Evidence of success

Is the way you practice based on sound research, or is it just the way it’s
always been done? Nurses are increasingly expected to keep abreast of current
research, by Greta Thornbory

The fact that you are reading this article indicates that you are interested
in improving practice and care, which is what continuing professional
development is all about.

However, occupational health practice, by its very nature, is often isolated
from other healthcare practice. So how do OH practitioners know that what they
are doing is the right thing? How do they keep up to date with the latest
practice? And how do they know what they are doing is the most efficient and
effective way to practice?

What is evidence-based practice?

This article aims to explore and discuss what ‘evidence-based practice’
really means, how it fits into clinical effectiveness and the steps that are
needed in order to ensure that OH nursing practice is evidence based. Although
there has been a move towards evidence-based practice. It does have its
limitations. Pearson, cited by Johnson and Griffiths1, cautions that it is not
a cure for all nursing ills and McKenna et al2 demolishes some of the myths
surrounding the concept.

Today’s nurses are expected to care for their patients, identify their
actual and potential problems, and develop research-based strategies "to
prevent, ameliorate and comfort" so says Dicenso et al3.

They go on to say that nurses are also expected to take on work
traditionally done by doctors and to be highly educated empathetic
communicators. They need to be critical thinkers and keep abreast of important
research findings. Traditionally, nursing has been derived from knowledge based
on anecdote and tradition1. Think back to your own training – why did you do
what you did? Was it because sister or staff nurse told you to – and why did
they do it? There have been some classic examples of ‘habit-based practice’
such as salt in the bath.

The evidence-based healthcare movement has developed rapidly over the past
10 years4 and is thought to have originated in Canada as "…the
conscientious, explicit and judicial use of current evidence in making
decisions about the care of individual patients".

Such a definition does not necessarily suit OH nursing because many
practitioners do not have individual patients – but rather clients – and it may
be populations of employees on which decisions about care are being made.
However, Dicenso et al3 say that research utilisation has been defined as the use
of research findings in all aspects of work as a nurse and they believe that
this is the same as the definition for evidence-based nursing.

But is all this known under another name and as part of ‘clinical
effectiveness’ defined by the RCN5 as "doing the right thing in the right
way at the right time for the right patient"? The RCN goes on to say that
clinical effectiveness, of which evidence-based practice is part, is about
making sure that you offer the best care possible for an individual patient or
for a population. Fennessy6 says that the concepts of evidence-based practice
and evaluation, or clinical audit, are brought together into a coherent model
for improving clinical practice and as such form the parts of clinical
effectiveness.

The steps for clinical effectiveness and evidence-based practice require an
enquiring mind, and an ability to look at and criticise one’s practice.

Recent questions about health assessment that have been asked on one of the
OH Websites indicate that nurses still cannot justify why they are undertaking
certain screening procedures for pre-employment health assessment.

Further questioning by expert practitioners indicates that they have not
considered the evidence base for their practice and cannot give an explanation for
their actions; rather their practice is based on habit. If occupational health
nurses are to move forward with clinical effectiveness and evidence-based
practice perhaps this is one area with which to start. The first steps require
looking at practice and developing a questioning attitude to day-to-day
practice5.

Information gathering

The next step is to gather the ‘evidence’, to search for and gather relevant
information and to look for the best available knowledge5,6. The problem here
is in deciding which evidence is ‘good’ and how to go about finding it in the
first place.

According to Evans and Pearson7 the demand for evidence to support practice
is growing, but finding the best evidence is becoming increasingly difficult.
They go on to say that the need for evidence on which to base care is growing
as a result of many factors such as:

– the expectation of high quality services

– the demand for redress and compensation

– the existence of many new technologies, procedures and products

OH practitioners are answerable to both employers and employees who all
expect a high quality of service. This is especially so because they are paying
for the OH service. OH practitioners must therefore be able to justify their
actions and give explanations for them.

Pre-employment health assessment is an example of OH nursing practice that
needs to be evidence based. What screening is actually undertaken during health
assessments and why? Does research indicate that one-off screening tests, such
as blood pressure measurements and urinalysis, are effective indicators of a
person’s health status and fitness to work?

Despite much research into the best ways to measure blood pressure there
remains considerable controversy8. Urinalysis may detect early signs of disease,
but research undertaken in 1992 showed that only 0.9 per cent of a sample were
undiagnosed diabetics9. Research-based evidence is available and it is a
practitioner’s duty to ensure that he or she finds it, reads it and acts upon
it, as nurses are personally accountable for their practice10.

These examples are only the tip of the iceberg and a thorough search of
nursing literature is necessary to ensure that all aspects of any topic are
explored.

Information is available in a variety of forms and it is important to be
clear about what you want to know or find out and to be aware of how to access
all forms of information. With the advance of technology and the Internet, more
and more resources are available and searching for information can be fun rather
than a chore.

Types of evidence

There are a number of different types of evidence:

– Primary research

– Systematic reviews

– Meta-analysis

– Clinical guidelines

– Textbooks

– Expert opinion

Each has its own place and significance in evidence-based practice and the
first four will be discussed, highlighting their relevance to OH nursing
practice. A thorough literature search is necessary to identify what evidence
is available.

Primary research

Primary research is usually published in professional journals. The best
evidence comes from ‘randomised controlled trials’ and results from such
research are ranked highly11. However, such research is not always ethically
possible with regard to nursing practice1.

Finding best evidence is becoming increasingly difficult7 and it is not
enough just to find relevant research, the work needs to be closely examined to
assess and decide on its quality and worth. This is where ‘critical appraisal’
skills are needed. Critical appraisal means checking that research was done
properly, that the method was suitable and that its findings are relevant to
your area of practice. It is worthwhile looking for a course to help with
developing these skills. Further information is given at the end of the
article.

Systematic reviews

To make life easier for evidence-based practice and to find a way around the
vast quantity of research, a system called ‘systematic review’ has been
developed.

Evans and Pearson7 describe systematic reviews as the ‘gatekeepers’ of
nursing knowledge and argue that they represent the ‘gold standard’ in research
summaries. Along with Johnson and Griffith1 they found that most research
regarded as credible in the healthcare sector depend on randomised control
trials and agree that such methods do not do justice to nursing research.

Their paper discusses the issues that need to be considered and addressed
for more appropriate systematic reviews of nursing research. They also say the
aim of a systematic review is to provide reliable summaries of past research
and this is exactly what OH practitioners need.

Magarey4 defines a systematic review as "the application of scientific
strategies that limit bias to the systematic assembly, critical appraisal and
synthesis of all relevant studies on a specific topic". In other words it
does the work for you. It is worth reading more about this topic and the
references given in this article are available free online to RCN members.
Systematic reviews can be found on a number of databases and in specialist
journals (see the list at the end of this article). It is also worth looking at
some reviews to get a clear idea of how they work and what they say.

Meta-analysis

Briefly, meta-analysis is a process of pooling together a number of, often
conflicting, small research studies on the same topic to give one overall
picture. It is necessary to be cautious about the results of this process, and
to understand it properly, before accepting the results on which to base or make
changes to practice.

Clinical guidelines

Clinical guidelines are developed by professional organisations, such as the
royal colleges or at local levels by large healthcare providers. In OH they may
have been developed by specific companies with large OH services. They should
be based on up-to-date and suitably appraised evidence and give guidelines for
practice and management, helping to set an overall standard. Clinical
guidelines are being developed on a number of topics at a national level and it
is worth looking at an example for OH practice, such as the UK Guidance on Best
Practice in Vaccination Administration12, available from the RCN. Don’t forget
that guidelines should be:

– Based on valid and reliable research

– Prepared by a multi-disciplinary panel

– Not past their use by date5

Implementation

It has been said, anecdotally, that to go from research to a change in
practice takes 10 years. To ensure that your practice is evidence based takes
time and a questioning mind. Nurses may not have the time or resources to
undertake searches or read research, reviews or guidelines. They may feel
threatened or anxious about making changes. But some will want to make changes
to practice for the benefit of their clients and the organisation they work for.
Changes can be made if they are handled carefully and evidence of the benefits
can be shown.

Working with a committed team helps, but if you work on your own it may take
more courage. Discussing this with a respected colleague, even in another
organisation, may help. The RCN5 suggests the following key points for
introducing change:

– Decide on priorities for change

– Don’t take on too much

– Be realistic

– Don’t try and do it on your own

– Involve your colleagues

– Remember, change can be difficult

– Don’t expect things to change over night

– And don’t forget to build in some evaluation, or clinical audit.

References

1. Johnson M, Griffiths R (2001) Developing evidence-based clinicians.
International Journal of Nursing Practice 7: 109-118

2. McKenna H, Cutliffe J, McKenna P (2000) Evidence based practice:
Demolishing some myths. Nursing Standard 5 January, 14(16): 39-42.

3. Dicenso A et al (2000) Introduction to evidence based
nursing.www.cebm.utoronto.ca 2002.

4. Magarey J M (2001) Elements of systematic review. International Journal
of Nursing Practice 7:376-382.

5. Royal College of Nursing (1999) Doing the right thing; clinical
effectiveness for nurses. London: RCN.

6. Fennessy G (1999) What’s the evidence? Clinical effectiveness. Nursing
Update

Unit 87, Nursing Standard Nov 11, 3(8).

7. Evans D, Pearson A (2001) Systematic Reviews: gatekeepers of nursing
knowledge. Journal of Clinical Nursing 10: 593-599.

8. Beever M (1998) On the way up: hypertension. Nursing Update Unit

80, Nursing Standard 18 March, vol 12(26).

9. Worral G, Moulton N (1992) The ratio of diagnosed to undiagnosed
diabetics in patients 40 yrs and older. Canadian Journal of Public Health
83(5): 379-381.

10. UKCC (1992) The Scope of Professional Practice. London: UKCC.

11. Belsey J, Snell T (1997) What is Evidence-Based Medicine? Hayward
Medical Communications Ltd.

12. Driver C et al (2001) UK Guidance on Best Practice in Vaccination
Administration, Shire Hall Communications.

Critical Appraisal11  

Critical appraisal is the method of
assessing and interpreting the evidence by systematically considering its
validity, results and relevance to the area of work being considered.

Questions to ask

– Do you know why you do what you do?

– Can you give an explanation as to why you are doing it?

– Are you up to date or is your practice based on habit?

Sources of  information for evidence-based practice

Journals

www.nursing-standard.co.uk
Register and you can access Nursing Standard’s archive and download research
articles and CPD articles from all the RCN journals

www.personneltoday.com
The site for Occupational Health journal

www.freemedicaljournals.com
This site concentrates primarily on medical journals but it is
good for some specialist information. Beware, as some of the journals are only
free for a trial period after which you will need to subscribe

www.nursingtimes.co.uk

www.heapro.oupjournals.org
This is the site for Health Promotion International with leads to Health
Education Research and many other relevant journals

www.nursing-libraries.org.uk
A new site aimed at nurses in Wales but will be expanding to cover the rest of
the UK. This site outlines where nurses can access libraries and which
facilities are available

http://omni.ac.uk/
An extremely useful site which provides a gateway to biomedical resources. It
includes some free access to Medline and other databases

www.nursingnet.org/
American site with links to electronic journals and some
interactive features

www.jr.ox.uk/bandolier/
For research systematic reviews

www.cochrane.hcn.net
For research on systematic reviews -the gold standard!

Nursing and health information sites

www.rcn.org.uk
If you are an RCN member you can register, log on and download several journals
(www.blackwell-synergy.com) as well as join BNI (British Nursing Index), which
gives you access to search facilities

www.nmap.ac.uk
An extremely informative site containing a lot of information relevant to
nursing practice including lots of links to other useful sites

www.nelh.nhs.uk
Part of the Government’s information for health strategy. This site is still
being developed but is worth visiting. A series of branch libraries is being
developed; the first includes Primary Care Groups and Mental Health

www.man.ac.uk/rcn
Linked to the RCN Research and Development Co-ordination Centre at Manchester
University. This website enables you to search according to geographic
area

www.shef.ac.uk/~nhcon/nuuk.htm
An extremely informative site containing a lot of information
relevant to nursing practice including links to other useful sites

www.healthcentre.org.uk/hc/default.htm
This site acts as a signposting service, providing information for patients and
carers as well as a separate staff room for healthcare professionals

www.healthgate.com
A useful site providing information for patients, carers and health care
workers. Includes separate healthcare centres for women’s health,
men’s health, mental health, alternative health, etc.

Also includes detailed research facilities

www.ukcc.org.uk

www.enb.org.uk

www.had-online.org.uk  (replaces HEA)

www.health-news.co.uk
Very useful site for up-to-date health care news of all sorts

www.who.dk
World Health Organisation Europe

www.icn.ch
International Council of Nurses

Occupational health sites

www.jiscmail.ac.uk

This site allows you to join the mailing list for OH professionals – go to
medicine and health and then scroll down to occupational health – click on and
join up.

NB – there are other specialties on this site – go to health
and pick your own topic area

Critical appraisal course information

www.phru.org.uk
Oxford Critical Appraisal Programme Old Road, Headington, Oxford,
OX3 7LF 01865 226968

Government sites

www.statistics.gov.uk
A site for all the statistics you want

www.hse.gov.uk

www.hsebooks.co.uk

www.doh.gov.uk

www.cdc.gov
American communicable diseases centre

www.eoc.org.uk
The site of the Equal Opportunities Commission

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