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Why Bother with Evidence-Based Practice?

Monday February 7, 2000
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What is evidence-based practice? Does it imply that there is something wrong with our practices lacking evidence? Why should the nurse who daily manages a full patient load and works a 10 or 12-hour shift even take notice of the increasing emphasis on evidence? This nurse barely has time to eat; now he or she is expected to know what evidence supports or disputes the care they provide everyday.
Consider the last question first, why should the nurse take notice of the increasing emphasis on evidence-based practice?
Grasping this concept and taking on the critical analysis that is a cornerstone to evidence-based practice is the key to nursing's survival as a professional discipline. We must confront the issues we see daily by knowing what practices are based on good science and by understanding how to obtain data, analyze it, and create a solution based it. In short, we must take charge of our own practice with data and science.
Adopting an evidence-based approach to our practice is a tall order for the bedside clinician. Our educational programs and our health systems are in transition to accommodate the rapidly evolving demands of the knowledge age. Therefore, many organizational cultures remain mired in the traditional approaches to delivery of care. Yet there are greater forces at work within our marketplace and within science that are paving a path toward evidence-based care.
In Learning to "Do the Right Things Right" Muir Gray describes our traditional healthcare culture as based on "habit and opinion." This rule-based culture bred such unsubstantiated practices as rigid time frames for vital signs, pain management by the clock, enemas for women in labor, limited family time with critical care patients, and electronic monitoring of fetal heart rate during labor.
In an evidence-based world, thinking critically by acquiring, analyzing and working from data is what is expected of a nurse. It forces us to define and measure outcomes when care is first initiated. Why do we take vital signs every 4 hours for a patient? What makes four hours better than 3 or 5 hours? And why should we wake a patient who is finally resting to accomplish this task? As RNs, we have the knowledge and judgement to assess the patient and define parameters appropriate to the patient.
Questions like these prompt a closer look at our professional responsibilities. They drive redefinitions of care for groups of patients, and significantly effects how nursing articulates staffing requirements. If nurses retain a stronghold on tasks and routines they will find themselves thrown from the end of the whip and replaced with faster moving drones.
Base Your Clinical Operations
on Evidence
Nurses who understand the value of using the latest advances in science for the improvement of care quality and to increase clinical efficiencies will lead the way in changing today's healthcare systems. Evidence-based practice extends beyond the application of current research for all aspects of operations. One example in defining and solving problems is patient transfer from ED to an in-patient bed. Nurses who confront this problem on a daily basis face -
an expensive issue with wasted caregiver time
a risk management issue with potential delays in administering a plan of care
a customer (patient) inconvenience or even hardship
and a public relations issue when your customers are waiting for a bed
If you are familiar with these problems, ask yourself if you are using traditional approaches based on "habit and opinion." Can you define an appropriate database to guide the gathering and analysis of information on this issue?
There are measurement methodologies currently used by other industries that can be helpful to clinical nurse practice issues. In order to move away from the reactive mode of solutions to a data-driven approach, we need to learn how to use these methodologies.
Is Evidence-based Practice Controversial?
Evidence-based practice may be seen by some professionals as discounting clinical expertise and placing too much emphasis on analysis. Evidence-based practice does not ask that nurses abandon experience or a patient's particular needs. In fact, in Evidence-based Medicine, Sackett states that, "evidence-based practice provides a useful set of tools for problem solving/decision making and for self directed patient/problem-centered, lifelong learning."
In Evidence-based Clinical Practice, Goode and Piedalue describe it from a nurse's perspective - "nursing literature has focused on research utilization and the activities that must occur when research is transformed into clinical practice. Evidence-based clinical practice builds on this literature by adding other forms of evidence that can be used in making clinical practice decisions."
Data Tables and the Wooden Spoons Drive Change
In 1854 Florence Nightingale took 38 women to Turkey to nurse wounded and sick British soldiers in the Crimean War. This was the first time the government had allowed women to do this. Her work brought her fame, and helped create a lasting change in the deployment and maintenance of British troops. She did this by carefully studying existing data, setting requirements for additional data and creating statistical tables. She believed passionately in the need to grasp problems with data and analysis.
Archie Cochrane, a British physician and epidemiologist, was incredulous at the reliance on habit and opinion in the medical profession, particularly in obstetrics and gynecology. And the unglamorous awarding of "the wooden spoon" by Cochrane, in 1972, was the birth of an international movement and collaboration for systematic reviews of the research and dissemination of the current and best evidence.
This was a pivotal point for health science; shortly thereafter, Chalmers initiated the Oxford Data Base of Perinatal trials, which has evolved into the multispecialty, international, and internet-based Cochrane Library and Collaboration. This is an interdisciplinary and international collaboration of professionals committed to consolidating the current randomized trials to make information accessible to busy clinicians, thereby moving the best of science into daily practice.
Evidence-based Care Begins with the Right Questions
Nurses can take initial steps toward evidence-based care but they cannot do it all alone. Evidence-based care is accomplished through interdisciplinary team efforts. It can help teach healthcare professionals how to ask questions about care systematically, and find the current evidence or identify the lack of it.
Talk with colleagues about evidence-based practice; find out what they know about it and ask other members of your interdisciplinary team how they are using evidence-based practice. Don't be surprised if you get quizzical looks. The term is not yet as commonly used in the US as it is in Canada, the UK, Australia, and other countries.
Check your unit resources
Policies, procedures, and critical pathways are currently up for examination for evidence-based practice. How are they developed? What literature is reviewed and graded to support a particular practice? Are you using any of the national guidelines?
Ask your health sciences librarian to assist you in gathering information on the topic and to explain their role in advancing evidence. Use the Internet as a resource. Websites for both the Cochrane Collaborative and the Agency for Health Research and Quality, AHRQ are readily available at the click of
a mouse.
Seize the knowledge today, and tomorrow you'll be amazed at the power you'll have acquired. Remember that Florence Nightingale changed the face of nursing through the use of data and analysis. The rest is up to you.