Lecture 2: Evidence and its use in practice

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Lecture 2 Evidence and its use in practice

• ModuleUEBC
• Martin.Lipscomb_at_uwe.ac.uk
• Sue Roulstone

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Lecture themes

• What is evidence
• What does evidence do whats it for?
• Judgement making decision taking
• Supporting
• Legitimating
• Improving
• Factors affecting judgement making/decision
  taking
• Tradition/habit
• Experience/intuition
• Barriers
• Drivers for change
• Professionalisation
• Clinical Governance
• Technology
• EBP (next week)

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What is evidence?

• Research evidence
• Quantitative
• Qualitative
• Mixed methods
• Non-research evidence contentious?
• Scholarly and expert opinion
• Experience
• Self
• Group
• Patients
• Local context

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What does evidence do?

• Supports judgements and decision taking.
• Evidence legitimates judgements
• Evidence supports the improvement of care
• Evidence is just one of the factors involved in
  judgement and decision making

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Supporting judgements and decision making
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Judgement and decision

• Judgement and decision making often used
  interchangeably
• Judgement regarded as the process of weighing the
  options
• Decision making is the process of choosing
  amongst the options
• Judgement is the process that leads the
  choosing/decision

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Making judgements decisions
Analytical
Intuitive
Well structured
Uncertain
Explicit evidence
Embedded evidence
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In making decisions we draw on

• Experience
• Appraisal of current situation
• Values attitudes beliefs
• Theory
• Knowledge
• Imperatives
• Judgement
• Burton Chapman, 2004

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Judgement in nursing

• Do nurses make judgements?
• Do nurses make decisions?
• What sort of judgements/decisions do nurses make?
• Under what conditions?
• To whom are they accountable?

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Evidence legitimates decisions and judgements
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Influences on decision taking
Evidence
Values
Resources
Muir Gray, 2001
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Evidence legitimates

• Legitimation
• Transparency
• Clarity
• Understanding
• Wanless report, DH, 2000
• fully engaged scenario requires people to
  make better decisions for their own health

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Evidence supports improvements in care
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Improving care

• Development of EB guidelines
• Eliminating inefficient practices
• Focus on effective practices
• Highlight research gaps by stimulating clinical
  questions
• Increases clarity about which practice is/is not
  supported by evidence

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Quality of care

• Quality nursing care is dependent on good
  clinical decision making, which is in turn based
  on accurate judgements . . the very least that a
  patient should be able to expect, from a legal
  and ethical perspective, is an adequate
  description by nurses of the judgements that lead
  to decisions.
• Thompson and Dowding (2002, p.48)

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Evidence is just one of the factors
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Tradition
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Habit
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Available resources
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Dissemination project

• Six workshops held to disseminate RCT
• 172 participants
• 148 completed questionnaires at the end of the
  workshops
• 43 returned questionnaires at 6 month follow-up

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Questionnaires asked

• what implications does the study have for your
  own practice and for your local speech and
  language therapy service?

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Emerging themes

• Making practice the best
• Making practice evidence based
• Delivering a service for which there is evidence
• A hope to provide something better

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Confirmatory Im doing it right Im doing it
wrong
Challenging I need to change
Thought provoking I need to think about this
Distressing Im helpless
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What has happened to services?
No change Change is desirable but not
happening (ways of dealing with
clients) Change not needed Service already
changed alternative therapies
Continued reflection Collecting local
evidence about outcomes Debate about
manageable Caseloads

• Changes occurring
• Targeting
• services
• Amount of
• intervention
• Focus of
• intervention
• goals
• Changing
• roles

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Influenced by

• Professional identity
• Other evidence
• Attitudes of colleagues
• Other initiatives (eg Sure Start)

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Factors affecting judgement making - decision
taking

• Tradition
• Habit
• Available resources
• Colleague expectation
• Experience
• Expertise
• Patient/client desires/wants
• Evidence
• Judgement a continuous process effected by many
  different factors

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Experience

• Problems
• Mistakenly identified with expertise?
• Necessarily limited
• Idiosyncratic
• Benefits
• Often sensible and correct

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Does experience equate with expertise?
A
Key Confidence C Ability A
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Novices and experts

• One of the main differences between expert and
  novice practitioners lies in their use of
  information when making judgements.
• Thompson and Dowding (2002, p.56)

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Novices experts

• Compared with novice nurses, expert nurses
• are able to distinguish relevant from irrelevant
  data (good discrimination skills)
• look quickly at a wide variety of options,
  factors data
• look across between categories
• reason forwards (future orientated) rather than
  backwards (past orientated)
• make faster more accurate judgements
  decisions

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Expert knowledge

• Acquired knowledge becomes integrated and
  organised to provide easy access for the working
  practice of the practitioner
• theories of practice
• Schon 1988

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Making knowledge accessible

• But . . .
• it is often difficult to articulate or provide a
  rationale for experiential knowledge
• it is difficult to position gut feeling in
  transparent judgements

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Barriers to evidence use - 1

• Lack of authority to effect change
• Unable to understand statistical analysis
• Lack of time
• Management bar implementation
• Nurse feels results are not generalisable to her
  own setting
• Unable to evaluate quality of studies
• Doctors will not cooperate

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Barriers to evidence use - 2

• Facilities inadequate for implementation
• Other staff unsupportive
• Relevant literature dispersed
• Nurse unaware of research
• Lack of reading time
• Implications for practice unclear
• Research report unclear
• Parahoo K (2000)

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Barriers to evidence use - 3

• Complexity of context
• Heterogeneous population
• Diversity of available practice
• Emphasis on individualisation
• Multiple roles of staff
• Unpredictability of life for patients
• Burton Chapman, 2004

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Obstacles

• Lack of time
• Lack of funding
• Staff shortages
• Lack of manager support
• Lack of education training
• Lack of motivation
• Low morale
• Lack of resources
• Senior staff set in ways
• Lack of support from nursing colleagues
• Parahoo K (2000)

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Drivers for change

• Professionalisation
• Clinical Governance risk management, risk
  reduction
• Technology
• Research /or evidence based practice

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Professionalism

• Distinct area of knowledge and theory
• Code of ethics and professional values
• Admission controls
• Power to discipline
• Professional subculture

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Professionalism

• Scope of professional practice, extended scope
• More stress on accountable autonomy
• a double edged sword?

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Professionalism

• Code of Professional Conduct
• 2.2 You are personally accountable for ensuring
  that you promote and protect the interests and
  dignity of patients and clients . .
• 6.5 You have a responsibility to deliver care
  based on current evidence, best practice and,
  where applicable, valid research when it is
  available.

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Clinical governance

• Quality and audit agendas 1980s 1990s
• Clinical Governance (DoH, 1998)
• . . a framework through which NHS organisations
  are accountable for continuously improving the
  quality of their services and safeguarding high
  standards of care by creating an environment in
  which excellence in clinical care will flourish
• (DoH, 1998, p.33)

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Clinical governance - WHO

• Professional performance
• Resource use
• Risk management (the risk of injury or illness
  associated with the service provided)
• Patients' satisfaction with the service provided.

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Clinical governance

• Clinical governance was introduced at the end of
  a decade in which quality had been more
  explicitly addressed than ever before. It offers
  a means to integrate previously rather disparate
  and fragmented approaches to quality improvement
  but there was another driver for change. The
  series of high profile failures in standards of
  NHS care in Britain over the past five years
  caused deep public and professional concern and
  threatened to undermine confidence in the NHS.
  Unwittingly, these events seem to have fulfilled
  a key criterion for achieving successful change
  in organisation the need to establish urgency.
• Halligan and Donaldson, 2001, p.1413 cited
  Watson 2004, p.38

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Clinical governance

• Formal duty to ensure that quality is improved
  falls to
• Boards of NHS organisations
• Commission for Health Improvement
• National Institute for Clinical Effectiveness

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Technology

• In what ways might technology, the way we think
  and the way we act interact?
• new clients and new treatments
• new tasks/responsibilities
• changing staff/patient relationships

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Evidence Based Practice

• Next week . . .