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
• aesthetic
• ethical
• personal.

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
• general.

Specific skills include being able to find, filter and extract relevant information (Bryar et al., 2003) as well as being able to appraise the evidence (Hek 2000), decide on its quality and its relevance to their practice. Information technology and development of critical reading skills are essential.

More general research appreciation skills are necessary to be able to understand some of the complex evidence that may need to be appraised prior to application in practice. The practitioner may also need to mentor and teach others about the nature of the evidence and its relationship to and potential impact on practice. Practitioners have to be able to extract evidence that is relevant and be able to recognise the different range of approaches that can inform practice. Finally, there is a need for good management and time management skills and to be able to create an appropriate culture for evidence-based practice to work effectively (Mulhall 1998).

Asking a question and developing your knowledge

Having looked at some of the issues around research and evidence, we now must look at how you can start to develop your own knowledge base relevant to orthopaedic or trauma practice. The ability to think critically in solving a health care problem is of essence to the process of EBP. Jones-Devitt and Smith (2007, p. 7) define critical thinking as:

Making sense of the world through a process of questioning the questions, challenging assumptions, recognising that bodies of knowledge can be chaotic and evolving; ultimately with the aim of continually improving thinking.

Lipe and Beasley (2004) warn of two main pitfalls in problem solving; firstly, the failure to clearly identify the real problem and secondly, the failure to eliminate preconceived ideas in identification of solutions. For example, with respect to surgical wound care the orthopaedic nurse may consider the fundamental question to be what type of dressing to use and search for evidence on whether to use honey, gel, occlusive, transparent or silver dressings. However, the first question should be do we need to dress the wound? Once this is answered the question of dressing type can then be addressed if necessary.

Below is a step-by-step method by which you can start to do this. It does not have to lead to a full research project and be undertaken for educational purposes; you can do it just to improve patient care.

1. Choose a subject area or set a question and discuss this with your managers and peers. Think about an area of expertise that you want to consolidate or develop. Maybe there’s something in your clinical area that makes you and others just stop and question why? Or could this be done in a better way? This first stage is probably the most important as without a clear search question the end result will be weak, inconclusive or unusable.
2. Start to look for information and identify the articles that pertain to your chosen area. Make notes of:
   • the databases that you searched
   • the key words that you used for your search and how you refined them
   • if you undertook any incremental searching (looking at the reference list at the back of published articles)
   • conversations with others who have a particular specialist interest in the area you have chosen.

     All the above are ways of accessing existing sources of knowledge but each will have its own issues for consideration:

   • Databases may be selective in the information that they hold or may contain so much information that it is difficult to decide what is important. You may have to limit to local holdings for financial reasons but this limits the scope of your knowledge development as well. Don’t limit your search to primary research only as evidence/knowledge is much wider than this, but do try to make sure the information you collect is peer-reviewed in order to ensure its credibility. Key words can be difficult to determine and define so it is important to ensure that you have been very specific in the choice of subject. Again, it is useful to discuss this with managers and peers in order to ensure that you have the correct words for the correct focus.
   • Incremental searching (looking at the reference lists on articles that you already have) is useful, particularly when the databases do not appear to be yielding very much. However, if you have an article from 2005 all the additional articles you get from this will pre-date it and may be considered too old to use.
   • Asking specialist/advanced nurses for information is also very useful and may yield some articles that you had not thought of or may be finding difficult to obtain. However, because of their specialist focus, you may find that the article selection is biased.

   While each method may have its limitations, if you identify material from a wider range of sources it is likely that you will end up with a pertinent dataset for use in the development of your knowledge base.

3. Once you have collected all the articles, read through them and identify from this the ones that you will select for consideration. You need to justify how you narrowed the articles down by setting inclusion and exclusion criteria. Once you have decided which are relevant, obtain a copy of each.
4. Start to acquaint yourself with the articles that you have identified. Get a feel for the area. Identify those that are primary research and those that are literature reviews, editorials, professional opinion etc.
5. Start to summarise the research articles using ‘research evidence summaries’ (see Table 2.1) and the other articles using ‘literature evidence summaries’ (see Table 2.2). You may want to design your own format if you find these too restrictive.
6. Once you have completed all the summaries, have a look through and see if you can identify any themes. For example; if you are looking at pre-operative fasting you may find that some of the articles are about fasting times whilst others may look at the outcomes associated with fasting times. Separate these and then put each of the articles on a matrix for each theme. Matrices for the research articles and other literature can be found in Tables 2.3 and 2.4 respectively.
7. Once you have identified all the different approaches taken in the research articles and inserted them into the matrix start reading around the research methods that have been utilised by the authors. Justham (2007) suggests a simple check list of questions that will get you started. The Critical Appraisal Skills Programme (2013) and the Joanna Briggs Institute (2013) web sites provide more in-depth appraisal tools. Access research methods texts from the library to help you to understand the methods discussed in the papers.
8. For the other articles it is useful to identify what type of evidence they represent (professional opinion, group consensus etc.) and their position relative to research in a hierarchy of evidence.

Models of application

Having gone some way to develop your knowledge base what do you do with it now? There seem to be three major models by which evidence may be applied in the clinical setting:

• linear
• multi-dimensional
• partnership.

The linear models indicate that there is some logical process occurring that has a beginning and an end starting with some form of problem assessment and ending with some form of evaluation and including the need to select and review evidence, develop policy, implement change and evaluate services/outcomes (Hewitt-Taylor 2002, Gerrish and Clayton 2004). Kitson et al. (1999) and Fitzgerald (2003) regard these models as problematic in the complex health care systems in which they are supposed to work.

Kitson et al. (1998) therefore propose a multi-dimensional model that identifies factors contributing to the successful implementation of evidence-based practice as a function of three factors:

• the type of evidence available
• the context in which the evidence is being applied
• the level of facilitation available.

This goes some way to explaining the complexities that nurses face, as does the partnership model described by Ross et al. (2001) who identify the value of the collaborative efforts of a number of individuals within the organisation.

A criticism of these models is that, in trying to move away from the linear models they lack the logicality that is often required for the purposes of accountability. However, we should look at all these models as being a partial representation of the reality of practice and see the “implementation” noted in the latter two models described as the logical processes of the former linear models. If we merge all these models we get the overall picture that there is some linear process occurring and that this is affected by the evidence, the context, the facilitator and the collaborative efforts of all involved. Davis (2004) exemplifies this in his critical discourse on venous thromboembolism prevention in orthopaedic health care practice. The discussion concentrates on three related elements: clinical practice improvement itself, the evidence base and aspects of change.

Context and collaboration may be particularly important in the field of orthopaedics and trauma because of the multi-professional nature of the speciality as Field (1987) identifies the different roles of the professionals:

• Doctor = Curative
• Physiotherapist = Restorative
• Nurse = Evaluative.

Each member of the team will have a different role but will need common knowledge to function effectively. Therefore, it makes sense to make sure that all are involved if there is to be any development in evidence-based practice as this may involve multiple adoption decisions.

In summary, an approach that develops knowledge and understanding to use in an evidence-based practice approach has six elements:

• search for evidence
• appraise evidence
• summarise evidence
• utilise
• embed
• evaluate the impact.

At its simplest, EBP is about good practice and improving the quality of health care (Baker 2010). Practitioners must continue to strive to generate and identify new knowledge for practice and apply it only after casting a critical orthopaedic nursing eye over it. We must listen to patient stories or narratives as they can be powerful and enlightening directors of decisions about care (Davis 2007). We must also listen to our own hearts and instincts and utilise evidence in a caring and empathetic manner.

Recommended further reading

1. Aveyard, H. (2010) Doing a Literature Review in Health and Social Care, 2nd edn. Open University Press, Maidenhead.
2. Aveyard, H. and Sharp, P. (2013) A Beginner’s Guide to Evidence Based Practice in Health and Social Care, 2nd edn. Open University Press, Maidenhead.
3. Bowling, A. (2009) Research Methods in Health, 3rd edn. Open University Press, Maidenhead.
4. Gerrish, K. and Lacey, A. (2010) The Research Process in Nursing, 6th edn. Wiley Blackwell, Oxford.
5. Jones-Devitt, S. and Smith, L. (2007) Critical Thinking in Health and Social Care. Sage, London.

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