In the second article in their two-part series on evidence-based practice, Jo Rhodes and Professor Anne Harriss outline effective scrutiny of practice guidelines, and assess the perils of media and online misinformation.
Jo Rhodes is an occupational health nurse and Professor Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, NTFHEA, PFHEA, FRCN is emeritus professor of occupational health and president of SOM.
The first article in this series of two covering evidence-based practice highlighted the importance of evidence-based practice and how evidence is sourced. There is reference within that article to the importance of the scrutiny of practice guidelines (PGs). These will be the focus of this article.
Evidence-based practice
CPD: gathering and interrogating evidence to improve your OH practice
Evidence-based practice: Do OH nurses support it?
As there is the potential for conflicting or poorly compiled guidelines, user scrutiny is essential. Guideline assessment tools assist in the critical evaluation of PGs. Brouwers et al (2010) recommend the benefit of the AGREE II (2010) tool, which consists of six domains and 23 associated characteristics, to assist in such evaluation.
This article highlights how these domains can be applied to the critical evaluation and development of PGs for use in the occupational health (OH) setting.
For example, when reviewing practice guidelines relating to back pain, the term “back pain” can be used to collect information regarding PGs to identify development strengths, weaknesses, and legitimacy for clinical implementation.
Sourcing high-quality research evidence
The TRIP clinical search engine can be used effectively as it is designed to quickly and easily source high-quality research evidence that can be used to underpin occupational health practice.
So, when searching using the term “back pain” TRIP located: “Low back pain and sciatica in over 16s: assessment and management” (National Institute for Health and Care Excellence (NICE), 2016 a) and “Non-invasive treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline” (American College of Physicians (ACP), 2017).
Domain 1 of the AGREE tool covers PG “scope” with clinical application criteria. In both documents, their aims, target (and exempt) populations, health questions and clinical management recommendations are well-defined and clearly stated.
The extensive web-based resources relating to PGs produced by NICE take time to navigate and are more complex than those produced by the American College of Physicians (ACP).
Unlike ACP, NICE includes reference to education, research, surgical interventions, general practice, pain management, osteopathy, nursing, radiology and psychology thus securing a diverse multi-disciplinary team. Contributors’ names, roles, organisations and conflicting interest data are annotated.
Participants’ contributions to NICE PG formation meetings are minuted with exclusions applied if conflicting interests arise. This reduces bias and suggests a quality PG (NICE, 2016 b).
Kredo et al (2016) emphasise the importance of encouraging stakeholders’ views. NICE works with patients, pharmaceutical businesses, charities and the general public (tobacco organisations are excluded).
Understanding the perspective of patients regarding treatments is important. PGs developed without patient involvement are unacceptable and NICE recognises this stance. By contrast, the contributors’ list suggests that this is not a priority for them scoring lower in domain 2 (Stakeholders).
NICE recognises the importance of equality and diversity using “equality impact assessments”. Furthermore, NICE Citizens’ Councils offer public perspectives and “social value judgements” regarding the ethical and moral elements of PGs (NICE, 2016 c, NICE 2016 d).
Good PGs encompass high-level evidence, which may be comparably interpreted by the producers of other guidelines (reproducibility). NICE details PICO questions, index terms (with Boolean operators and truncation).
The ACP cite 184 references with annotated evidence-quality gradings showing strengths and weaknesses as advocated by Kredo et al (2016). Interestingly, APC used its own grading system to rate evidence strength rather than a neutral system such as GRADE (BMJ, 2019).
The ‘GRADE’ acronym
The GRADE acronym represents: Grading of Recommendations, Assessment, Development and Evaluations. This framework presents summaries of evidence providing a systematic approach for making clinical practice recommendations and is the most widely adopted tool for grading the quality of evidence.
Existing research deficits impacting on current recommendations are clearly explained by the APC. This assists researchers to prioritise future trials.
APC and NICE score well in the “Rigour of Development” (domain 3), contrasting positives and potential harms of back pain treatments, there is the potential for negative evidence being “hidden” and APC describe areas of insufficient evidence to robustly inform policy. New research findings influence current practices.
Therefore, to retain credibility, PGs must be regularly reviewed. Vernooij et al (2014) state frequency requirements are ambiguous with non-specific updating processes. NICE updates are easily identifiable although APC PG review dates are not evident, reducing PG quality. Both PGs have undergone peer and expert opinion review.
Stakeholder comments are documented; NICE respond accordingly although replies from APC cannot be seen.
Healthcare professionals and patients must be aware of potential positives and negatives of treatment outcomes to make informed choices. Both PGs give clear advice regarding treatment options and specific key recommendations relating to best-evidence practice (domain 4).
High levels of clarity are achieved by using “specific, unambiguous” recommendations. APC displays a useful “what to ask your doctor” section and “patient summary” although patient-specific information is more wide-ranging with NICE (2016 e).
Domain 5 concerns “Applicability” with NICE highlighting processes and resources for PG application. NICE field teams assist local implementation, offering solutions to potential barriers. This is relevant as Kredo et al (2016) describe a general lack of guidance for clinicians to implement PGs.
It is important to consider PG audit activity whilst finding variables in audit standards. Although sometimes difficult to locate, NICE does provide web-based audit information; this may deter organisations from undertaking audit. No audit information was found within APC resources.
High-quality PGs must be cost-effective and include appropriate resources. NICE offers “resource planner” tools considering financial implications of PG application; environmental and sustainability factors are also considered. Editorial independence (domain 6) relates to bias reduction and conflict of interests in PG development.
NICE PG planning meeting minutes are available for public perusal. Potential influences to committee members are annotated (for example pharmaceutical industries paying for consultants’ hotels to attend conferences).
When this arises, NICE removes that individual’s right to contribute to specific areas of PG formation. Although APC stipulates conflicts of interest information is available, the link repeatedly did not work.
NICE guidelines are globally recognised for excellence and validity and, as APC AGREE tool scorings were lower, the NICE back pain PG is recommended for implementation.
Doniselli et al (2018) confirm many back pain PGs to be “high quality” and essential for promoting standardised excellence of care. However, gold standard PGs also retain flexibility, allowing clinicians to apply professional judgement for individual patient requirements.
Nurses must champion PG development as many essential nursing procedures are still not covered by PGs with the potential to cause local variations of care delivery.
Understanding media manipulation
The assertion that evidence can be manipulated in a variety of ways and for a variety of reasons will be discussed, focusing on media manipulation. Implications for healthcare delivery and the impact to service users will also be evaluated.
Practitioners must remain cognisant of the potential for biased media reporting, whereby positive drug outcomes are accentuated whilst usage restrictions, costs and harmful side-effects omitted.
An example is the media highlighting an individual who self-funded the drug Avastin (£21,000), living four years longer than the average six weeks life-expectancy increase (Goldacre, 2010 b).
Goldacre believes press attention emphasised an anomaly rather than taking a balanced view, and the issue of non-infinite NHS resources was not considered. Stories that emphasise risks, human interest, or political aspects sell better (Bomlitz and Brezis, 2008).
By implying Avastin was a wonder drug, denied by NICE to cancer sufferers, the press managed to capture the human elements of the story, create anger towards NICE and instigate questioning about the state of the NHS to the government.
Guillaume and Bath (2008) state the media’s primary aims are profit-making and particularly for the “red tops” (tabloids), audience entertainment. The King’s Fund (2003) referred to health and research misreporting 16 years ago.
Since then, communication portals have expanded through widespread internet access, social media and 24-hour news streams. Newspapers are pressurised to retain public attention and editors’ deadlines might compromise health reporting accuracy.
Negative news may be exaggerated and public perception of risk elevated as a consequence. Dean (2013 p.333) gives examples of media “hysteria” disproportionate to actual risk for SARS and MRSA, whilst deaths from smoking attract little attention as risks are well established but not newsworthy (Bomlitz and Brezis, 2008).
Subsequently, distortion of health news “confuses” the public and raises health concerns. This can lead to greater uptake of medical resources like GP appointments for the “worried well”.
The NHS website “Behind the Headlines” analyses health related news, presenting real facts although the extent of public uptake of the facility is unknown (NHS, 2019 a).
Navigating vaccine misinformation
Widespread vaccination and “herd immunity” reduce disease prevalence and deaths globally. This is of particular importance now that vaccinations for Covid are now available.
Occupational health nurses (OHNs) must advocate patient safety through effective immunisation uptake reiterating how international research indicates that immunisations are safe (World Health Organization, 2018).
Discredited findings by Wakefield et al (1998), linking the measles, mumps and rubella (MMR) vaccine to autism and bowel problems, still reduces uptake of MMR vaccination (Royal Society for Public Health (RSPH), 2018).
Although Dean (2013, pp.328) describes the government promptly defending MMR vaccination, the RSPH (2018) blames subsequent disease outbreaks on sensationalist media reporting and fuelling of anti-vaccination sites (Hussain et al 2018).
Wakefield’s MMR paper was retracted when the journalist Brian Deer and the BMJ challenged his study claims (BMJ, 2010). Wakefield was “struck off” the medical register when Deer proved he breached ethical and financial considerations by subjecting children to unnecessary medical procedures and filing patents for separate MMR component vaccines (Beer, 2017).
Hysteresis, the historical negative perception towards vaccination despite positive new evidence is significant as discouraging media reports influence negative opinions, which linger even when the media changes focus. For example, The Daily Mail’s early anti-MMR alliance (Goldacre, 2009 pp.315) eventually changed to a positive endorsement (Mail Online, 2017). This confers challenges to OHNs trying to promote vaccination and may cause patient distrust of clinicians.
Dean (2013 pp.331) discusses emotive television images of mothers with autistic children shown during the MMR vaccination crisis, negatively influencing decisions for vaccination uptake. Goldacre (2009, pp.240) condemns the media’s power to transform medical issues into public forum debates.
This leads to opinions from unreliable sources including lay people and celebrities gaining media attention (Goldacre, 2009 pp.308). “Fake news” is a serious threat to immunisation uptake particularly with emerging powerful influences of Facebook, YouTube and Twitter (Tominey, 2019).
Dean (2013, pp.328) suggests the media promotes politicians’ non-evidence based viewpoints to secure public votes. He uses an example of the Conservative Party endorsing single-component MMR vaccines running up to the 2001 election, opposing Labour’s triple vaccine advocacy.
Further media attention ensued as Tony Blair refused to confirm his son had received MMR (Goldacre, 2009 p.303-306). Evidence-based care should be championed regardless of political persuasion. It could be argued that MMR media attention was avoidable if The Lancet had robustly peer-reviewed Wakefield’s findings before publishing.
Goldacre (2015, pp.32-34) explains how fees charged for accessing research papers reduces key information availability and essential facts are hidden. The issue is worsened by the pharmaceutical industry’s influence on medical journal content, as sponsored reprint issues endorse positive research findings (Smith, 2018). Stone (2011) subsequently accused the BMJ of having competing interests by doing this whilst assisting Beer’s MMR enquiry.
There is the potential for the public to be subtlety manipulated by health literature. An example is including the logos of formula milk manufacturers displayed on breastfeeding literature distributed by midwives Goldacre, 2013 a pp.341). These resources are funded by formula milk producers possibly conflicting with the health messages from health professionals, including nurses, midwives and health visitor aiming to encourage breastfeeding.
Goldacre (2010 a) describes widespread issues of “publication bias” when drug companies only submit positive research data, which medical journals are more likely to accept. The loss of “unflattering” trial evidence adds to the problem.
As Goldacre (2013 b, pp.11) explains in his example of Lorcainade, negative research findings must be published to maintain patient safety. Failure to do so, although currently not illegal, could be construed as “research misconduct” or fraud.
Parliament is debating existing clinical trials rulings in response to Goldacre’s reports, although the current EU Clinical Trials Regulations may change following Brexit, conferring further challenges.
Conclusions
In conclusion, media evidence manipulation causes public confusion, leading to reputational and financial damage to the UK. Expensive resources including national campaigns are then needed to re-educate service users, causing a drain on public finances. Individuals may choose non-regulated forums for information which may ultimately result in human cost and suffering.
Enhancement of the knowledge of evidence-based practice (EBP) by OH professionals is essential to ensure the highest quality of professional practice. Strategies supporting EBP include specialist journal and online library subscription, affording access to relevant research (Aveyard and Sharp, 2013 pp.142).
Attendance and contribution to relevant CPD, including journal clubs, promotes cultural awareness and research analysis skills. Barriers to EBP arise from clinicians’ poor ability to undertake high-quality evidence searches leading to reduced clinical application. “Behind the Headlines” (NHS, 2019 b) provides accessible “round-ups” of current health literature for inclusion in monthly departmental meetings.
Increased national and international policy awareness may inform PG implementation, although Bramberg et al (2017) suggest time and restricted resources hamper this. “Cultural shifts” are needed as workload pressures and managers’ ambivalence to EBP cause nurses to postpone EBP initiatives. It is therefore imperative for OHNs to communicate issues and solutions to managers.
The Faculty of Occupational Health Nursing and Royal College of Nursing offer valuable networking and CPD opportunities promoting EBP through study days and online resources. Additionally, SEQOHS and MoHaWK assessment allows OHNs to map service delivery against recognised EBP standards as part of healthcare governance and service assurance. Participation would enhance the reputation of defence OH delivery but requires financial backing from budget holders.
Forging links to work collaboratively with NHS health and work development units will also inform evidence-based innovative practice aligned to priorities including the NHS Long Term Plan (NHS, 2019 b).
In addition to client feedback being audited, OHNs could establish working groups with patient representatives for greater input on service delivery providing opportunities for improving worker health reducing health inequalities and maximising employment. Embracing EBP ensures OHNs can be at the forefront of this, leading with confidence and integrity.
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Jo Rhodes is an occupational health nurse and Professor Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, NTFHEA, PFHEA, FRCN is emeritus professor of occupational health and president of SOM.
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