Peter Davis MBE1 and Mark Limb2
1 Newark, Nottinghamshire, UK
2 School of Nursing and Midwifery, University of Sheffield, UK
The aim of this chapter is to enable the orthopaedic practitioner to appraise evidence related to daily care decisions in a sound and unbiased manner and then apply the findings and evaluate the care outcomes. Hunt (1938) gives a very insightful view of her experience in developing orthopaedic nursing and the impact of social and political factors she had to face. Since this publication there have been many books written to help both student and qualified orthopaedic practitioners (Powell 1986, Footner 1987, Davis 1994, Maher et al., 2002, Kneale and Davis 2005) along with journals and individual papers. Over time, there has developed a rich and varied body of knowledge. Content has gradually moved away from descriptions of what should be done to patients to a more considered view of patient care based on current evidence and more of a focus on how to engage with the patient.
There have been a number of influences on the development of nursing knowledge. The Briggs report in 1972 (Committee on Nursing) suggested that nursing should become a research-based profession and there has been much written about how and why this is necessary, the impact it has on patient care and the view of nursing by other professions. Care up to this point had often been based upon what had traditionally been delivered under the authority of senior staff. Whilst this may have been based on years of experience there was no real assurance that the care delivered was the best possible or was even effective. Policies and education began to respond to this but, over subsequent decades, it had been noted that the uptake of research by nurses had been sporadic and sometimes limited. Hunt (1981) identified that research was still not really finding its way into practice a decade after the report was published. Another decade later Closs and Cheater (1994) felt that research had started to permeate the culture of nursing, although they did not think it was a clearly embedded concept. Nearly thirty years later Batteson (1999) felt that many practices were still based on local circumstance rather than research.
There appears to have been a number of driving forces for the need to use research in practice over the years since 1972 and these have been propelled by both economic and educational factors. Clarke (1999) looks at this in terms of efficiency and effectiveness in clinical decision making and Gerrish and Clayton (1998) add the concern for quality improvement and cost consciousness. Particular attention was paid to effectiveness by the NHS executive (1998) as they began to ask that clinical decisions should be based on the best possible evidence of effectiveness. This often results in the generation and application of clinical guidelines. But effectiveness is not the only criteria by which to judge new knowledge and evidence: feasibility, appropriateness and meaningfulness, particularly for the patient, are also important.
Effectiveness and economics may not have been the only driving force. French (1998) noted that as data were collected regarding practice on computer databases, there were geographical variations in care and this may not have been what is most effective, but what individual practitioners had traditionally done or wanted to do. This, according to Hicks and Hennessey (1997), brings in the notion of accountability as care cannot be delivered based upon opinion and/or authority; it needs some form of justification. This has also led to a number of organisations such as Cochrane, Joanna Briggs and NICE (National Institute for Clinical Excellence) developing a number of resources and databases for both practice and teaching purposes.
There was also the encouragement of research utilisation, and Horsely et al. (1978) examined the complex organisational functions that range from problem identification to the implementation of an innovation. Many research texts were then published looking at how to undertake and critique research including chapters on change management. However, research can be used in more than one way and may not just be about innovation and change in practice. Estabrooks (1998) identified that it can be used as action research when directly applied to practice with change and evaluation taking place as part of the research. However, it can also be used conceptually to enlighten understanding and persuasively to change the views of others. As Bircumshaw (1990) suggests, research can be used in other ways without the need to directly implement it.
Until recently there has been little mention of evidence-based practice and more of a focus on research and its utilisation. This can be regarded as a problem as there is a tendency to use these terms interchangeably. Whilst evidence-based practice may encompass research utilisation, evidence is more than the findings of research and, as pointed out by McKenna and Cutcliffe (1999), the absence of research does not mean that evidence-based decisions cannot be made.
The most frequently cited definition of evidence-based practice is that of Sacket et al. (1996) and focusses on ensuring that current best evidence should be used in making decisions about medical care. They identify the best evidence as systematic research but note that individual clinical expertise needs to be integrated with this. This does not, however, help us to understand what would happen in the absence of research or consider the patient in the decision making process. Ryecroft-Malone et al. (2004) provide a more encompassing definition and incorporate the need to look at the impact of research, the effectiveness of expert knowledge and the need to integrate patients’ experiences into decision making. See Figure 2.1
Ingersoll et al.’s (2000) definition brings in the nursing context and notes that it is more about theory-derived research-based information, about care delivery to groups and individuals and, most importantly, is considerate of individual needs and preferences. This definition does not imply that primary research is the only form of evidence and it includes the patient in decisions reflecting the increased levels of health related knowledge of patients and the view that ‘medicine knows best’ is quickly being eroded by the ‘expert’ patient.
Nurses must embrace this issue from their own professional perspective as well as differentiate their professional roles and responsibilities. Whilst evidence-based care is becoming a priority in health care, Banning (2005) found that nurses were not able to differentiate very well between evidence-based medicine and evidence-based practice. Whilst nurses take on more advanced roles that often merge with the boundaries of other disciplines, the development of knowledge and understanding must continue to build on their professional knowledge.
More recent research into evidence-based practice tends to move away from how it is defined and considers how it works in practice. This is important in relation to the changing roles of the nurse in modern health care. Some may argue that, up to now, there is little indication that evidence-based practice works. Gerrish et al. (2011), for example, examined how nurses in advanced roles act as ‘knowledge brokers’ for clinical nurses, thus enabling them to use evidence effectively. Whilst nurses may be working in complex and advanced roles, they can develop and use knowledge and skills that facilitate the use of evidence by others who are less experienced. Thus evidence is combined with expertise in helping others deliver care.
There are two main misperceptions within EBP. The first is the assumption that research has been carried out on the particular clinical issue or problem of interest. This is often not the case. For example, if a search is conducted for evidence to support the premise that early mobilisation in orthopaedic patients is beneficial, very little if any original research will be found. The second assumption is that all published research is of good quality. The appraisal process often shows research to be poorly constructed and conducted, and therefore cannot be trusted for implementation. Santy and Temple (2004) identify in their critical review of skeletal pin site care that only two pieces of evidence were found that were of sufficient quality to be trusted and used to direct nursing care.
Evidence-based practice has three components (Aveyard 2010). Firstly, the evidence about the feasibility, appropriateness, meaningfulness and effectiveness of health care practices is sought. Secondly, the quality of that evidence is assessed and appraised. Finally, the evidence should be applied to the context in which it is relevant. An example of the entire process, from setting the question to implementing findings, is provided in a review of pre-operative exercise in knee replacement surgery (Lucas 2004).
Hierarchies of evidence
There is a good deal of debate about what is best evidence and nurses need to be able to navigate this complex, evolving web of information. When deciding what evidence is best a number of authors have made some attempt to apply categories to help clarify what may be the most rigorous. Bircumshaw (1990) suggests a fairly simplistic hierarchy to help the reader understand the relationship between research and practice, tying the availability of research into the responsibility of the nurse. This model places the emphasis on the primacy of empirical research, as do the hierarchies of Fawcett (1984) and Davis (1990). This should not be seen as too much of a problem as different research designs may be regarded as more valid and reliable than others. However, other models are much more encompassing than this and encapsulate a broader range of evidence types ranging from personal and peer experience to meta-analyses and systematic reviews. A succinct overview of these may be as follows:
- quantitative research
- qualitative research
- expert opinion
- personal experience.
This is not too far removed from Carper’s (1978) classification of nursing knowledge that identified four levels that were evident in nursing practice at the time:
Empirical research appears to have great pre-eminence in these hierarchies and Griffiths (2002) feels that this may be because questions about issues such as effectiveness and efficiency are best addressed by such methods, particularly the randomised controlled trial (RCT). Quantitative research may not, however, be able to solve all problems. Mulhall (1998) points out that there are ‘untidy’ aspects of caring that need to be examined such as emotion and feeling. Decision-making around these may not be best served by the RCT. McCormack (2004) suggests that qualitative research is an important element of practice but, because of perceived problems relating to reliability and validity, it is placed lower in the hierarchies. Howard and Davis (2002) describe and explain the relatively weak position of qualitative research in orthopaedics and suggest a new approach they label as ‘diagnostic research’. Evidence has to be selected on the basis of the problem being addressed and, with this in mind, Naish (1997) feels that the levels of evidence should be regarded as more elastic and without one having privilege over another. Quantitative research may identify a clinical problem but qualitative research may set it in context.
Mantzoukas (2007) suggests we abandon the hierarchy altogether as this often serves to impede the implementation of evidence-based practice. An alternative offered is reflection on practice in order to make decisions relating to care. To do this a good deal of clinical experience is required and, at the same time as there is a growing body of evidence in nursing, there is also a growing body of experience that has been gained by individual practitioners. Gerrish and Clayton (2004) found that experience was frequently used as a source of evidence. Intuition and experience in expert practice is important as the development of quality services cannot be delayed by lack of research findings (Ellis 2000) and intuition uses the untapped resource of tacit knowledge (Meerabeau 1992). This complicates matters; on the one hand evidence-based practice tends to under-emphasise intuition and experiential knowledge and stresses the examination of clinical research, whilst on the other hand it can never replace individual expertise (Rolfe 1999).
Finding and dealing with the evidence
Having examined the meaning of evidence-based practice it is useful to consider the skills required for delivering this effectively. These can be categorised under two broad areas:
Specific skills include being able to find, filter and extract relevant information (Bryar et al