Evidence Based Nursing

Excellence in Evidence-Based Nursing Information Instruction

One of the best breaks to come the way of a busy practitioner in our profession is coming across continuing education instructors who truly bring the special librarian right up to the cutting edge of knowledge in a field vital to our work. Such was the case in my recent encounter in a class on Evidence-Based Nursing  with Dolores Z. Judkins  [email protected] of the Oregon Health  Sciences University and Patrice O’Donovan [email protected] of the Linfield College School of Nursing. The following represents a small fraction of the information learned from that encounter. Any errors in its recounting, are of course, my own.

Evidence-Based Nursing

Evidence-Based Nursing (hereafter EBN)  is arguably the most important  trend in the teaching and practice of Nursing today.  It is partly an offshoot of Evidence-Based Medicine (EBM), a movement pioneered by the late Scottish physician, Archie Cochrane a critic of the practice of contemporary hospital-based  medicine in the UK (and ultimately around the developed world), in whose honor  the Cochrane Systematic Reviews  are named. The basic idea is that while much research of varying quality is published in health care, little of the best of it is applied in a timely fashion. Part of this has to do with the fact that not all published research studies are created equal, and therefore some of them should never be applied without further study, but partly also with the fact that according to one estimate, it takes 17 years before a clinical development of demonstrated validity becomes widely applied to practice. This is, by consensus, largely due to the dominance of the rule of “We’ve Always Done it That (Other) Way.”

What Constitutes Evidence? Where EBM & EBN Concur

Medicine and Nursing diverge somewhat on what constitutes evidence worth applying in that EBM rigorists tend to use a rather strongly hierarchical ranking system of what counts, and will only apply that which is conclusively proven to work. At the top of medicine’s heap is the meta-synthesis (a quasi-mathematical merging) of multiple instances of well-designed large-scale randomized clinical trials (RCTs) . Underneath that would be a few intermediate RCTs or one large  RCT.  Under that would be a well-designed, statistically significant controlled trial where the physicians (or more rarely,  the patients themselves), might be aware whether or not  given patients were receiving the standard mode of treatment or a sham, or in some cases, were simply not treated at all. 

Out of Necessity, EBN Tolerates More Ambiguity

It is after this point  that EBM begins to diverge from EBN, because EBM tends to discount as marginal (if not backed by meta-syntheses of multiple RCTs) , Consensus Opinion Panel studies or editorials by experts.  Nursing, while certainly willing to acknowledge the superiority of the higher-ranked studies, often operates on the notion that specialty committee reports, and endorsements of procedures in major journals, are often all that one has to go on. Indeed in some troubling clinical cases, EBN is willing to consider clusters of case studies and laboratory reports as better than the absence of any other published knowledge. Ultimately, this is not because nurses are somehow inferior in their sense of judgment. It is rather, that nurses have to face, for extended hours on every shift,  patients and their families who often demand that they “do something” and that nursing is seen (and is in reality) as a profession  clearly expert in patient-comforting techniques that are often not closely considered by physicians who spend little  “face-to-face” time with the afflicted on a daily basis.

A Key Feature of EBN: Special Attention to the Wishes of the Patients & their Families

One major component of EBN that tends to be discounted in EBM is the notion of the centrality of the will of the patient and the cultural context of the hospital, in determining if a proposed treatment  is “best .”   In other words, might a treatment that  EBM regards as vastly superior be rejected because it violates the patient’s sense of what is religiously or ethically justifiable, according to the patient’s deeply felt beliefs. While no EBM of which this author is aware mandates that  physicians routinely override the clearly stated negative treatment wishes  of a patient (and in most countries this would be against the law), there is little sense that a different or traditional treatment of borderline efficacy would be regarded by EBM as appropriate to attempt  in place of the systematically reviewed superior treatment. In other words, in EBM, the facts stay the facts, no matter what the patient or the family says, and a marginal alternative treatment is just that, and might best not be carried out at all. In EBN, there is more leeway for “Plan B”, and ratings of an accommodating alternative procedure’s acceptability to the patient’s community are arguably as important as some statistical factor in judging whether or not it could prove useful. In a sense, EBN sees patients holistically, as opposed to EBM, which sees patients as embodied diseases which are best attacked by  methods proven by inductive logic not by sensitivity to feelings.

EBN is Moving Closer to the Bedside Through Newer Electronic Products

While the nurse with time on his or her hands would ideally like to be able to read several studies to determine whether or not a procedure that is be applied to a patient represents the best of EBN, the fact is that floor nurses are typically overworked with  several patients presenting with differing needs that have to resolved on an eight hour shift.  There has been up to now, a rather large and growing number of electronic services advertised as being EBM, which claim to be quick, on point, and represent the best that the  evidence has to say.  Using these tools, nurses could sometimes come up with good findings in real time that would apply to their situation,  but their information needs were considered quite secondary to those of the physicians who were the primary market.  This is changing.  New products are emerging already to fill this void for Nursing, more are in the pipeline, and readers may wish to examine all of them for their Nursing clientele, before considering any licensing.

CINAHL Plus with Full Text – Evidence Based Care Sheets is now exclusively an EBSCO  Product owing that firm’s purchase of the database a few years ago.  Not only does one get the material with which to build one’s own background EBN knowledge since  CINAHL remains for now as the gold standard for tracking down virtually all the articles in Nursing, but there are now practice-oriented sheets which bring some of that information to the practitioner in rather short order, saving them time. There is some worry however, that the number of these handy digests will be curtailed so as to make purchase of the following product more or less mandatory.

Nursing Reference Center is a parallel EBSCO product that is much more focused on delivering short forms of condensed EBN  information on typical presentations of unfamiliar diseases, treatments, drug interactions, and proven tools of the trade, all of which  are said to have been  rigorously reviewed at some point along the information building and transfer assembly line, but without providing the reader all the indexing to all the original journal articles that underlie these claims.  This product is being marketed as an always available and always up-to-date  substitute for the handy nursing practice and health reference handbooks found at the nurse’s stations of every hospital floor.  There is some evidence that it might well succeed in that claim, because EBSCO as an aggregator still negotiates with a great many differing publishers, and can lever their clout as a print and electronic journal vendor somewhat to avoid being shut out of good content  because of exclusionary rights. Justly worrisome to hospital librarians, however, is the announced plans for EBSCO to first attempt to market this product through the hospital librarians, and if unsuccessful, to bypass them and try selling it directly to the  Chiefs of Nursing Services.

Mosby’s Nursing Consult is Elsevier’s response to recent developments in the ownership of CINAHL. It is doubtlessly based on their highly successful MDConsult . Mosby is a wholly owned subsidiary of Elsevier and has, along with another Elsevier acquisition Saunders, a very long tradition of publishing excellent texts and journals in Nursing. While there are fewer claims that every item ( book chapters,  articles, patient handouts) made accessible to the busy nurse through MNC is EBN-based, there is exceptional searchability and practicality.

ProQuest Nursing & Allied Health Source clearly has two advantages not seen in its competition: nursing theses and dissertations (where EBN is being more and more the topic  or the methodological approach being applied to some clinical intervention) and access to select documents from the Joanna Briggs Institute, arguably the world  leader in generating and indexing the newest EBN  information.  (Indeed, the Joanna Briggs Institute Database is so important as to merit its own blog, coming soon.)

EBN Evolves its Own Journals

At least three journals/alerting-services now deal explicitly with EBN (and a great many more are requiring an EBN approach of their submitting authors).  The best known EBN journals are:

Primarily for commentaries on work published elsewhere:  Evidence-Based Nursing from the BMJ (British Medical Journal ) Group and the Royal College of Nursing in the UK. They work with Stanford University Libraries” HighWire Press in handling the electronic publishing aspects.

http://ebn.bmj.com/

British nurses can get this service as an add-on to Nursing Standard,  the main journal for RNs in the UK. Most American libraries will have to sign for a site license,  based on FTEs and other countable metrics which go towards determining the price.

WORLDviews  of Evidence Based Nursing (the peculiar capitalization is the publisher’s )

http://www.nursingsociety.org/Publications/Journals/Pages/worldviews.aspx

This is a collaborative effort of an international honor  society of nursing,  Sigma Theta Tau, and Wiley-Blackwell.  It has somewhat more original articles per issue -----i.e. studies specifically written for the journals as opposed to the analyses of what has come out in other journals----than does EBN above, but in any case, both are valuable resources.

The International Journal of Evidence Based Healthcare is also from Wiley-Blackwell, but is not focused exclusively on Nursing. On the other hand, it has strong roots in the Joanna Briggs Institute, and continues to publish its Best Practices and related documents, making it vital in any comprehensive collection.

SELECTED RECENT REFERENCES  AND  A CLASSIC BY MELNYK &  FINEOUT-OVERHOLT

(Late 2008-2009 titles are in the pipeline, and can be ordered in advance.)

Ackley, B.J. et al. 2008. Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions. St. Louis, MO: Mosby – Elsevier.

Ackley, B.J. & G.B. Ladwig. 2008. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. St. Louis, MO: Mosby-Elsevier.

Brown, S.J. 2009. Evidence-Based Nursing: the Research-Practice Connection. Sudbury, MA: Jones & Bartlett.

Brunt, B.A. &   J. Gisonde. 2008. Evidence-based Competency Management  for the Intensive Care Unit. Marblehead, MA:  2008.

Cullum,  N.  2008. Evidence-Based Practice Nursing: An Introduction. Malden, MA:  Wiley-Blackwell.

Dickson, G. L. & L. Flynn. 2008. Nursing Policy Research: Turning Evidence-Based Research into Health Policy.  New York: Springer.

Dunn, W. 2008. Bringing Evidence into Everyday Practice . Thorofare, NJ: Slack.

Editorial Staff of Lippincott, Williams & Wilkins. 2009. The Evidence-Based Nursing Guide to Disease Management. Philadelphia: Lippincott, Williams & Wilkins.

Fawcett, J. 2008. Evaluating Research for Evidence-Based Nursing Practice. Philadelphia: F.A. Davis.

Foreman, M.D.,   T. Fullmer & K. Milisen. 2008. Evidence-Based   Critical Care Nursing of Older Adults. New York: Springer Publishing Company.

Houser, J. 2008. Nursing Research: Reading, Using, and Creating Evidence. Sudbury, MA: Jones & Bartlett.

Larrabee,    J.H. 2008. Nurse to Nurse: Evidence-Based Practice. New York: McGraw-Hill.

MacNee, C.L. & S. McCabe. 2008. Understanding Nursing Research: Using Research in Evidence-Based Practice. Philadelphia: Wolters - Kluwer Health / Lippincott, Williams & Wilkins.

Melnyk, B.M. & E. Fineout-Overholt. 2005. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia: Lippincott, Williams & Wilkins.

Newhouse, R.P., S.L. Dearholt, S.S. Poe, L.C. Pugh & K.M. White.  2007. Johns Hopkins Nursing: Evidence-Based Practice Model & Guidelines.  Indianapolis, IN: Sigma Theta Tau International.

Polit, D.F. & C.T. Beck. 2007. Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia: Lippincott, Williams & Wilkins.

Schmidt, N.A. & J.M. Brown. 2009. Evidence-Based Practice for Nurses: Appraisal and Application of Research. Sudbury, MA: Jones & Bartlett.

Springhouse Editorial Staff.  2007. Best Practices: Evidence-Based Nursing Procedures. Philadelphia:  Lippincott, Williams & Wilkins.

Springhouse Editorial Staff.  2008. The Evidence-Based Nursing Guide to Disease Management . Philadelphia: Springhouse.

Springhouse Editorial Staff. 2008. The Evidence-based Guide to Sign & Symptom Management. Philadelphia: Springhouse.

Vacarolis, E.M., and M.J. Halter. 2008. Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care. Philadelphia: Saunders.

Tony Stankus, [email protected] Life Sciences Librarian & Professor

University of Arkansas Libraries MULN 223E

365 North McIlroy Avenue

Fayetteville, AR 72701-4002

Voice: 479-575-4031

Fax: 479-575-4592

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