The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [26]
to be aware of what EBN means
to know what constitutes evidence
to understand how EBN differs from EBM and EBP
to know how to engage with and apply the evidence.
(Scott and McSherry 2009)
We contextualize our information and decisions to reach best practice for patients and the ability to use research evidence and clinical expertise together with the preferences and circumstances of the patient to arrive at the best possible decision for that patient is recognized (Guyatt et al. 2004).
Leaders of EBP such as Greenhalgh and Sackett have changed their focus away from solely the evidence of effectiveness through research to consider other areas of evidence (Greenhalgh 2002, Paley 2006, Traynor 2009). Thus the evidence required today to support all of these principles needs to come from a range of sources, as proposed by Higgs and Jones, who consider that evidence should be: ‘Knowledge derived from a variety of sources that has been subjected to testing and has been found to be credible’ (Higgs and Jones 2008, p.311). Credibility, as raised above, is a key issue (McKenna et al. 2000, Scott and McSherry 2009). As such, the emphasis and value of expert opinion highlighted here should in no way allow nurses to disregard research evidence (McKenna et al. 2000). Moreover, nurses’ and midwives’ professional code now insists on use of best available evidence (NMC 2008b).
Knowledge can be gained that is both propositional, that is from research and generalizable, and non-propositional, that is implicit knowledge derived from practice (Rycroft-Malone et al. 2004b). In more tangible, practical terms, evidence bases can be drawn from a number of different sources, and this pluralistic approach needs to be set in the context of the complex clinical environment in which nurses work in today’s NHS (Pearson et al. 2007, Rycroft-Malone et al. 2004b). The evidence bases can be summarized under four main areas.
1. Research
2. Clinical experience/expertise/tradition
3. Patient, clients and carers
4. The local context and environment
(Pearson et al. 2007, Rycroft-Malone et al. 2004b)
These four areas can also be regarded as corresponding to the empirical, personal, ethical and aesthetic categories of evidence which Carper (1978) espoused. What can be regarded as evidence to facilitate clinical decision making needs further consideration. When making clinical decisions, clinicians use evidence that relates to the four principal interests of:
feasibility: practical and possible
appropriateness: fits or is suitable for a situation
meaningfulness: personal experience, opinions, values of the patient
effectiveness: achieves the intended outcome.
(Pearson et al. 2007)
In the clinical environment, practitioners will draw upon and integrate these forms of evidence in order to deliver person-centred care, which underpins EBN. Of the sources of evidence available, research has been regarded as the best form. However, in some areas of nursing practice there is a lack of evidence available to support decisions made in practice (Pearson et al. 2007). In addition, there is also debate about the types of evidence available to support practice. Within nursing, qualitative research is the prevalent design used, whilst within the field of evidence-based practice there is the perception that quantitative evidence is superior to that which is qualitative (Rolfe and Gardner 2006), although this has been debated (Hewitt-Taylor 2003). Narrative, intuitional and clinical practices still have their place with EBP, especially where evidence is lacking (Greenhalgh 1999, 2002). Indeed, there are different opinions on the value of different types of research for EBP and it is important to consider, as Mulhall suggests,