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How can we argue for evidence in nursing?
Annette F Street
Professor, Cancer and Palliative Care Studies; Director, Centre for Research in Nursing, School of Nursing, La Trobe University, Bundoora VIC
Article Text
'What is your evidence for this claim?' As a practitioner, whenever I wanted to institute change, the CEO would question me on the evidence available to support the need for change and to inform the direction of any new proposal. The kind of evidence he required was that provided by substantiated research on similar organisational changes or therapeutic interventions. Likewise, during my undergraduate and postgraduate education, this question rang through my ears. As a student I soon learnt that if I was going to make a claim of any sort I needed to have the evidence to back it up. Now as a teacher of nurses I have often commented on the need for a stamp with this question printed on it that could be used in the margins of the essays and thesis drafts I am correcting. In clinical areas, when challenges are made to traditions and taken-for-granted assumptions underpinning nursing, then a justification for the proposed changes needs to be provided.
However, the notion of evidence in health care has taken on a new potency over the last decade. Following the publication of Archie Cochrane's (1972) landmark book Effectiveness and Efficiency: Random Reflections on Health Services, where he draws attention to the collective ignorance about the effects of health care, evidence based medicine has been developing. Sackett & Rosenberg (1995) acknowledged that few health professionals have the time to search for, nor the skills to critically evaluate, evidence on which to base their practice. They recognised that the way to encourage doctors to base their practice on evidence was to assemble the evidence for them. In 1993 the international organisation Cochrane Collaboration was formally established to assist people make 'well-informed decisions about healthcare by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions', initially in controlled trials.
Lawyers and historians have very clear criteria for what is admissible evidence or acceptable forms of source material. Funding bodies and review committees have followed suit with systematic reviews being valued for their capacity to demonstrate the 'best evidence'. Although the interests of early practitioners were based on reviews of randomised controlled trials it soon became apparent that there were many topics that had not been investigated in this manner. This led to the evolution of levels of evidence upon which best practice could be based:
- Level I- Evidence obtained from a systematic review of all relevant randomised controlled trials.
- Level II- Evidence obtained from at least one properly designed randomised controlled trial.
- Level III.1- Evidence obtained from well-designed controlled trials without randomisation.
- Level III.2- Evidence obtained from well-designed cohort or case control analytic studies, preferably from more than one centre or research group.
- Level III.3- Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments.
- Level IV- Opinion of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
As is apparent, these levels classified and legitimated research activities on the basis of their capacity to be controlled, randomised and generalisable. The intention is to create cause and effect forms of knowledge to guide practice. The problem with these levels is that they ignore the kind of qualitative and action-oriented research that is also important to the understanding and development of nursing practice.
Therefore, although the evidence based practice movement has been widely adopted by medicine, it has had mixed reviews by nurses. Some nurses have embraced the concept. They use systematic reviews to guide practice and have begun developing their own systematic reviews (Droogan & Song, 1996; Simpson, 1996; McCarthy & Hegney, 1998; Kitson et al., 1998). Nursing initiatives, such as the multi-sited Joanna Briggs Institute for Evidence Based Nursing & Midwifery, have developed strategies to provide systematic reviews of nursing interventions and to conduct randomised controlled trials in areas where gaps have been perceived. Best practice guidelines have been developed from reviews of nursing related topics such as falls in hospital, constipation in older adults, pressure sore management, smoking cessation interventions and strategies, or tracheal suctioning of adults with an artificial airway. The intention of these reviews has been to discover evidence of effectiveness, that is, evidence that is able to predict the outcome of such nursing interventions.
Health care consumers expect that nurses will make decisions on their health care based on the best evidence available. Health promotion and health education programs, along with the plethora of information readily available on the Internet, have helped to develop a much more knowledgeable consumer. Many people with chronic illnesses become experts in the specific scientific evidence related to their condition and its treatment. It is hard to disagree with the need for reliable evidence of efficacy. However, the evidence based approach has not been without its detractors. Many nurses have been tempted to disregard the evidence based practice movement. They value those research methods that enable them to explore the lived experience of people with illnesses, understand historical and contextual influences, debate ethical questions, examine policy, explore consumer and clinical needs, develop collaborative partnerships, participate in change processes and critique established health care practices. In other words, these nurses acknowledge the importance of understanding the psychological, social, spiritual, ethical, political and economic concerns of patients and their families that influence their willingness or capacity to benefit from interventions based on evidence derived from experimental studies. In order to address these concerns, some nurse researchers have argued that we need to develop systematic criteria to examine and defend the kind of evidence that can be discovered using qualitative approaches (Sandelowski et al., 1997; Popay et al., 1998; Lemmer et al., 1999). Pearson(1998) suggested that that nursing needed not only evidence of effectiveness, but also evidence of appropriatenessand feasibility.
The challenge becomes: How do we develop evidence of appropriateness and feasibility? Is such an approach helpful for nursing questions? Evidence of appropriateness can be discovered in many ways. Many qualitative methodologies favoured by nurses (phenomenology, ethnography, grounded theory, or discourse analysis) and their hybrids (such as phenomenography, historiography or ethnomethodology) enable us to locate the person in their social, cultural, economic, ethical and spiritual context. They allow us to address questions of meaning, culture, theory generation and social constructions. Thus these methods enable us to answer questions of acceptability such as:
- What is it like to be a teenager with diabetics?
- How can we delineate the concept of hope?
- What is the meaning of inflicting and relieving pain for nurses?
- What are the competing discourses that frame the experience of breast cancer?
- What are the experiences of Vietnamese women with reproductive health services?
Likewise, feminist, praxis and action-oriented critical or post-colonial approaches, directed at changing practice, are able to provide evidence of feasibility. Such methodologies are designed around reflexive processes of simultaneous action and evidence gathering. They focus on the process and effects of the desired intervention in order to be able to demonstrate how it may be feasible. The intention is not only to find out what works but also to be able to provide evidence of why it works and under what conditions it works so that the lessons learnt can be adapted to another context. Research processes that enable us to gather evidence of feasibility enable us to address such questions designed to improve or change a situation:
- How can we improve the care provided to stroke patients?
- How can we develop and evaluate the role of an advanced breast care nurse?
- How can we involve families in the care of their elderly resident of an aged care facility?
- How can nurses effectively meet the needs of people from culturally and linguistically diverse backgrounds?
- How can midwives work with pregnant, homeless substance abusers to provide quality midwifery care?
These questions are just as valuable as those evidence based questions directed at generalisable predictive evidence of effectiveness. However, if we are to make a case for the valuing of different forms of qualitative evidence, we also need to make sure that our evidence is sound, that it has rigor and merit. We cannot take the high ground and make claims concerning the value of our qualitative studies if we are not prepared to put the rigor of our processes and strategies under review. There has been some outstanding nursing scholarship that has taken qualitative approaches. Such studies have changed the thinking and practices of nurses worldwide. Unfortunately there have also been many small, short projects that report themes or categories of information that a good nurse could have described without doing the research. Maintaining excellence in design and execution of research requires sound methodological knowledge of the particular research tradition that informs the study. Planning a number of related studies to expand the knowledge base of health care in particular areas is one way to address the lack of continuity in some areas of some nursing scholarship. Another approach is to engage in multi-disciplinary, multi-method research that incorporates qualitative studies into larger research programs.
If we are to seriously consider the need to develop evidence to inform nursing care then perhaps more energy needs to be directed towards defining and defending criteria of evidence that is focused on answering questions about the appropriateness or feasibility of the nursing interventions. To do this we need to consider the development of criteria that defines high quality qualitative research using a range of methods to answer nursing questions.
References
Cochrane AL (1972): Effectiveness and Efficiency: Random Reflections on Health Services. Nuffield Provincial Hospitals Trust, London.Droogan J & Song F (1996): The importance of systematic reviews. Nurse Researcher 4(1): 15–26.
Kitson A, Harvey G & McCormack B (1998): Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care 7: 149–58.
Lemmer B, Grellier R & Steven J (1999): Systematic review of non-random and qualitative research literature: Exploring and uncovering an evidence base for health visiting and decision making. Qualitative Health Research 9: 315–28.
McCarthy A & Hegney D (1998): Evidence-based practice and rural nursing: A literature review. Australian Journal of Rural Health 6(2): 96–9.
Pearson A (1998): Excellence in care: Future dimensions for effective nursing. NT Research 3(1): 25–27.
Popay J, Rogers A & Williams G (1998): Rationale and standards for the systemic review of qualitative literature in health services research. Qualitative Health Research 8(3): 341–51.
Sackett DL & Rosenberg WMC (1995): On the need for evidence-based nursing. Health Economics 4: 249–54.
Sandelowski M, Docherty S & Emden C (1997): Qualitative metasynthesis: Issues and techniques. Research in Nursing and Health 20: 365–71.
Simpson B (1996): Evidence-based nursing practice: The state of the art. The Canadian Nurse 92(10): 22–5.
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