Appraisal of four pieces of evidence in accident and emergency
Executive summary
The concept of evidence has been explored widely in the literature and interpreted differently by the scholars. Evidence is vitally important to support the scientific and non-scientific sources in clinical practices. Thus, it is imperative to understand better the use of evidence in clinical practices. According to Scott-Findlay and Pollock (2004) the term evidence should be reserved for research results, while also acknowledging that other ways of knowing (e.g., clinical experience, patient preferences) are to be valued and embedded in clinical decision making. Scott-Findlay and Pollock (2004) further explain that evidence is information that has been subjected to testing and found to be credible.
There are different types of evidences which are used in the medical related activities. For example, evidence may come from well-designed controlled trial without randomization or it may come from well-designed case-control and cohort studies. Further, evidence is also obtained from systematic reviews of descriptive and qualitative studies. The fourth type of evidence is derived from evidence from a single descriptive or qualitative study.
Introduction
The term evidence-based practice (EBP) emerged in the 1980s and marked a new paradigm to base clinical decisions more on evidence and less on observation or tradition. In contrast with the concept of research utilization, which heretofore was the basis for evidence in practice, EBP encompasses not only research utilization, but the expertise of the clinician as well as patient preferences and values (Rutledge, 2000). Nursing scholars have largely embraced this paradigm and EBP has entered the discourse on how to define nursing education, knowledge, and practice.
Estabrooks, Floyd, Scott-Findlay, O’Leay, and Gushta (2003) conducted a systematic review of studies that e examined the influence of individual factors on the research utilization behavior of nurses. These authors found 20 studies that met the criteria of measuring one or more individual determinants of research utilization with a dependant variable of research utilization. Measurement of the same variable was unusual across studies, but where comparison could be make, results for educational level, years of experience, years in current role, and professional membership activities were equivocal with significantly, or non significant being evenly split. Age of the nurse was found to be non-significant in all studies in this review.
EBP is one of the five competencies outlined in the Institute of Medicine (2003) report on quality of heath care. It is no longer acceptable for the nursing profession to continue to base nursing care on the way it has always been done, but rather to seek the best approach that is both outcomes based and cost effective.
Over the past two decades, there has been a shift in healthcare towards practice that embraces evidence over tradition. This shift has started a discourse in nursing education, practice, and administration for the need to develop initiatives to create and sustain nursing practice that is based on high quality evidence. The information explosion of the 21st century has served to create a plethora of research, opinion articles, and textbooks for the best evidence for nursing care along with a need to translate all of this into clinical practice. However, the gap between evidence and practice has not diminished (Levin & Feldman, 2006; Melnyk et al. (2004). There is need to know how emergency nurse integrate and implement EBP into their practice and what are the most useful evidences.
Emergency departments provide resuscitation, diagnosis, and interventions for critical and urgent conditions. Patients arrive unscheduled and often undiagnosed. Emergency nurses practice in a fast paced, mostly episodic environment where treatment and nursing care decisions must be swift and accurate. In this hectic environment, emergency nurses must make quick triage decisions and identify immediate care needs. There is limited time to consult a protocol or procedure manual before care is initiated, so emergency nurses must have internalized knowledge to perform at their best. This environment may create special challenges to the use and implementation of EBP.
Studies have supported improved outcomes when health care is based on findings from well designed studies (Melnyk, Fineout-Overholt, Stone, & Ackerman, 2000). However, a recent study of U.S. nurses found that nurses are not prepared to implement EBP due in part to lack of time, lack of value for research, and lack of skills to search for and evaluate bibliography database (Pravikoff et al., 2005). In order to overcome deficits to implementation of EBP, Melnyk (2002) suggested the first step is to assess and identify the obstacles to evidence-based care. Assessment findings can then be translated into action plan that build a foundation for implementing evidence based practice.
Sources of emergency nurses’ knowledge and skills for findings and reviewing best evidence and facilitation to support changing practice must be identified if emergency nurses are to develop a blueprint for incorporating more evidence to guide practice. The challenge is to find ways to generate, disseminate, and use knowledge that informs and is informed by the practice of nursing (McCormack, 2004). Finding the factors to assist the emergency nurse in the endeavor of EBP is timely and important.
Theoretical framework
Research and expert opinions are the cornerstone of EBP. In order to realize the benefits, these works must make it form the page to the clinical arena. Understanding how knowledge is obtained and synthesized by the individual and adopted for practice is essential for moving forward with EBP.
Rogers (1995) defines the diffusion process as that “which is the spread of a new idea from its source of invention or creation to its ultimate users (group) or adopters” (individuals). Antecedents to the diffusion process include absorptive capacity for new knowledge, preexisting knowledge / skills base, and ability to find, interpret, and integrate new knowledge (Greenhalgh, Rober, McFarlane, Bate, & Kyriakidou, 2004).
The diffusion of EBP involves both individual and organizational factors. Factors influencing adoption of the innovation include (a) characteristics of the adopter, (b) characteristics of the organization, (c) communication channels, and (d) the innovation itself (Rogers, 1995).
The adoption process by nurses begins with sufficient knowledge of EBP’s purpose and how to use it. Successful adoption is enhanced when there is a clear advantage for the use (Rogers, 1995). Nurses who reported a belief that EBP was important and benefited their practice were more likely to use EBP (Melnyk et al., 2004).
Knowledge of where and how nurse obtain practice knowledge is important to discover how best to reach the individual nurse with the information necessary to implement EBP. Adoption of innovations by individuals is enhanced if the organizations (or unit of the organization) have similar educational and professional background. These individuals within the organization who have influence on the belief of their colleagues can help or hinder diffusion (Greenhalgh et al., 2004). Persons with positional authority, such as managers or administrators also have influence over diffusion success (Funk, Champagne, Tornquist, & Wiese, 1995).
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Nursing scholars have embraced the EBP movement and define its use for the discipline of nursing as a systematic approach to determine the most current and relevant evidence upon which to base decisions about patient care (Melnyk & Fineout-Overholt, 2005). Sigma Theta Tau International (2002) defines evidence based nursing as an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.
The Institute of Medicine (2003) outlined tasks that are essential to EBP. These include knowing where and how to find best evidence, formulating clinical questions, searching for answers (evidence), determining validity of the evidence, and finding ways to integrate findings into clinical practice. In step with these elements, Melnyk and Fineout-Overholt (2005) cite the following elements for nursing EBP: (a) asking a clinical question; (b) searching for the best evidence; (c) critically appraising the evidence; (d) integrating the evidence with one’s own clinical expertise, the patient’s condition, and patient preferences and values; and (e) evaluating the results.
There is debate in the literature regarding what is or should constitute the concept of “evidence” in EBP. Scott-Findlay and Pollock (2004) call for specificity when using the term “evidence.” These authors postulate that the term evidence should be reserved for research results, while also acknowledging that other ways of knowing (e.g., clinical experience, patient preferences) are to be valued and embedded in clinical decision making. Evidence is information that has been subjected to testing and found to be credible. Knowledge, on the other hand, is the product of knowing and resides only in the human factor. Knowledge is obtained when the individual who takes in information integrates it into their own experiences (Scott-Findlay & Pollock).
As evidence to support clinical practice incorporates findings from scientific and non-scientific sources, it is important to consider what the best evidence available is. Meta-analysis and individual randomized controlled trials are generally considered the highest level of evidence. However, many clinical questions are best answered by qualitative or other types of studies (Melnyk & Fineout-Overhlot, 2005). A hierarchy that encompasses a broad range of evidence types is necessary to guide clinicians’ evaluation of the best available evidence. The Journal of Worldviews on Evidence-Based Nursing published evidence-based studies and opinion articles which identify levels of evidence based on the following hierarchy:
Level 1: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCT), or evidence-based practice guidelines based on systematic reviews of RCT’s
Level 2: Evidence obtained from at least one well-designed RCT
Level III: Evidence obtained from well-designed controlled trials without randomization
Level IV: Evidence from well-designed case-control and cohort studies
Level V: Evidence from systematic reviews of descriptive and qualitative studies
Level IV: Evidence from a single descriptive or qualitative study.
Level VII: Evidence from the opinion of authorities and / or reports of e expert committee (Melnyk & Fineout-Overholt, 2005).
French (1999) operationalized the EBP propositional and non-propositional knowledge approach in his account of an evidence based practice project. His analysis of the concept of EBP led to the following definition which defined his study:
The definition of evidence based practice is the systematic interconnecting of scientifically generated evidence with the tacit knowledge of the expert practitioner to achieve a change in a particular practice for the benefit of a well defined client / patient group. (p. 74).
His project brought together clinical nurses who completed practice-based research projects which were born out of their own professional practice. This is the inherent difference between research utilization and EBP. The EBP concept is practice driven, with an active integration of tacit and propositional knowledge that is linked to quality outcomes and is immediately applicable to the dialy clinical environment of the clinician (French, 1999).
Milton (2007) argues for the nursing profession to resist exclusionary methods for evidence in nursing. From the premise of nursing being both an art and a science. Milton postulates that the lived experience of what is important in health and quality of life from the patient’s persepctive3 should be honored as evidence of values. Documenting and articulating the non-research evidence presents nursing with the most difficulty (EStabrooks, 1998).
Part B
Where and how nurses obtain the knowledge for their practice is an antecedent to implementation of EBP. Sources of knowledge are those places from which the nurse draws data with which to solve clinical problems and make clinical decisions (Estabrooks, 1997).
Carper (1978) proposed that nursing knowledge could be classified into empirics (science), aesthetics (art), ethics (moral), and personal knowledge. Tacit knowledge, which encompasses personal knowledge and the art of a discipline, is part of the learned, transmitted, and unarticulated knowledge of practice which is acquired through experience (Scott-Findlay & Pollock, 2004). Because of its subjectivity, tacit knowledge lends itself less to empirical testing, an therefore is difficult to communicate effectively.
Within the context of EBP, Raycroft-Malone et al., (2004) describe four constructs for knowledge in nursing practice: (a) knowledge from research evidence; (b) knowledge from clinical experience; (c) knowledge from patients, clients, and caregivers; and (d) knowledge from local context (audits, patient narratives, organizational culture, and local policies). These constructs combine to form the basis for clinical practice.
Estabrooks (1998), in a study of research utilization, examined sources of practice knowledge. Using a randomly selected sample, she mailed a self-developed questionnaire to 1,500 staff nurses, resulting in a final sample of 600 nurses (40% returns). Nurses in this study had a mean age of 41 and had graduated from basic nursing education an average of 18 years of prior to the study. Scores for knowledge source questions were ranked one to five being the most frequently used knowledge source. The most frequently used knowledge source was information learned from the patient (4.286), personal experience of nursing over time (4.109), information learned in nursing school (3.827), information from attending in-services / conferences (3.774), information from policy and procedure manuals (3.61), and information shared by fellow nurses (3.637). sources of knowledge least used were identified as articles published in nursing journals (3.251), articles published in nursing research journals (2.550) and information from the media, internet, television, and popular magazines (2.410). These results are instructive, as the most frequent sources of knowledge appear to be experiential. As scientific, peer reviewed journals are the primary source of research dissemination, these results indicate that this is significantly less important as a knowledge source and print journals may not be right vehicle for empirical knowledge transfer (Estabrooks).
Gerrish and Clayton (2004) asked 330 nurses in a large teaching hospital to identify sources of knowledge used to inform practice and skills. Experiential sources of knowledge were used more frequently than either colleagues advice or literature sources. Internet sources were the least used source of knowledge. Self-reported skills in finding, reviewing and using different sources of evidence to change practice were also assessed in this study. Nurses reported being more skilled at finding and using organizational information than finding and using research information. Using research to change practice was the most problematic skill for nurses in this study.
The goal of EBP is to use the best available evidence to influence practice, which in turn creates positive outcomes for patients. In order to design interventions to increase utilization, it is necessary to understand individual factors that influence use of EBP.
Rodgers (2000) conducted a study of 680 Scottish nurses to identify individual factors influencing levels of research utilization. Correlations of nurse characteristics with mean research scores were conducted. Results showed that time from degree (r = 0.03, N = 677) and age (r = 0.002, N = 678), were found to be non-significant. However, highest degree held was found to be significantly correlated to research utilization (rho = 0.12, p = <0.01, N = 646).
Champion and Leach (1989) surveyed 59 community hospital nurses to determine individuals variables to nurses’ use of research utilization. Age, highest degree obtained, and years of nursing experience were found to be not significantly correlated with research utilization. No correlations statistics were reported for these variables.
A sample of 382 nurses in China was surveyed to determine e factors influencing research utilization (Tsai, 2000). Results indicate that the higher the educational level, the higher research utilization. Nurses with graduate degree (n = 15) had a mean research participation score of 18/33, as compared to baccalaureate graduates (n = 115) with a mean score of 6/33, and diploma graduates (n = 235) with a mean score of 2/33. Statistically significant relationships were also found between research utilization and years of work experience. Subjects with greater than 10 years of experience (n = 160) had a median research utilization score of 5/33, with those who had 0=5 years of experience (n = 134) and those with > 5 to 10 years of experience (n = 88) having medium scores of 1/33 and 2/33 respectively.
Estabrooks, Floyd, Scott-Findlay, O’Leay, and Gushta (2003) conducted a systematic review of studies that e examined the influence of individual factors on the research utilization behavior of n nurse. These authors found 20 studies that met the criteria of measuring one or more individual determinants of research utilization with a dependant variable of research utilization. Measurement of the same variable was unusual across studies, but where comparison could be make, results for educational level, years of experience, years in current role, and professional membership activities were equivocal with significantly, or non significant being evenly split. Age of the nurse was found to be non-significant in all studies in this review.
Certification in specially practice denotes a standard of knowledge. CEN (Certification in Emergency Nursing) denotes a specified body of knowledge in emergency nursing, a measure of knowledge and critical thinking skills for emergency practice (Emergency Nurses Association, nd.). certification testing compels the nurse to stay current with the unique information and skills required to provide quality care and ensure consistency of knowledge (Grief, 2006). Staying current implies practicing within the current best evidence within the profession. No studies were found that evaluate certification in emergency nursing with EBP.
Uncertainly remains whether individual characteristics are determinants of research utilization. There is a paucity of literature on individual characteristics of specialty nurses that may influence EBP utilization. Emergency nurses, as a specialty group, would benefit from knowledge of which, if any, characteristics enhance the development of EBP.
Lack of time to read research, lack of skills to evaluate research, and lack of administrative support for the process continue to be significant barrier to implement sustained evidence based clinical environment. Methods to assess evidence have certainly changed over this time period. Computer data bases have usurped card catalogs and on-line journals have eclipsed trips to the library. The EBP studies have addressed the electronic age barriers to evidence gathering. Despite the electronic revolution, as evidenced by the long history of studying barriers to research utilization and more recently EBP, there is still a wide gap between evidence findings and clinical practice. Identification of those elements that inhibit the attitudes, knowledge and access to the multimode of evidence to inform practice is the key to creating interventions that are effective.
Critical Analysis of the study
This paper has explored different theories of evidence based practices of nurses in healthcare facilities. It has also reviewed different types of evidences to support the clinical services. In clinical settings there has been placed an emphasis on the evidence in nursing education, practice, and administration for the need to develop initiatives to create and sustain nursing practice. Evidence is vitally important for all such fields as it helps in reducing time and energy of the decision making process in critical incidences. Further, it renders authenticity to the action taken in case of emergency like accidents where the healthcare providers have to respond instantly. Thus, the use of evidence based practice is imperative to discharge professional services. Emergency nurses practice in an episodic environment that may have distinct attributes that affect the use of EBP principles. Evaluating this unique group of nurses’ readiness for EBP will be beneficial in building the implementation strategies to link evidence to improved outcomes.
