorous qualitative research is based on explicit purposive strategies, in depth analysis of data, and a commitment to examining alternative explanations. In this issue of Evidence-Based Nursing, qualitative studies examine parents’ experiences with a critically ill child in the paediatric intensive care unit (Mu and Tomlinson, p60); patients’ experiences of nursing (Kralik et al, p63); experiences of long term oxygen therapy (Ring and Danielson, p64); women’s role as carers (Wuest, p62); and patterns of violence experienced by homeless battered women (Clarke, p61).

Through Evidence-Based Nursing we hope to convey that good evidence does involve more than RCTs and systematic overviews. Each research design has its purpose, its strengths, and its limitations. The key is ensuring that the right research design is used to answer the question posed.

The ultimate goal of nursing is to deliver to patients the best available care. Despite numerous barriers to using research there continues to be strong motivation among nurses to learn the skills required to practice evidence-based nursing. The application of research findings to practice goes hand in hand with clinical expertise and with patient preferences and values. The types of study designs that form the basis for evidence-based practice will vary depending on the nature of the question asked.

We have attempted to identify and address common misconceptions about evidence-based nursing. Readers are encouraged to comment and to let us know if there are additional impediments to this relatively new initiative in nursing.

Anne Mulhall, Nursing, research, and the evidence [editorial]. Evidence-Based Nursing 1998 Jan;1:4-6.

Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?

Research has been used to legitimise nursing as a profession, education has been radically reformed to reflect a research base, and academic nurses have built their careers around it. However, despite the length of time that research has been on the agenda and the influential bodies involved, only a moderate proportion of nurses use research as a basis for practice.29

What has gone wrong?

Part of the difficulty is that although nurses perceive research positively,30 they either cannot access the information, or cannot judge the value of the studies which they find.31 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long.32

Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly ‘scientific’ research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research might best provide those answers.

What is nursing about?

Increasingly, medicine and nursing are beginning to overlap. There is much talk of interprofessional training and multidisciplinary working, and nurses have been encouraged to adopt as their own some tasks traditionally undertaken by doctors. However, in their operation, practice, and culture, nursing and medicine remain quite different. The oft quoted suggestion is that doctors ‘cure’ or ‘treat’ and that nurses ‘care’, but this is not upheld by research. In a study of professional boundaries, the management of complex wounds was perceived by nurses as firmly within their domain.33 Nurses justified their claim to ‘control’ wound treatment by reference to scientific knowledge and practical experience, just as medicine justifies its claim in other areas of treatment. One of the most obvious distinctions between the professions in this study was the contrast between the continual presence of the nurse as opposed to the periodic appearance of the doctor. Lawler raises the same point, and suggests that nurses and patients are ‘captives’ together.34 Questioning the relevance of scientific knowledge, she argues that nurses and patients are ‘focused on more immediate concerns and on ways in which experiences can be endured and transcended’. This highlights the particular contribution of nursing, for it is not merely concerned with the body, but is also in an ‘intimate’ and ongoing relationship with the person within the body. Thus nursing becomes concerned with ‘untidy’ things such as emotions and feelings, which traditional natural and social sciences have difficulty accommodating. ‘It is about the interface between the biological and the social, as people reconcile the lived body with the object body in the experience of illness.35

What sort of evidence does nursing need?

These arguments suggest that nursing, through its particular relationship with patients and their sick or well bodies, will rely on many different ways of knowing and many different kinds of knowledge. Lawler’s work on how the body is managed by nurses illustrates this.6 She explains how an understanding of the physiological body is essential, but that this must be complemented by evidence from the social sciences because ‘we also practice with living, breathing, speaking humans.’ Moreover, this must be grounded in experiential knowledge gained from being a nurse, and doing nursing. Knowledge, or evidence, for practice thus comes to us from a variety of disciplines, from particular paradigms or ways of ‘looking at’ the world, and from our own professional and non-professional life experiences.

Picking the research design to fit the question

Scientists believe that the social world, just like the physical world, is orderly and rational, and thus it is possible to determine universal laws which can predict outcome. They propose the idea of an objective reality independent of the researcher, which can be measured quantitatively, and they are concerned with minimising bias. The other major paradigm is interpretism/naturalism which takes another approach, suggesting that a measurable and objective reality separate from the researcher does not exist; the researcher cannot therefore be separated from the ‘researched’. Thus who we are, what we are, and where we are will affect the sorts of questions we pose, and the way we collect and interpret data. Furthermore, in this paradigm, social life is not thought to be orderly and rational, knowledge of the world is relative and will change with time and place. Interpretism/naturalism is concerned with understanding situations and with studying things as they are. Research approaches in this paradigm try to capture the whole picture, rather than a small part of it.

This way of approaching research is very useful, especially to a discipline concerned with trying to understand the predicaments of patients and their relatives, who find themselves ill, recovering, or facing a lifetime of chronic illness or death. Questions which arise in these areas are less concerned with causation, treatment effectiveness, and economics and more with the meaning which situations have–why has this happened to me? What is my life going to be like from now on? The focus of these questions is on the process, not the outcome. Data about such issues are best obtained by interviews or participant observation. These are aspects of nursing which are less easily measured and quantified. Moreover, some aspects of nursing cannot even be formalised within the written word because they are perceived, or experienced, in an embodied way. For example, how do you record aspects of care such as trust, empathy, or ‘being there’? Can such aspects be captured within the confines of research as we know it?

Questions of causation, prognosis, and effectiveness are best answered using scientific methods. For example, rates of infection and thrombophlebitis are issues which concern nurses looking after intravenous cannulas. Therefore, nurses might want access to a randomised controlled trial of various ways in which cannula sites are cleansed and dressed to determine if this affects infection rates. Similarly, some very clear economic and organisational questions might be posed by nurses working in day surgery units. Is day surgery cost effective? What are the rates of early readmission to hospital? Other questions could include: what was it like for patients who had day surgery? Did nurses find this was a satisfying way to work? These would be better answered using interpretist approaches which focus on the meaning that different situations have for people. Nurses working with patients with senile dementia might also use this approach for questions such as how to keep these patients safe and yet ensure their right to freedom, or what it is like to live with a relative with senile dementia. Thus different questions require different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question.

Research designs useful to nursing

Nursing presents a vast range of questions which straddle both the major paradigms, and it has therefore embraced an eclectic range of research designs and begun to explore the value of critical approaches and feminist methods in its research.36 The current nursing literature contains a wide spectrum of research designs exemplified in this issue, ranging from randomised controlled trials,37 and cohort studies,38 at the scientific end of the spectrum, through to grounded theory,39 ethnography,40 and phenomenology at the interpretist/naturalistic end.41 Future issues of this journal will explore these designs in depth.

Maximising the potential of evidence-based nursing

Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients.42 Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioners.43

In summary, in embracing evidence-based nursing we must heed these considerations:

  • Nursing must discard its suspicion of scientific, quantitative evidence, gather the skills to critique it, and design imaginative trials which will assist in improving many aspects of nursing
  • We must promulgate naturalistic/interpretist studies by indicating their usefulness and confirming/explaining their rigour in investigating the social world of health care
  • More research is needed into the reality and consequences of adopting evidence-based practice. Can practitioners act on the evidence, or are they being made responsible for activities beyond their control?
  • It must be emphasised that those concerns which are easily measured or articulated are not the only ones of importance in health care. Space is needed to recognise and explore the knowledge which comes from doing nursing and reflecting on it, to find new channels for speaking of concepts which are not easily accommodated within the discourse of social or natural science–hope, despair, misery, love.

In summary, in embracing evidence-based nursing we must heed these considerations:

Sample scenarios, searches, completed worksheets and CATs for evidence-based nursing

Choose one of the following scenarios:

References

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  2. Heater BS, Becker AM, Olson R. Nursing interventions and patient outcomes. A meta-analysis of studies. Nurs Res 1988;37:303-7. 
  3. Bostrom J, Suter WN. Research utilisation: making the link to practice. Journal of Nursing Staff Development 1993;9:28-34. 
  4. Luker KA, Kenrick M. An exploratory study of the sources of influence on the clinical decisions of community nurses. J Adv Nurs 199217:457-66. 
  5. Ketefian S. Application of selected nursing research findings into nursing practice: a pilot study. Nurs Res 1975;24:89-92. 
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  9. Ulrich’s international periodicals directory. New York: Bowker, 1996. 
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  11. Meah S, Luker KA, Cullum NA. An exploration of midwives’ attitudes to research and perceived barriers to research utilisation. Midwifery 1996;12:73-84. 
  12. Sackett DL, Rosenberg W, Gray JAM, Haynes RB. Evidence-based medicine: What it is and what it isn’t. BMJ 1996;312:71-2. 
  13. Flemming K. Asking answerable questions. Evidence-Based Nursing 1998;1:36-7. 
  14. McKibbon KA, Marks S. Searching for the best evidence. Part 1: where to look. Evidence-Based Nursing 1998;1:68-70. 
  15. McKibbon KA, Marks S. Searching for the best evidence. Part 2: searching CINAHL and Medline. Evidence-Based Nursing 1998;1:105-7. 
  16. DiCenso A, Cullum N, Ciliska D. Implementing evidence-based nursing: some misconceptions. Evidence-Based Nursing 1998;1:38-40. 
  17. Jadad AR, Haynes RB. The Cochrane Collaboration – Advances and challenges in improving evidence-based decision making. Medical Decision Making 1998;18:2-9. 
  18. Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington, DC: National Academy Press, 1990. 
  19. Thomas L. Clinical practice guidelines. Evidence-Based Nursing 1999;2:38-9. 
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  26. White S. Evidence-based practice and nursing: the new panacea? British Journal of Nursing 1997;6:175-7. 
  27. Rush J, Fiorino-Chiovitti R, Kaufman K, et al. A randomised controlled trial of a nursery ritual: wearing cover gowns to care for healthy newborns. Birth 1990;17:25-30. 
  28. Hoe NY, Nambiar R. Is preoperative shaving really necessary? Ann Acad Med Singapore 1985;14:700-4. 
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