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Evidence based nursing: contributions and proposals

Alberto Gálvez Toro, M. Román Cereto, M.J. Ruiz Román, C. Heierle Valero, J.M. Morales Asencio, E. Gonzalo, M.N. Romero

Index de Enfermería [Index Enferm] 2003; 40-41:47-50 (original version in Spanish, printed issue)

 

 

 

 

 

 

 

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Gálvez Toro A, Román Cereto M, Ruiz Román MJ, Heierle Valero C, Morales Asencio JM, Gonzalo E, Romero MN. Evidence based nursing: contributions and proposals. Index de Enfermería [Index Enferm] (digital version) 2003; 40-41. In </index-enfermeria/40-41revista/40-41e47-50.php> Consulted

 

 

 

Abstract (Nursing based in evidences: contributions and proposals)

This text summarizes the conclusions of the I Meeting on Nursing Based in Evidence (Granada, 29 November 2002) once it has been consensuated by the participants. The themes and main objectives of this forum were four: to evaluate the activity of Nursing Based in Evidence that is taking place in Spain; to make public the different groups that are working on Nusing Based in Evidence in Spain; to propose jointed working strategies for the future; and to define a reference frame for the Spanish Nursing following the international lines of development. The recommendations and proposals derived from the meeting have been grouped in four general questions that refer to each of the objectives that were formulated at the begining of the conferece: Which is the reference framework for scientific evidence in Nursing as a discipline?, What has been done in Spain about Nursing Based in Evidence?, Which are the main lines of work?, Which is the contribution of the concept of scientific evidence to the practice of nursing cares? 

 

 

 

 

 

 

 

Introduction

 

In recent years, different people and groups of work of Spanish nurses have implemented some of the proposals made by the Scientific Evidence movement to Spanish nursing. With the aim of evaluating and sharing experiences, the 29th of November 2002, Index Foundation called the Comunidad Científica de la Enfermería Española (Scientific Community of Spanish Nursing) to a scientific meeting on Evidence Based Nursing. The themes and main objectives of this forum were four: to evaluate the activity of Evidence Based Nursing that is taking place in Spain, to make public the different groups that are working on Evidence Based Nursing in Spain, to propose jointed working strategies for the future and to define a reference frame for the Spanish Nursing following the international lines of development.

The recommendations and proposals derived from the meeting have been grouped in four general questions that refer to each of the objectives that were formulated at the beginning of the conference: Which is the reference framework for scientific evidence in Nursing as a discipline?, What has been done in Spain about Evidence Based Nursing? Which are the main lines of work, and Which is the contribution of the concept of scientific evidence to the practice of nursing cares?

This text summarizes the conclusions of the meeting once it has been consensuated by the participants. The methodological process was carried out in three stages and it lasted four months. During the first stage, a report was elaborated by some experts and Members of the Scientific Committee attending the meeting. The second stage consisted on sharing this report with people taking part in the meeting and people interested in it, so that findings were made public. The text of the report was published on the web, in html format and an e-mail was sent to all he participants saying that there was a period to revise the text presented by the Committee and the group of experts. In March 2003 the Scientific Committee wrote the following final report for its publication in the scientific press.

 

What is the reference framework of the Evidence Based Nursing?

 

Evidence Based Nursing (EBN) has taken the model of the Medicine Based on Evidence for its development. In this sense, the EBN has developed the way suggested by the Scientific Evidence, that is, as a secondary research -selective bibliographic revision- based on methodological criteria, which considers that the best evidence or scientific test is the one from experimental designs: the best reference is the one derived from a random clinical trial or from a metaanalysis. It can be verified by having a look at the literature published in Spanish scientific journals, in revision articles and in secondary researches based on the search for what it has been called the best evidence.

Nevertheless, there is general agreement that the use of secondary research from Scientific Evidence opens up new possibilities for nurses. This movement reveals powerful and useful proofs for managing, clinical, teaching and research nurses and they are easily found in systems such as Cochrane Library, Best Evidence or MEDLINE. Evidence Based Nursing becomes a useful instrument to choose the best experimental research published in the world about a problem of interest for nurses' practice and, therefore, the way it is been developed in Spain, the EBN is a theoretical and critical movement which makes us be aware of nurses' potential in our Health System. It means that there are evidences that strongly support the efficiency of nurses in the Health System and it also proves that an efficient Health System requires the approach of nurses, more freedom and power of decision when talking about the health of patients, families and community. In this sense, it is useful for Spanish nurses to know about those evidences because they are valuable instruments to demand autonomy and capacity against the hegemonic approach, which is unable to assume the independent value of nurses in Health.

But, at the same time, as some Anglo-Saxon writers had already done in the book The Nature of Qualitative Evidence (Morse, Swanson, & Kuzel 2001), the nature of the experimental evidence has also been questioned during this meeting in order to suggest that there are valid evidences of qualitative nature that nurses should not reject. From the beginning, the EBN has showed that the scientific tests of interest to nurses should not been classified according to the sole criterion of the design of the study, but according to their quality and pertinence. That is why the secondary journal Evidence-Based-Nursing dedicates one section to critical comments of qualitative design articles.

Therefore, Spanish nurses have overcome the first problem that meant the approach of the Medicine Based on Evidence, called methodological reductionism. The search for useful Evidences to solve applied problems can be based on both the quantitative and the qualitative paradigm. Nevertheless, it is obvious that the search for evidences in the first paradigm is more developed, but in spite of that it is necessary to make an effort to create methods that make visible evidences from a qualitative paradigm.

Taking into account what it has been said before, it is acceptable to define the EBN from a constructivist point of view, assuming that there is not just one reality, but different realities which are determined by the context, the culture and the historical moment. It is easy to understand that Evidence Based Nursing is just the systematic search for an answer based on useful and relevant research for nurses' practice, but it considers a reflexive and interpretive approach that makes it possible to make use of the research findings when considering the individual reality of the nurse (see table 1). It clarifies that EBN is not just a search for quantitative evidences. It also implies an ideological way of thinking, or, in other words, the possibility of considering an interpretive frame created from the point of view of nurses. Finally, there is a third quality concerning this definition: the use of scientific (quantitative and qualitative) tests so as to make visible actors and health phenomena, considered invisible for the hegemonic thinking (from nurses as a value, to familiar care as the basis of health).

We can conclude that even when in Spanish nursing, the vision of Scientific Evidence has been developed as secondary experimental research, we do not underestimate other kind of evidendes or research findings generated in different paradigms. This is an aspect that has not been considered as a future horizon, which should be built from the present time.

 

Which are the contributions of the Spanish nurses to the Scientific Evidence?

 

In general, there is a limited but emergent scientific production. Most of the production on EBN has a conceptual and academic nature; nevertheless, from the year 2000 some nursing journals have published an increasing number of secondary research or have created a special section called "Scientific Evidence". The journals Enfermería Clínica, Enfermería Nefrológica and Index de Enfermería are some examples. They are all working hard to lead, from complementary aproaches, the creation of Evidence Based Nursing (see table 2). Enfermería Clínica usually publishes academic revisions; in Enfermería Nefrológica we can often see brief critical comments on important evidences for this speciality and Index de Enfermería usually publishes critical revisions together with analitical and extensive comments- analysis of internal and external validity and applicability of findings- about paradigmatic studies on nurses' practice. The important and complementary spread of evidences of the secondary journal Gestión Clínica y Sanitaria was also highlighted because it is also useful for nurses following the perspective of the Scientific Evidence.

The work carried out in recent years by different groups of research, that is, their contribution to research into search for evidences, has also been considered at this meeting. We had the chance to share contributions of some groups coming from Cataluña, Navarra, Valencia and Andalucía, from the clinical - Specialized and Primary Attention- management and educational areas.

It becomes obvious that people are interested in the Scientific Evidence model and that we can deal with it from different work areas where nurses are competent. Finally, and beyond our geographical border, we heard the way the Scientific Evidence is consulted in Latin America, more specifically in Colombia and Argentina. From those parts, they make us know that the Scientific Evidence is at this moment in time a product of the west and that we must question the nature of the scientific test promoted from the orthodoxy of the experimental thinking of the Medicine Based on Evidence, fighting for contextualization, which makes it possible to have in mind the level of economic development and the diversity of cultures, so that the NBE movement achieves a universal status.

We can conclude that there is an objective product, made up of Spanish nurses, which makes it possible to talk about a scientific, applied and conceptual movement called Evidence Based Nursing.

 

Which are the main lines of work?

 

The possibilities of the action depend on the place from where each nurse delivers his or her speech. Teaching nurses have shown us the usefulness of the learning process based on problems at university and in postgraduate education. The university promotes a model of teaching that considers the model of the Scientific Evidence as an instrument for the decision-making when considering patients' care. Managing nurses are trying to find and share evidences which are then used by responsible managing employees and clinical nurses. The aim is to show that we still have a lot to learn and to do in relation to our Health Systems in order to improve efficiency, quality of care and professional and intraprofessional coordination. When considering the hospital, the scientific evidence makes nurses ask themselves about their practice, to doubt about what it is happening daily and that is the previous step for change. Clinical nurses make us realize of the applied meaning of evidence: the patient and the family, the community, that is, people who are cared for. They make progress as they show research projects related to qualitative evidence or as they clear up some points such as the use of alcohol when vaccinating or the use of music to treat anxiety in patients with mechanical ventilation. Finally, in relation to scientific publications, it is necessary to promote the synthesis of evidences which are being found by the groups of work.

We can consider the followings as points of work for the future:

1. To promote a learning method based on problems.

2. To promote a professional culture of collaboration, also open to innovations where all the actors of care can take part: patients, nurses, doctors, technicians, etc. but also teachers, research and managing nurses.

3. To promote qualitative evidences and qualitative designs of research.

4. To focus attention on the implementation. So far, the EBN has been more worried about looking for evidences than about using or implementing them. In fact, we know that even if there are clear evidences about specific subjects (e.g. ulcers by pressure), they have not been put into practice -the complexity of the organization makes it difficult to use. It is necessary to change radically the method suggested by the Scientific Evidence: less secondary research and more use and evaluation of evidences .The bibliographic database (e.g. Cochrane Library) has enough evidences useful for practice so as to change it radically.

5. Teachers, research, clinical and managing nurses must come to an agreement when considering a dynamic model of practice that changes both the professional and organizational culture in order to make it permeable to the known evidences, but also changeable. That restricts the Scientific Evidence movement: the use of the research results in social reality requires sociocultural approaches.

6. Nursing journals should become permeable and sensitive to diversity. They should also promote this diversity as an example of the heterogeneity of live.

 

Which is the contribution of the concept of scientific evidence to the practice of nursing cares?

 

As it has been said before, in the cycle of preparation-discovery-use of the nursing knowledge, it is clear that the theoretical-scientific production is out of step with the clinical practice. Even if it is a problem for the development of clinical nursing, it is common to all areas of knowledge. On the one hand, Nursing has increased its conceptual corpus, with a certain tendency to the "epistemologic blockade" and it is essential to evolve towards explanatory models of reality which go beyond the confrontation between paradigms (positivist-hermeneutic-sociocritical) and which make it possible a closer approach between theory and praxis, as Meleis suggests.

On the other hand, the use of nursing research should go beyond the barrier of conceptual genesis so as to have access to the instrumental and persuasive field (Estabrooks). That is why we cannot continue to create a conceptual structure on the one side, and to have that in mind when considering the educational training period, to promote the training period and the direction of the clinical nurses' practice according to its parameters, to develop implementation strategies for health services and not to use them for applied research.

There are few bibliographic references where Systems of Standardized Language are used as the substratum of a research study. It should also be highlighted that it takes a long time for research findings to be included into different classifications and nursing taxonomies. As an example of that, very few clinical trials are published in order to evaluate the effectiveness of NIC interventions or some results of the qualitative research about human answers (e.g. despair) are not considered to be distinctive characteristics of the NANDA. In addition to that, there is an increase of the variability concerning the clinical practice of nurses.

Finally, the influence of the organizations on the model of the clinical practice of nurses often makes it not possible to implement the results of the research, together with the effects it has on the clinical results, as it is being proved by important studies about it (Needleman, Aiken, etc). As the WHO reveals, there are a lot of areas in which Nursing proves to be effective and that makes it possible to reduce variability, to make the decision-making easier for nursers and users, to plan health resources, etc.

Considering the situation, it is necessary to face these questions:

1.Evolution to post-empirical paradigms to better explain the complex reality of the nursing practice.

2.Extensive use of the nursing conceptual frame in the applied research.

3.Reorientation of the health organizations so as to encourage nurses to keep informed.

The EBN is a means (not a purpose), a helpful means to answer to all those questions. It makes it possible to link theory and action systematically and it also provides instruments to evaluate, diffuse and implement the results of the research between clinical nurses. It means an advantage to reduce clinical variability and also the variability of the results in terms of health care. Combining nursing models, standardized language systems, nursing process, research and evidence is an exercise which implies a big effort, but it becomes unavoidable if our aim is to create a coherent model of Science of Care.

References

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Estabrooks C. Will Evidence-Based Nursing Practice Make Practice Perfect? . Can J Nurs Res 1999; 30(4): 273-294.

Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse staffing, levels and the quality of care in hospitals. N Engl J Med, 2002; 346:1715-22.

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