Evidence for Decision-making – different perspectives

1. B71P02 - Foundations in Evidence Based Practice Evidence for Decision-making – different perspectives

2. Session Outcomes At the end of this session you will be able to: • Identify a range of perspectives that influence evidence based nursing practice • Consider the extent to which these perspectives facilitate or complicate evidence based nursing practice • Appreciate how user involvement influences the delivery of care

3. Different Forms of Evidence Evidence based practice is ‘the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences, in the context of available resources’ (DiCenso et al, 1998)

4. Perspectives on Evidence Research Evidence Nursing action Patient / User perspectives Clinical expertise Nursing outcomes Practice context

5. Research Evidence • Arising from well conducted and reviewed research studies, ideally conducted in clinical areas. • Published in peer reviewed journals and other sources (Cochrane library) and thus exposed to external/expert scrutiny • Clinical expertise and the user voice may be present in published research e.g. through action research or qualitative studies of user experience • ‘..there has been anxiety that the emphasis on evidence ignores practitioner’s skills and individual patient preferences…’ (Closs and Cheater (1999)

6. Clinical expertise • Gates and Atherton (2001) note that in a study conducted by Tsafrir and Grinberg (1998) ‘…physicians considered review articles and meta-analysis extremely reliable for information purposes but for practical patient care they tended to rely upon the judgement of peers and experts…’ (p.518) • There is a potential gap between national agendas and what nursing staff consider to be local priorities (Brooks & Barrett, 2003) • Colbrook (2002) writes that the Medical Defence Union advise that healthcare staff are not obliged to follow national clinical guidelines when they can justify that they were not in the patient’s best interests or applicable to the patient’s particular circumstances.

7. User/patient perspectives ‘… practitioners do not necessarily know what is in the best, personal interests of an individual patient..’ (Closs & Cheater, 1999)

8. User/patient perspectives ‘…there is abundant evidence demonstrating wide discrepancies between patient’s and professional’s judgements about what constitute desirable or successful outcomes…’ (Closs & Cheater, 1999)

9. User/patient perspectives ‘…past experience, individual beliefs, family/peer pressure or greater access to information may lead patients to request a particular intervention…’ (Closs & Cheater, 1999)

10. User/patient perspectives • ‘It is not only practitioners who need to know about the latest evidence of the effectiveness of treatments and services. Service users need this information in order to make their own choices based on the research evidence and a whole range of other complex factors, some of which will be unique to them’ (Needham, 2000, p.144) • A well informed patient may change the practice of the health professional and information can change the patient-practitioner relationship from one in which the patient passively accepts advice to one in which the patient becomes a partner in shared decision-making (Needham, 2000)

11. Implementing EBP: A Conceptual Framework Kitson et al (1998) have argued that implementing research into practice may be expressed in this equation: SI=f (E,C,F) Where SI=successful implementation; E=evidence; C=context; F=facilitation; and f=function of.

12. Session summary ‘...Evidence based practice is not simply a pragmatic, logical process, involving access to, and the subsequent use of best research evidence. There is an interplay of multiple factors that influence decisions about patient care; an amalgam of evidence, context, expert practice/experience and patients’ preferences and wishes…’ (Closs & Cheater, 1999)

13. References • Barnett (1997) in Brechin, A. (2000) ‘Introducing critical practice’ in Brechin, A., Brown, H. and Eby, M. (eds) (2000) Critical Practice in Health and Social Care, London, Sage Publications/Open University. • Brookes, N. and Barrett, A. (2003) ‘Identifying nurse and health visitor priorities in a PCT using the Delphi technique’, British Journal of Community Nursing, Vol.8, No.8, pp. 376-380. • Closs, S.J. and Cheater, F.M. (1999) ‘Evidence for nursing practice: a clarification of the issues’, Journal of Advanced Nursing, Vol.30, No.1, pp. 10-17. • Colbrook, P. (2002) The Legal Status of NICE Guidelines, The Medical Defence Unit, London. • DiCenso, A., Cullum, N. and Ciliska, D. (1998) ‘Implementing evidence-based nursing: some misconceptions’, Evidence Based Nursing, Vol.1, pp. 39-39. • Gates, B. and Atherton, H. (2001) ‘The challenge of evidence-based practice for learning disabilities’ British Journal of Nursing, Vol.10, No.8, pp. 517-522 • Gomm, R. (2000) ‘Would it work here’ in Gomm, R. and Davies, C. (eds) (2000) Using Evidence in Health and Social Care, London, Sage Publications/Open University. • Kitson, A., Harvey, G. and McCormack, B. (1998) ‘Enabling the implementation of evidence based practice: a conceptual framework’, Quality in Health Care, 7, pp. 149-158. • Needham, G. (2000) ‘Research and practice: making a difference’ in Gomm, R. and Davies, C. (eds) (2000) Using Evidence in Health and Social Care, London, Sage Publications/Open University.