Anne Mulhall, Nursing, research, and the evidence [editorial]. Evidence-Based Nursing 1998 Jan;1:4-6.
Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?
Research has been used to legitimise nursing as a profession, education has been radically reformed to reflect a research base, and academic nurses have built their careers around it. However, despite the length of time that research has been on the agenda and the influential bodies involved, only a moderate proportion of nurses use research as a basis for practice.1
What has gone wrong?
Part of the difficulty is that although nurses perceive research positively,2 they either cannot access the information, or cannot judge the value of the studies which they find.3 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long.4
Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly 'scientific' research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research might best provide those answers.
What is nursing about?
Increasingly, medicine and nursing are beginning to overlap. There is much talk of interprofessional training and multidisciplinary working, and nurses have been encouraged to adopt as their own some tasks traditionally undertaken by doctors. However, in their operation, practice, and culture, nursing and medicine remain quite different. The oft quoted suggestion is that doctors 'cure' or 'treat' and that nurses 'care', but this is not upheld by research. In a study of professional boundaries, the management of complex wounds was perceived by nurses as firmly within their domain.5 Nurses justified their claim to 'control' wound treatment by reference to scientific knowledge and practical experience, just as medicine justifies its claim in other areas of treatment. One of the most obvious distinctions between the professions in this study was the contrast between the continual presence of the nurse as opposed to the periodic appearance of the doctor. Lawler raises the same point, and suggests that nurses and patients are 'captives' together.6 Questioning the relevance of scientific knowledge, she argues that nurses and patients are 'focused on more immediate concerns and on ways in which experiences can be endured and transcended'. This highlights the particular contribution of nursing, for it is not merely concerned with the body, but is also in an 'intimate' and ongoing relationship with the person within the body. Thus nursing becomes concerned with 'untidy' things such as emotions and feelings, which traditional natural and social sciences have difficulty accommodating. 'It is about the interface between the biological and the social, as people reconcile the lived body with the object body in the experience of illness.'7
What sort of evidence does nursing need?
These arguments suggest that nursing, through its particular relationship with patients and their sick or well bodies, will rely on many different ways of knowing and many different kinds of knowledge. Lawler's work on how the body is managed by nurses illustrates this.6 She explains how an understanding of the physiological body is essential, but that this must be complemented by evidence from the social sciences because 'we also practice with living, breathing, speaking humans.' Moreover, this must be grounded in experiential knowledge gained from being a nurse, and doing nursing. Knowledge, or evidence, for practice thus comes to us from a variety of disciplines, from particular paradigms or ways of 'looking at' the world, and from our own professional and non-professional life experiences.
Picking the research design to fit the question
Scientists believe that the social world, just like the physical world, is orderly and rational, and thus it is possible to determine universal laws which can predict outcome. They propose the idea of an objective reality independent of the researcher, which can be measured quantitatively, and they are concerned with minimising bias. The other major paradigm is interpretism/naturalism which takes another approach, suggesting that a measurable and objective reality separate from the researcher does not exist; the researcher cannot therefore be separated from the 'researched'. Thus who we are, what we are, and where we are will affect the sorts of questions we pose, and the way we collect and interpret data. Furthermore, in this paradigm, social life is not thought to be orderly and rational, knowledge of the world is relative and will change with time and place. Interpretism/naturalism is concerned with understanding situations and with studying things as they are. Research approaches in this paradigm try to capture the whole picture, rather than a small part of it.
This way of approaching research is very useful, especially to a discipline concerned with trying to understand the predicaments of patients and their relatives, who find themselves ill, recovering, or facing a lifetime of chronic illness or death. Questions which arise in these areas are less concerned with causation, treatment effectiveness, and economics and more with the meaning which situations have--why has this happened to me? What is my life going to be like from now on? The focus of these questions is on the process, not the outcome. Data about such issues are best obtained by interviews or participant observation. These are aspects of nursing which are less easily measured and quantified. Moreover, some aspects of nursing cannot even be formalised within the written word because they are perceived, or experienced, in an embodied way. For example, how do you record aspects of care such as trust, empathy, or 'being there'? Can such aspects be captured within the confines of research as we know it?
Questions of causation, prognosis, and effectiveness are best answered using scientific methods. For example, rates of infection and thrombophlebitis are issues which concern nurses looking after intravenous cannulas. Therefore, nurses might want access to a randomised controlled trial of various ways in which cannula sites are cleansed and dressed to determine if this affects infection rates. Similarly, some very clear economic and organisational questions might be posed by nurses working in day surgery units. Is day surgery cost effective? What are the rates of early readmission to hospital? Other questions could include: what was it like for patients who had day surgery? Did nurses find this was a satisfying way to work? These would be better answered using interpretist approaches which focus on the meaning that different situations have for people. Nurses working with patients with senile dementia might also use this approach for questions such as how to keep these patients safe and yet ensure their right to freedom, or what it is like to live with a relative with senile dementia. Thus different questions require different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question.
Research designs useful to nursing
Nursing presents a vast range of questions which straddle both the major paradigms, and it has therefore embraced an eclectic range of research designs and begun to explore the value of critical approaches and feminist methods in its research.8 The current nursing literature contains a wide spectrum of research designs exemplified in this issue, ranging from randomised controlled trials,9 and cohort studies,10 at the scientific end of the spectrum, through to grounded theory,11 ethnography,12 and phenomenology at the interpretist/naturalistic end.13 Future issues of this journal will explore these designs in depth.
Maximising the potential of evidence-based nursing
Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients.14 Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioners.15
In summary, in embracing evidence-based nursing we must heed these considerations:
- Nursing must discard its suspicion of scientific, quantitative evidence, gather the skills to critique it, and design imaginative trials which will assist in improving many aspects of nursing
- We must promulgate naturalistic/interpretist studies by indicating their usefulness and confirming/explaining their rigour in investigating the social world of health care
- More research is needed into the reality and consequences of adopting evidence-based practice. Can practitioners act on the evidence, or are they being made responsible for activities beyond their control?
- fIt must be emphasised that those concerns which are easily measured or articulated are not the only ones of importance in health care. Space is needed to recognise and explore the knowledge which comes from doing nursing and reflecting on it, to find new channels for speaking of concepts which are not easily accommodated within the discourse of social or natural science--hope, despair, misery, love.
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- Lacey A. Facilitating research based practice by educational intervention. Nurs Educ Today 1996;16:296-301.
- Pearcey PA. Achieving research based nursing practice. J Adv Nurs 1995;22:33-9.
- Mulhall A. Nursing research: our world not theirs? J Adv Nurs 1997;25:969-76.
- Walby S, Greenwell J, Mackay L, et al. Medicine and nursing: professions in a changing health service. London: Sage, 1994.
- Lawler J. The body in nursing. Edinburgh: Churchill Livingstone, 1997.
- Lawler J. Behind the screens nursing. Edinburgh: Churchill Livingstone, 1991.
- Street AF. Inside nursing: a critical ethnography of clinical nursing practice. New York: State University Press of New York, 1992.
- Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997;52:223-8.
- Kushi LH, Fee RM, Folsom AR, et al. Physical activity and mortality in postmenopausal women. JAMA 1997;277:1287-92.
- Rogan F, Shmied V, Barclay L, et al. Becoming a mother: developing a new theory of early motherhood. J Adv Nurs 1997;25:877-85.
- Barroso J. Reconstructing my life: becoming a long-term survivor of AIDS. Qual Health Res 1997;7:57-74.
- Thibodeau J, MacRae J. Breast cancer survival: a phenomenological inquiry. Adv Nurs Sci 1997;19:65-74.
- Sackett D, Haynes RB. On the need for evidence-based medicine. Evidence-Based Medicine 1995;1:5-6.
- Gordon DR Tenacious assumptions in Western biomedicine. In: Lock M, Gordon DR, eds. Biomedicine Examined. London: Kluwer Academic Press, 1988;19-56.