The exponential growth in knowledge and the ease of access to vast amounts of information present significant opportunities and challenges for nurses in the community. Expectations that nurses will base their practice on the ‘best’ available evidence have developed alongside the availability of online resources, graduate preparation of nurses and consumer expectations. Nurses in the community require knowledge and skills to discern how evidence and information should influence their decisions to review and change approaches to clinical practice.
In 1983, Lisbeth Hockey said, ‘Nurses who really care, in the true sense of the term, will not be content. They will question, read and avail themselves of the new knowledge for the benefit of their patients and clients.’ Few could have predicted the growth in knowledge and its availability since the early 1980s. Crucial to this are the skills of nurses in accessing, appraising and evaluating the quality of information to inform changes in practice.
The aim of this paper is to inform professional dialogue and to appraise the expectations around evidence-based practice (EBP) for community nursing. Developments in EBP and approaches to evidence synthesis are presented. This includes accessing, appraising, analysing and synthesising evidence and judging clinical relevance drawing on practice examples.
This paper is timely given that the British Journal of Community Nursing and a range of other nursing journals publish evidence summaries through the Cochrane Nursing Care Field (e.g. Barrett, 2019). Such evidence summaries provide clinicians with a synthesised synopsis of key evidence from the academic literature of a clinical issue, question or problem. Importantly, they identify the implications for nursing practice and, through rigorous assessment of the quality of available evidence, provide guidance for EBP and clinical decision-making.
Evidence-based practice
Despite the well-documented need for, and benefits of, EBP, the literature reveals various barriers and challenges to its successful implementation. These include lack of time, high workload, poor knowledge and skills about research and evidence and lack of nursing autonomy (Brown et al, 2009; Dalheim et al, 2012; Grant et al, 2012). Community nurses face a range of complex situations in the households and communities they serve, and they work with a range of stakeholders across health and social care and the third sector. It is, therefore, important that they have the time and skills to identify clinical issues or problems, reflect on clinical practice and incorporate research-based knowledge into their clinical practice. However, in many contexts, this requires an ideological shift, supportive leadership, clients who are aware of their role in healthcare decisions and organisational culture (Edwards et al, 2002).
In a recent qualitative study, Teodorowski et al (2019) explored community nurses' experiences of EBP. Three pathways to change were proposed by the participants as reflecting their experiences: bottom-up, top-down and collaborative pathways. These pathways are not mutually exclusive, and there exists overlap, but the nature of the proposed change, the available evidence, ‘buy in’ from colleagues and issues around implementation are key to the approach taken. These findings identify a need for practitioners to be supported through a complex process of change, with opportunities for ongoing education, robust managerial support, accessible online resources and support through a practice development role. Forming collaborative partnerships between academia and practice could be one of the options to strengthen EBP.
The context in which community nurses work is important, and those in resource-constrained countries are confronted with a myriad of challenging situations. The changing patterns of disease, re-emergence of previously controlled infectious diseases and antibiotic resistance are key challenges. This constant change creates opportunities for community health practitioners to initiate the process of evidence synthesis and the creation of new and resourceful ways of providing healthcare in the community.
The context-driven nature of EBP, alongside the need to recognise the autonomy and belief systems of patients and families, signifies the complexity involved in identifying a need for change and the need for community nurses to formulate critical questions about their practice. Advocacy for enhanced collaborations between knowledge producers (researchers) and knowledge translators (practitioners) might address the need to translate research results into practice (Banner et al, 2019).
Policy is influential to EBP and can be the main driver for change, often reflecting a ‘top down’ approach (Teodorowski, et al 2019). Davies (2014) defined knowledge translation as the process of mobilising evidence into heath policy and service delivery, and this is the essence of EBP in many areas of healthcare practice. Stakeholder agreement and the co-creation of new possibilities lie at the heart of EBP, alongside opportunities to enact new theories of care, increase client satisfaction with care and ensure the competence of practitioners.
Implementing EBP into routine clinical practice, even when there is a strong and convincing case to do so, is complex and requires planning. Growing research in implementation science is available for community nurses to access for this purpose (Bauer et al, 2015). In order to base clinical decisions and actions on the best available evidence, community nurses need to understand evidence and approaches to evidence synthesis.
Evidence synthesis
Parallel to developments in EBP, approaches to evidence synthesis are now a global endeavour. For the purpose of this paper, evidence synthesis is defined as ‘the interpretation of individual studies within the context of global knowledge for a given topic’ (Evidence Synthesis International, 2019). Such syntheses provide a strong, transparent knowledge base for applying research in clinical decisions. The advantage of evidence synthesis is that all studies on a topic are collectively assessed in context (Evidence Synthesis International, 2019).
Evidence synthesis, the process of analysing the findings from all the studies on a topic together in context and using a robust and transparent method, underpins EBP. Evidence synthesis provides information, and pools available evidence through a transparent method, rather than individual studies that may or may not be free from bias. Therefore, such an approach has an important role to play in EBP.
Established in 1993, the Cochrane collaboration was developed primarily in response to calls for evidence-based medicine (Sackett et al, 1996). Cochrane is an independent, global endeavour with contributors from across 130 countries and 53 topic groups. The main output from Cochrane is systematic reviews, which follow a rigorous methodology and peer review process at each stage of title registration, protocol development and completion of the review. REVMAN software is used to summarise the best available evidence from primary empirical studies, and completed reviews are published in the Cochrane library. Cochrane reviews are arguably the ‘gold standard’ in evidence synthesis, given the rigour with which they are developed and the authors’ responsibility to update reviews at regular intervals (normally 2–4 years) to ensure new knowledge is captured. Establishing the clinical relevance of review findings, public engagement, dissemination, developing methods of research synthesis and appraising the contextual issues around implementation of research findings into clinical practice are also priority areas for the collaboration (Cochrane UK, 2019).
Cochrane mainly focuses on evidence from randomised controlled trials (RCTs) and other quantitative approaches involving an intervention and comparator group. There are developments in qualitative synthesis in Cochrane, but, to date, they are recognised as the main producers of quantitative systematic reviews. Cochrane reviews have been criticised as not relevant to all questions and interventions of interest to nursing. As in primary research methods, one size does not fit all and nor should it, given the complex, transactional nature of nursing practice. Evidence synthesis as a methodology has a range of approaches and tools, and it is beyond the scope of this paper to present all of these.
The Joanna Briggs Institute (JBI) was established in 1996, and, as part of the evidence-based movement, its focus has been on establishing collaborating centres and training for systematic reviewers. The main outputs from JBI are ‘best-practice information sheets’ to inform clinical decision-making at the point of care delivery. JBI best-practice statements draw on a wide range of available evidence to inform clinical questions (Joanna Briggs Institute, 2019). It is important to note that while Cochrane reviews focus mainly on RCTs, which are considered to be the most robust research design, JBI reviews and the integrative review approach detailed below are more inclusive. When reviewing the findings of Cochrane and other types of review, it is important to understand the ‘confidence’ attributable to them.
When synthesising evidence, it is not a requirement to align to an organisation such as Cochrane or JBI, and many systematic and integrative reviews are published that report a clear methodology that deviates from those of these organisations. Another approach that is appropriate for clinical questions is the integrative review methods proposed by Whittemore and Knafl (2005). The purpose of integrative reviews is to synthesise all the available evidence, be it quantitative or qualitative, and provide a descriptive thematic representation of the results.
Regardless, there are some common features of the systematic approach to evidence synthesis, and these are detailed in Box 1. The differences in how these are applied lie in the nature of the review questions, available evidence, approaches to analysis and contextual relevance. Quality appraisal is relevant to Cochrane and integrative reviews and sets this approach to reviewing the literature apart from narrative reviews. Given the need for the judicious use of evidence, there is arguably no longer a place in healthcare practice and decision-making for the narrative approach.
Box 1.Attributes of systematic and integrative reviewsFormulation of a review/research questionDevelopment of a robust search strategy to include key words, databases, search limits and resultsData evaluation and analysis—exclusion and inclusion criteriaPresentation/synthesis of resultsDecision-making by researcher—possibility of errorExplicit inclusion/exclusion criteriaSelection and analysis of data by two peoplePresentation of results in tablesReasons for exclusion documentedAssessment of strength of evidence
Having established the links between EBP and evidence synthesis, what does this mean for nurses in the community and their day-to-day work? Community and district nurses need to make decisions about their work with people, patients, families and communities. Given the complex nature of EBP and discerning the quality of evidence available to inform decision-making, a clinical scenario is presented to illuminate some of the challenges of combining policy, practice and evidence, drawing on an example relevant to clinical practice—metastatic spinal cord compression.
The case of metastatic spinal cord compression
Metastatic spinal cord compression (MSCC) is a significant complication of advanced, progressive cancer and an oncological emergency. An acute, complex-onset condition, the secondary spread of cancer to the spinal cord can result in paraplegia within 24 hours if not diagnosed and treated quickly. People presenting with MSCC are likely to have short life expectancy, and a paradox may exist for clinicians in managing an acute-onset medical emergency for a patient in need of palliative and end-of-life care. If a patient presents with symptoms of MSCC, then emergency referral is essential to the cancer centre. An MRI scan within 24 hours is recommended, and the patient should be assessed for pain, mobility and bladder and bowel care. Once a confirmed diagnosis of MSCC is made, the nurses providing care for these patients lack clear evidence to inform patient positioning (mobilisation) and bracing for pain relief and spinal stability (Lee et al, 2015).
The available National Institute for Health and Care Excellence (NICE) guidelines cover a range of aspects linked to MSCC, including initial diagnosis and some advice about positioning, mobilisation and rehabilitation (NICE, 2008). These guidelines were reviewed in February 2019, but no new evidence was uncovered on patient positioning and bracing for pain relief and spinal stability (NICE, 2019). The Cochrane systematic review by Lee et al (2012, updated 2015) did not identify any RCTs about patient positioning and bracing for pain relief and spinal stability in adults. Given the absence of RCTs, the authors concluded a lack of evidence-based guidance around how to correctly position and when to mobilise patients with MSCC or whether spinal bracing is an effective technique for reducing pain or improving quality of life (Lee et al, 2015). In the absence of robust evidence, clinical decision-making about mobilising patients, bed rest and keeping the person flat are subject to individual clinician preferences and may not reflect patient preferences or the quality-of-life aspects of palliative care.
Kilbride et al (2010) conducted an integrative review of 35 papers to synthesise the available evidence about the management of MSCC. They concluded that the evidence related to spinal stability, bracing, patient mobilisation and positioning is limited and inconclusive. For patients with MSCC and a poor prognosis, therefore, individual preferences and quality of life should be considered. These findings are corroborated by those of Lawton et al (2019), who recommended that the patient's goals and psychosocial needs be considered when agreeing a treatment plan for MSCC.
Given that the evidence around the best approaches to managing aspects of MSCC is limited and inconclusive, how do practitioners decide what to do? Patients and families need care and advice when coping with the challenges of MSCC, so the needs and preferences of the patient should be central to joint decision-making. In this case, there exists no clear evidence to guide the actions of community nurses. It is, therefore, important that practitioners know about and understand the lack of conclusive evidence to support interventions such as nursing the patient flat or immobilising them. This allows the nurse to focus on the needs and preferences of the patient rather than implementing a care routine that lacks rigorous evidence to underpin it.
Discussion
EBP and evidence synthesis are important concepts for community nurses to understand and embrace. This article discusses the relationship between these areas and highlights the complexity of clinical decision-making when considering the available evidence, the quality appraisal of that evidence and whether a particular intervention or approach is justified against the needs and preferences of patients and their families. Recognising different pathways to the implementation of EBP can help community nurses determine what is driving the change in standards and help them to better discern the appropriate responses to the clinical, policy or patient-specific issue or problem (Teodorowski et al, 2019).
The contextual and relational aspects of clinical practice need to be recognised in EBP, and while community nurses need to be able to source and understand evidence, patient preferences and needs must be considered. In many respects, agendas around EBP, evidence synthesis and co-production and creation of care decisions are at odds with each other. Arguably, EBP suggests there exists a ‘right’ way to do things by drawing on evidence synthesis to inform actions. The context and everyday realities of working together with people demonstrate that this is far from straightforward.
Conclusion
This article identifies a number of challenges around the intersection of practice, policy and evidence. No more so than in the present climate do community nurses need to embrace and engage in the developments around evidence synthesis to ensure delivery of the best care based on the best available evidence. Importantly, if nurses understand the status of evidence underpinning areas of practice, they can ensure that the preferences and needs of patients and their families are met.
KEY POINTS
- The exponential growth in knowledge and ease of access to vast amounts of information presents significant opportunities and challenges for nurses in the community as they seek to implement evidence-based practice (EBP)
- Evidence synthesis, the process of analysing the findings from all the studies on a topic together in context using a robust and transparent method, informs EBP and is now a global endeavour
- EBP is complex and in order to base clinical decisions and actions on the best available evidence community nurses needs to understand evidence and approaches to the synthesis of evidence
- If nurses understand the status of evidence underpinning areas of practice they can ensure the preferences and needs of patients and families are met
CPD REFLECTIVE QUESTIONS
- What areas of your practice do you think are amenable to evidence-based practice? Where is that evidence drawn from?
- How confident are you that the evidence is robust enough to justify developing or changing something you do?
- How do you take in to account the needs and preferences of patients and families?