Introduction JANAC Vol. 12, Supplement, 2001 Baigis, Hughes / Evidence-Based Practice
Evidence-Based Practice Judith Baigis, PhD, RN, FAAN Anne Hughes, RN, MN, FAAN This article provides an overview of evidence-based practice (EBP). It will discuss the background of EBP and barriers to using it. The state of HIV nursing research evidence, as well as methods to rate that evidence, will be described. Types of data sources will be identified. The article will conclude with selected clinical applications of EBP. Key words: evidence-based practice, evidence-based nursing, evidence-based medicine, HIV, AIDS
The goals of nursing are to restore, maintain, or promote health. The scope of nursing’s concern is with problems of health. And when nursing practice assists people back to a healthy condition, successful outcomes are correctly declared (Baigis, 1998). But what are the best methods for accomplishing those crucial goals of restoring, maintaining, or promoting health? Nursing is based primarily on the conception of the person as a biopsychosocial being. Thus, nurses need a grasp of the theoretical principles underlying this notion from, for example, specific natural sciences (e.g., chemistry), biological sciences (e.g., anatomy, physiology, microbiology), and behavioral sciences (e.g., psychology) in order to guide their practices. Nursing as technique focuses on clinical experience. Armed with the understanding of general principles and faced with a patient, nurses try to associate physical and psychological clinical findings with underlying physiologic and pathophysiologic mechanisms. Thus, it would seem that nurses, armed with their grasp of general scientific principles and the integration of this understanding with their clinical experiences, have a solid foundation upon which to make sound judgments about a particular patient’s health status. However, except for instances of “classical
textbook” disease conditions in patients (and we know how rare these are), this is not the case. Knowing the general principles of immune function is one thing; understanding the specifics of David’s or Jean’s immune system is another matter. Human psychology and physiology are very complex subjects, and there is a great deal we still do not know about the human organism. Regardless of such uncertainties, nurses in clinical practice are faced with the task of making decisions about the health status of their patients. The means by which we can gain access to information that will improve our knowledge and practice is at hand. There is a health care revolution in progress, with new kinds of data being produced when once known, understood, and applied in practice should improve patient care (Sackett, Richardson, Rosenberg, & Haynes, 1998, p. 5). So, to make sound clinical decisions, scientific theoretical principles and practice tools are necessary but now clearly insufficient in this information age. Nurses must also have the best, up-to-date data—what can be called best evidence data—retrieved from the various databases. The practice built on this best evidence is called evidence-based practice (EBP). The purpose of this article is to present the background of EBP, reasons for this practice, its components, barriers to doing it, data sources for it, and selected clinical applications of it.
Judith Baigis, PhD, RN, FAAN, is a professor at the Georgetown University School of Nursing and Health Studies, Washington, D.C. Anne Hughes, RN, MN, FAAN, is a clinical nurse specialist in Palliative Care Services at the Laguna Honda Hospital and Rehabilitation Center, San Francisco Department of Public Health, San Francisco, California.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 12, Supplement, 2001, 9-18 Copyright © 2001 Association of Nurses in AIDS Care
10
JANAC Vol. 12, Supplement, 2001
What EBP Is and Is Not Several definitions of EBP are provided in the literature, and they generally have a common core: well-designed research + clinical expertise + patient concerns and preferences = EBP. Specifically, evidencebased nursing is defined as the incorporation of evidence from research and clinical practice plus patient preferences into clinical decisions (Munhall, 1998). Evidence-based medicine is defined as the “judicious application of current best available evidence when making decisions about the care of individual patients. It integrates clinical expertise with the best available clinical evidence from systematic research, and the thoughtful and compassionate consideration of patients’ situations in decisions about care� (Sackett et al., 1998, p. 2). The Agency for Healthcare Research and Quality (AHRQ) emphasizes the rigorous evaluation of research data in light of science (with rigorous comparisons of the alternatives) and the selection of the best evidence for application to patient problems. Clinicians who use the principles of EBP, then, are opposed to practice based on intuition and opinion (as many of the complementary and alternative therapies are), ritual and tradition (those who say, for example, that jobs are always done a certain way), and ideology (care based on politics in which certain people viewed as different or deviant are categorized as ill).
Recent Background of EBP in Nursing and Medicine Among the research utilization projects in nursing, two of the earliest will be presented here. In the 1970s, the Western Council for Higher Education in Nursing Regional Program for Nursing Research Development began a research utilization project for nursing with the goal of using research findings to improve nursing practice. The council established research groups composed of clinicians, educators, researchers, and administrators who assisted nurses in accessing research findings, critically evaluating research findings, managing change and applying change theories, coping with problems that result from risk taking, and making changes and evaluating the effects of those changes on health care (Krueger, Nelson, & Wolanin,
1978). Nolan, Larson, McGuire, Hill, and Haller (1994) provide an overview of research utilization projects in nursing. The Michigan Nurses Association conducted the Conduct of Research in Nursing (CURN) Project over 5 years. Its goal was to find a method of transferring research into institutional practice. (The Western Council for Higher Education in Nursing concentrated a bit more on the clinical nurse than on the institution.) The CURN process involved the identification and synthesis of valid and replicated studies, the transformation of these findings into clinical protocols, and the implementation of the protocols on pilot units in institutions with methods to diffuse the material beyond the trial unit and maintain the innovation over time (Horsley, Crane, Crabtree, & Wood, 1983). In medicine, meanwhile, epidemiologist Archie Cochrane, in Effectiveness and Efficiency (1972), stated that carefully controlled research using randomization for unbiased comparisons among study groups is required to ensure that research results applied in practice do more good than harm. Cochrane was critical of the health professions for not instituting methods to summarize and regularly update relevant information from well-designed clinical trials that could then be used to inform choices made in patient care (see Chalmers, Sackett, & Silagy, 1997). Such criticism of professionals in health care practice was the impetus for the formation of the Cochrane Collaboration, an international effort to prepare systematic reviews, using meta-analyses when appropriate, of all well-designed randomized controlled trials (RCTs) evaluating medical interventions. All trials in all languages are sought, including unpublished studies and those with negative results. From the founding of the first Cochrane Center in Oxford in 1992, nearly 40 collaborative review groups were formed in the first 4 years (Chalmers et al., 1997, pp. 231-232). The systematic reviews of research evidence are regularly made available, and a system for updating evidence has been established. There are hundreds of reviews of the effects of health care; as time passes, it is expected that there will be thousands (Cochrane Database of Systematic Reviews, 1996). Evidence-based medicine instruction in medical schools has been done for the past decade at McMaster University in Canada, where faculty members have
Baigis, Hughes / Evidence-Based Practice
attempted to show that medical decisions should be based on clinical experience as well as a distillation of the best evidence from research to guide clinical choices. In the United States, the AHRQ created a national network of Evidence-Based Practice Centers (EPCs), which are seen as the logical successors to the agency’s previous guideline activities (see www.ahrq.gov/ clinic/epc [accessed November 29, 2000]). These EPCs are asked to produce evidence reports on selected topics; that is, careful analyses that can be used to develop guidelines, performance measures, educational materials, and other quality improvement programs. The EPCs represent a mix of academic institutions and private organizations with national and international reputations for their work on systematic reviews, meta-analyses, and technology assessment. The EPCs are viewed as building on the work of the Cochrane Collaboration.
Rating the Evidence The EPCs within the AHRQ, members of the Cochrane Collaboration, and other groups doing systematic reviews of the research literature have agreed on transparent guidelines for assessing the quality of that literature. Such guidelines generally include search strategies, criteria for what is to be included in a review, specific criteria for critically evaluating each component of an article such as strengths and limitations of the research, and identification of conflicts among similar studies. From this analysis, synthesis of the studies results in rating the quality of the research. Conclusions can then be reached on what constitutes best evidence to date. These guidelines can be viewed as extensions of the strategies used in those early nursing utilization projects. What has happened since the 1970s, of course, is the growth of global communication. It is now possible to search for the best evidence globally, something that was not possible only 5 years ago. One rating schema (the AHRQ’s) for judging the quality of reviewed studies is presented: I. a. Meta-analysis of RCTs b. One RCT
11
II. a. One well-designed controlled study without randomization b. Another type of well-designed quasiexperimental study III. Comparative, correlation, or other descriptive study IV. Evidence from expert committee reports and expert opinions (I = best evidence, IV = poorest evidence). Within this schema, the RCT is the gold standard for evaluating the efficacy of therapy (e.g., Does the intervention being tested do more good than harm?). Meta-analyses can pull relevant well-designed studies together so that the data can be treated as one data set. If no trials have been done for the problems one is presented with, then one goes to the next best source of evidence and works from there. Thus, although no generally accepted research evidence is systematically excluded from the rating schema, certain types of evidence are seen as more robust and much more likely to inform rather than mislead the clinician (Sackett et al., 1998).
Rating the Evidence in HIV Nursing Research The development of an HIV/AIDS nursing research knowledge database (funded by the Helene Fuld Health Trust through Sigma Theta Tau International) using arcs computer software (Graves, 1999) has begun and was supported by the Association of Nurses in AIDS Care (ANAC) (Goldrick, Baigis, Larsen, & Lemert, 2000). The HIV/AIDS nursing research literature was reviewed from 1986 through 1997, producing 1,005 nursing research articles for analysis. All have been entered into the arcs Knowledge Builder HIV/AIDS database. A subgroup of 246 patientfocused research studies was analyzed for their causal and associational relationships. Of those 246 studies, only 12% (n = 29) were intervention studies (experimental, quasi-experimental). In the 11 years of nursing research captured in the Knowledge Base thus far, the intervention that seems to make the most difference (decreases hospitalizations, increases quality of life) is
12
JANAC Vol. 12, Supplement, 2001
the nurse-managed care practice model. If this Knowledge Base is periodically updated, the HIV/AIDS nurses can keep track of what evidence there is and the quality of that nursing evidence. The HIV/AIDS nursing field has begun to produce research that provides evidence to guide care. To meet its promise, the arcs Knowledge Base needs to be continually updated. The work done thus far includes the development of the search strategy and entry of the research literature published through 1997 into the Knowledge Base. Sigma Theta Tau International is continuing to update the HIV/AIDS index. Relevant research studies from that index for 1998 to the present needs to be entered into the Knowledge Base. The Knowledge Base can be accessed in read-only format through the Virginia Henderson International Library, Sigma Theta Tau International link, at www.nursingsociety.org. There is also a link from ANAC’s Web page to Knowledge Base.
Why Do EBP? Although clinicians’ superb education may have prepared them for practice, many place too much trust in the utility of that education for far too long. For example, studies done with physicians show that once their formal education is completed, they do not have effective ways to keep abreast of current clinical knowledge and validated procedures. Barriers identified to keeping up to date for clinically important information included lack of time, outdated textbooks, and the sheer volume of the clinical literature (Sackett et al., 1998, p. 8). In polling attendees at grand rounds in U.K. medical schools, Sackett et al. showed that up to 75% of interns have not read anything about the problems presented by their patients in the previous week. These interns were being taught by senior consultants (attendants), up to 40% of whom did not read anything either. A survey of North American general practitioners showed that they felt they needed new and important clinical information about once or twice a week. Further questioning and shadowing showed that general practitioners needed this new information up to 16 times in 4 hours per day, and that four clinical decisions in that time would have been changed if they had had the latest information (Covell, Uman, & Manning, 1985). The situation is no better in nursing.
Barnsteiner (1996) wrote of a 10- to 15-year gap in nursing practice between the generation of new, useful knowledge and its implementation in practice. EBP should also decrease errors in practice. In the fall of 1999, the Institute of Medicine (IOM) released its first of a series of reports on the quality of health care called To Err Is Human: Building a Safer Health System. Extrapolations from the data used by the IOM showed that at least 44,000 and up to 98,000 people die each year because of errors made by health care providers. That number of deaths is higher than the number of people in the United States who die yearly from AIDS. The IOM report states further that medication errors are estimated to account for more than 7,000 of those deaths. Most of the medication errors are preventable. One strategy for moving toward safer practice was the IOM’s suggestion that safety issues be tied to contracting decisions, with relevant knowledge of the safety record of an organization shared with a plan’s employees and beneficiaries. In other words, show that standards of care are being raised and payment for services will follow.
A Worry About EBP Although the founding members of the EBP movement began with the idea that evidence-based practitioners should learn to do their own searches and evaluation of the original research literature, some members now suggest alternative approaches in light of their personal experiences in educating physicians. Although “the skills needed to provide an evidence based solution to a clinical dilemma include defining the problem; constructing and conducting an efficient search to locate the best evidence; critically appraising that evidence; and considering that evidence and its implications in the context of the patients’ circumstances and values” (Guyatt, Meade, Jaeschke, Cook, & Haynes, 2000, p. 954), finding the best evidence is time consuming. Therefore, most clinicians will probably use material for clinical decision making generated by others, including evidence-based summaries, practice guidelines, and protocols (Guyatt et al., 2000). It seems reasonable to conclude that if all health care practitioners practiced at this level, the quality of health care should markedly improve. But the clinician’s practice is just one part of the equation. The
Baigis, Hughes / Evidence-Based Practice
administrative structure in the clinician’s workplace must support EBP activities if they are to flourish. A good library, a reference librarian, reference retrieval systems, computers, and the appropriate computer connections are necessary to access the databases.
EBP and Nursing Theories For some nursing scholars, EBP is a denial of the essence of nursing that ought to be gleaned from nursing theories, where nursing is viewed as more art than science. According to Mitchell (1999), The idea that nurses require evidence to know they should listen or be open to unique patterns of health, for instance, is a dangerous notion—if one can take it seriously at all. . . . It is possible to imagine that EBP could propel nursing toward a purely technical vocation, which questions the need for professional nurses. . . . EBP may represent one more example of how nurses embrace what they think will liberate them when, in reality, the initiative ensures their subservience to other interests and other disciplines. (p. 32)
Why Is Evidence Required as a Basis for Clinical Practice Now? In the past decade, policy makers, health care analysts, and funders have demanded that health care providers demonstrate that care delivery is efficacious, efficient, and cost-effective (Rosswurm & Larrabee, 1999; Valanis, 2000). In other words, does the intervention work? How much time does it take? What does it cost? In HIV/AIDS care, as in other nursing practice specialties, we are being asked to describe the outcomes of our care. Sometimes, the unspoken concern is that if we are unable to document the effects of our interventions, employers and other planners will ask the question, What does the nurse contribute to HIV/AIDS practice? However, as previously discussed, not all of nursing practice can or should be based on the results of an RCT. Many HIV/AIDS nursing activities that restore, maintain, or promote health do not lend themselves to this type of inquiry. Nevertheless, a number of financial, regulatory, and
13
accrediting bodies have required health care organizations to provide outcome data (evidence) to document the efficacy of care (Valanis, 2000). Nurses have professional and ethical obligations to advance nursing knowledge and to protect the public. Meeting these obligations invariably means participating in activities to study and to evaluate best nursing practices. Nursing’s legacy in studying and quantifying aspects of nursing care and clinical outcomes dates back to Florence Nightingale, the mother of modern nursing. In Notes on Nursing, published in 1859, Nightingale wrote, “In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort” (p. 70). Using evidence as a basis to improve care does not always mean personally reviewing all published literature related to a particular topic. In HIV care, such a task may be impossible. Rather, the selected review of evidence (e.g., meta-analysis, systematic review, even a review article) may prove sufficient. Consider the following examples of how nurses use evidence every day to improve care. How can an advanced-practice nurse counsel a person with symptomatic HIV infection about antiretroviral options if she or he is not familiar with the Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents developed by the Department of Health and Human Services and the Henry J. Kaiser Family Foundation (see www.hivatis. org [accessed January 28, 2000])? If an HIV prevention program intends to enlist recovering addicts as outreach workers, how can the program be successful and avoid unnecessary pitfalls if the efforts of others who have used a peer education model are not reviewed beforehand? When developing a clinical pathway for the inpatient management of the person with severe Pneumocystis carinii pneumonia, how can an interdisciplinary task force create a valid care management tool without examining institutional data about the experiences of other patients with PCP managed at the same hospital in the past year? Still another example is the development of clinical procedures or a training program. How confident would one be about a clinical procedure (or training program) for administering cancer chemotherapy in one’s institution if the
14
JANAC Vol. 12, Supplement, 2001
authors (educators) neglected to review the Cancer Chemotherapy Guidelines published by the Oncology Nursing Society (Fishman & Mrozek-Orlowski, 1999)? Clearly, there are a number of ways evidence is used every day to improve nursing care and to promote competent practice.
Using Evidence to Improve Nursing Practice: Clinical Applications There are a number of data sources that can be used to identify evidence for improving nursing practice (see Appendixes A and B). Data sources include bibliographic searches (e.g., MEDLINE). Systematic reviews are available from the Cochrane Collaboration, the Cumulative Index for Nursing and Allied Health Literature, and Sigma Theta Tau, and journals that promote EBP include the British Medical Journal, Evidence Based Nursing, and Evidence Based Health Care. Some journals are available free online. The AHRQ (formerly known as the Agency for Health Care Policy and Research), in collaboration with other organizations, sponsors a Web site library of clinical practice guidelines that are evidence based. Finally, institutions have a number of internal data sources that may be useful, such as infection control surveillance data, quality management and risk management data, medical record information, supply cost, pharmacy drug utilization, and adverse drug reaction data.
Improving HAART Administration in the Inpatient Setting: Using Institutional Data Jones and Holloman (2000) described a recent quality improvement project that used internal data to evaluate and improve the quality of care. The primary goal of the project was to decrease the potential for the development of antiretroviral drug resistance in the inpatient setting due to incorrect timing of medications vis-Ă -vis food interactions. A secondary project goal was to improve highly active antiretroviral therapy (HAART) patient education provided by the nursing staff. The impetus for the project was a qualitative study of HIV-positive subjects in which all nine
subjects expressed concern about the risk of the potential development of drug resistance. Three subjects in the study discussed dissatisfaction with the manner in which their HAART medications were administered while they were inpatients. The concerns of these subjects were the basis of the quality improvement project. The project used a continuous quality improvement methodology commonly used in clinical settings, FOCUS-PDCA. The acronym describes a process of using an interdisciplinary team to understand a care process (e.g., medication administration practices) that needs improvement. Then, the performance improvement team selects, implements, and evaluates an improvement strategy. Using this framework, Jones and Holloman (2000) described a project to improve HAART medication administration and patient education. A literature review was conducted by the pharmacist on the team to identify dosing recommendations vis-Ă -vis food and fluid. Internal data sources were used to understand the variations in how HAART medications were timed for administration. These data sources included (a) concurrent and retrospective review of medication administration records, (b) computerized pharmacy records of HAART orders, (c) direct observation of clinical unit during standard medication administration times, (d) medication delivery time schedules, (e) routine medication administration time schedule, and (f) meal tray delivery time schedule. No documentation of patient education was found in the medical records. Based on an analysis of these findings, the improvement project team selected an acronym (ACT) to describe its outcomes: Administer target medications (ritonavir, nelfinavir, saquinavir, indinavir, and didanosine) at the correct time to avoid drug interactions, Consult with the physician to reduce missed doses because of procedures, and Teach patient about HAART medications and document patient education in the medical record. The system or structural changes made to ensure appropriate timing of medications was as follows: correct the medication and meal/snack delivery times, individualize scheduling of HAART medications to maximize therapeutic benefit, educate nursing staff about the findings and about HAART medications, and develop tools to support best practices. Some of the tools
Baigis, Hughes / Evidence-Based Practice
developed to improve HAART administration practice included a chart titled To Eat or Not to Eat, That Is the Question? which used symbols to indicate whether the medication should be given with food. A physician reminder sticker was developed to decrease missed doses due to scheduling and to NPO preparatory requirements for certain diagnostic or therapeutic procedures. The team reviewed patient education materials available from pharmaceutical companies for inclusion in its educational efforts. A 30-minute inservice was given to all nursing staff as an introduction to the project. Repeated reviews of medication administration records and nursing documentation of patient education related to HAART indicated sustained improvement: target medications were charted as given with correct food/fluid requirements to ensure therapeutic benefit, missed doses occurred only when medically necessary, and documentation of HAART patient education improved. This project raised a number of interesting unanswered questions related to HAART administration in an inpatient setting for which research evidence is lacking. First, what is the effect of missed doses when NPO requirements prohibit administration of scheduled HAART medications? What is the best way to administer these medications if they can only be given with sips of water? When a patient is intubated and ventilated, what should happen to HAART medications? Finally, what is the optimal time to dose HAART medications when a patient is being hemodialyzed? This project was a wonderful example of improving clinical care through the use of institutional or internal evidence.
Managing a Treatment Side Effect: Using the RCT The RCT is considered the gold standard for EBP. Some nurse researchers studying symptom management have used this research design. Dodd et al. (2000) reported an RCT that tested the use of three mouthwashes to treat chemotherapy-induced oral mucositis along with a systematic oral hygiene regimen. Mucositis is a common side effect of certain chemotherapeutic agents used to treat cancer. As many as 40% of cancer patients treated with chemotherapy may develop oral mucositis (Scully & Epstein, 1996).
15
Oral mucositis may cause odynphagia and dysphagia and contribute to secondary nutritional problems. Malignancies have been a common complication and comorbidity of HIV infection. The literature suggests that the course of cancer may be altered in the setting of HIV infection (Kaplan & Northfelt, 1997). Outpatients with cancer who had been diagnosed with oral mucositis were approached to participate in this study. Study exclusion criteria included inability to read/understand English, Karnofsy Performance Scale score < 60, receiving concurrent radiation therapy to head and neck region, diagnosis of leukemia, diagnosis of HIV/AIDS, or undergoing bone marrow transplant. The rationale given for excluding patients with these diagnoses or receiving these treatments was that the pathophysiologic manifestations would confound the study’s findings (Dodd et al., 2000). Subjects were randomized to one of three mouthwash groups: salt and soda (saline and sodium bicarbonate solution), chlorhexidine gluconate mouthwash (0.12%), and “magic mouthwash” (combination solution compounded by local pharmacists that included viscous lidocaine 0.5% solution, diphenhydramine hydrochloride [Benadryl], and aluminum hydroxide suspension [Maalox]). In addition to the 20-second qid mouthwash protocol, each subject was coached to perform an oral hygiene regimen. The oral hygiene regimen included inspecting the mouth before brushing; brushing teeth for 90 seconds twice per day; flossing teeth daily; and rinsing with 20 cc[s] mouthwash, swishing thoroughly for 20 seconds, and spitting out the mouthwash four times a day. Subjects were advised to get a new toothbrush with each cycle of chemotherapy; to not eat or drink anything including water for 30 minutes following the mouthwash; and to avoid smoking, alcoholic beverages, and spicy foods. Subjects were also advised on what signs/symptoms to report to the study nurse (Dodd et al., 1996). An intervention nurse used the Eilers Oral Assessment Guide to evaluate the severity of the subject’s mucositis prior to beginning the trial and telephoned the subjects every other day to monitor the signs and symptoms. One hundred forty-two subjects completed the trial. Ninety-nine subjects refused to participate because they were too busy, did not want to be randomized to a particular mouthwash group, or were fearful of tooth staining. Another 49 subjects did not complete the trial
16
JANAC Vol. 12, Supplement, 2001
because they were too sick, were in severe pain, felt nauseous, did not like taste of the mouthwash, or experienced numbness. Of those subjects who completed the RCT, there were no statistically significant differences in the cessation of signs/symptoms of mucositis. Furthermore, there were no significant differences in pain score according to mouthwash group. Because there was no added value with any of the mouthwashes, the researchers recommended the least costly (salt and soda) mouthwash. It is difficult to translate these RCT findings into HIV nursing practice. First, there was the exclusion of persons with HIV/AIDS despite their risk for cancer and risk for receiving stomatotoxic agents. Second, the sample was remarkably homogeneous, limiting its generalizability to other communities. Third, if the nurse did not call the outpatients every other day, would they follow the protocol? Fourth, how could the oral hygiene regimen be adhered to if the person lacked resources such as a toothbrush and running water or had impaired vision and, thus, was not able to monitor the status of the oral lesions? How are client preferences taken into account? Finally, how are outcomes affected if the protocol is not followed precisely? Valanis (2000) identified a number of challenges to the application of RCT findings to clinical practice. She contended that an RCT links single causes to single effects and controls the contextual factors that may be uncontrollable in clinical practice. The RCT does not take into account the client’s preferences. Study samples may not match the sample of a clinical setting. Additionally, Valanis contended that research approaches are generally not clinical decision informing. Clearly, interpreting research findings in the clinical setting requires effective translation and effective organizational dissemination.
What Do You Do When There Is Little Evidence as a Basis for Clinical Practice? Despite the limitations of applying RCT findings to the clinical setting, a more common problem clinicians face is a lack of evidence to guide practice. One example of this problem is as follows: How can we
effectively assess and manage pain in the person with HIV/AIDS who also uses heroin? There are no RCTs to suggest best assessment or management strategies for HIV-related pain among drug users. There have been some elegant descriptive studies, many conducted by nurses and published in JANAC (Holzemer, Henry, & Reilly, 1998; Hoyt, Nokes, Newshan, Staats, & Thorn, 1994; Newshan, 1998). In Hoyt et al.’s (1994) study, there were no significant differences in pain perception between subjects with a history of chemical dependency and subjects without a history of chemical dependency. In Newshan’s (1998) study of hospitalized AIDS patients with pain, those patients with a history of drug use reported that health care professionals did not always listen to or believe their complaints of pain. Breitbart et al. (1997), in the largest study to date on the subject, described the adequacy of analgesics, pain reports, and psychological variables in persons with AIDS with and without a history of injection drug use. More than 500 AIDS patients were followed in the study. The prevalence, pain intensity scores, and interference of pain with activities of daily living were not significantly different between the groups. Injecting drug users, however, were more likely to receive less adequate analgesia and to report less pain relief and more psychological distress. There are no published guidelines for the most effective ways to manage pain in persons with HIV infection who also use drugs. The Agency for Healthcare Research and Quality Cancer Pain Management Clinical Practice Guidelines (Jacox et al., 1994) address the problem of HIV-related pain and the problem of pain management in substance users as special populations. The panel reached consensus on two statements related to pain management in substance users: (a) these patients are at risk for undertreatment of pain, and their care should be directed by clinical experts knowledgeable about both pain management and substance abuse, and (b) nonopioids should not be substituted for opioids to treat severe pain. Individual clinicians in this situation are left without clear guidance on how to assess and manage their HIV/AIDS patients who are substance users, other than the reminder that this group’s pain is probably undertreated. Some clinicians will examine the data from their own practices or institutions to identify
Baigis, Hughes / Evidence-Based Practice
trends and to develop a protocol. For others, consultation with colleagues, case reports, and past experience will direct their management.
Most EBP in Nursing Equals System Change Barriers to implementing EBP include system/ institutional barriers, individual clinician barriers, and patient/client barriers. Institutional barriers include organizational cultures resistive to change or invested in past practices, a failure to value research utilization, and decision-making processes that are complex and protracted. Clinician barriers include attitudes that question a need for change, some distrust of research findings as not reflective of real nursing, and limitations in resources such as staffing and time. Patient/ client barriers include no felt need to change how the client is managing the problem, a desire to be a good patient in order to please the health care professional by agreeing to change but not adhering to the protocol, and inadequate resources to manage the change. The majority of nurses, unlike physicians, do not have a caseload of clients for whom they assume sole responsibility and accountability. Most nurses work for organizations. As a result, nursing practice occurs as negotiated practice between and among a group of nurses caring for a group of clients. Therefore, to use evidence to change practice, nurse colleagues and the systems that employ nurses must be supportive. Rosswurm and Larrabee (1999) described a model for moving nursing systems to an EBP approach. The model includes six processes: (a) assess the need for a change in practice, (b) link the problem with interventions and outcomes, (c) synthesize the best evidence, (d) design a practice change, (e) implement and evaluate change in practice, and (f) integrate and maintain the change in practice.
17
the ways to rate the evidence will assist nurses to translate research and quality improvement results into their practices. For many clinical nursing problems, RCTs are not available and may not be available in the near future. In those instances, using patient population data, case reports, and institutional data to analyze and improve practice may be the basis for evidence-based nursing. Using evidence to inform nursing practice will help nurses to meet the goals of restoring, maintaining, and improving health.
Appendix A: Possible Sources of Evidence Bibliographic searches (e.g., MEDLINE) Systematic reviews (available from CINAHL, Cochrane Collaboration, and Sigma Theta Tau) Published clinical practice guidelines (e.g., Agency for Healthcare Research and Quality [formerly known as the Agency for Health Care Policy and Research] Cancer Pain Management Clinical Practice Guidelines] or HIV/AIDSspecific guidelines available through the HIV/AIDS Treatment Information Service) Standards of care (e.g., chemoprophylaxis in the person with HIV infection with positive tuberculin skin test but lacking evidence of active tuberculosis) Benchmarking data (e.g., Patient Falls Index rate) Institutional data sources (e.g., infection control surveillance data, quality management data [e.g., patient satisfaction surveys], risk management data [e.g., patient falls], medical record information, supply costs, pharmacy drug utilization data, and pharmacy adverse drug reaction data)
Appendix B: Evidence-Based Practice Web Resources
Conclusion EBP seems destined to be part of HIV/AIDS care for the foreseeable future. Understanding the sources of evidence available to inform practice, becoming savvy with information technologies, and appreciating
www.hivatis.org (HIV/AIDS Treatment Information Service) www.guideline.gov (National Guideline Clearinghouse) http://www.mlanet.org/index.html (Medical Library Association [has an evidence-based practice tutorial])
18
JANAC Vol. 12, Supplement, 2001
www.cochrane.org (Cochrane Collaboration) www.cinahl.org (Cumulative Index in Nursing and Allied Health Literature) www.highwire.stanford.edu (free online medical journals)
References Baigis, J. (1998). Health conceptualization. In Enclyclopedia of nursing research. New York: Springer. Barnsteiner, J. H. (1996). Research-based practice. Nursing Administration Quarterly, 20, 52-58. Breitbart, W., Rosenfeld, B., Passik, S., Kim, M., Funesti-Esch, J., & Stein, K. (1997). A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse. Pain, 72, 235-243. Chalmers, I., Sackett, D., & Silagy, C. (1997). The Cochrane collaboration. In A. Maynard & I. Chalmers (Eds.), Non-random reflections on health services research: On the 25th anniversary of Archie Cochrane’s “Effectiveness and efficiency” (pp. 231249). London: British Medical Journal Books. Cochrane, A. L. (1972). Effectiveness and efficiency: Random reflections on health services. London: Nuffield Provincial Hospitals Trust. Cochrane Collaboration. (1996). Database of systematic reviews [Online]. Oxford, UK: Author. Avaliable: www.cochraine.org. Covell, D. G., Uman, G. C., & Manning, P. R. (1985). Information needs in office practice: Are they being met? Annals of Internal Medicine, 103, 596-599. Dodd, M. J., Dibble, S. L., Miaskowski, C., MacPhail, L., Greenspan, D., Paul, S. M., Shiba, G., & Larson, P. (2000). Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surgery, Oral Medicine, Oral Pathology, 90, 39-47. Dodd, M. J., Larson, P. J., Dibble, S. L., Miaskowski, C., Greenspan, D., MacPhail, L., Houck, W. W., Paul, S. M., Ignoffo, R., & Shiba, G. (1996). Randomized clinical trial of chlorhexidine versus placebo for the prevention of oral mucositis in patients receiving chemotherapy. Oncology Nursing Forum, 23, 921-927. Fishman, M., & Mrozek-Orlowski, M. (Eds.). (1999). Oncology Nursing Society cancer chemotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Goldrick, B. A., Baigis, J. A., Larsen, J., & Lemert, J. L. (2000). Nursing research and HIV infection: State-of-the-science. Journal of Nursing Scholarship, 32, 233-237. Graves, J. R. (1999). What is a knowledge base? [Online]. Accessed November 29, 2000. Available: www.nursingsociety.org Guyatt, G. H., Meade, M. O., Jaeschke, R. Z., Cook, D. J., & Haynes, R. B. (2000). Practitioners of evidence based care. British Medical Journal, 320, 954-955.
Holzemer, W. L., Henry, S. B., & Reilly, C. A. (1998). Assessing and managing pain in AIDS care: The patient perspective. Journal of the Association of Nurses in AIDS Care, 9, 22-30. Horsley, J. A., Crane, J., Crabtree, M., & Wood, D. (1983). Using research to improve nursing practice: A guide. New York: Grune & Stratton. Hoyt, M. J., Nokes, K., Newshan, G., Staats, J. A., & Thorn, M. (1994). The effect of chemical dependency on pain perception in persons with AIDS. Journal of the Association of Nurses in AIDS Care, 5, 33-38. Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. Jacox, A., Carr, D. B., Payne, R., et al. (1994). Management of cancer pain: Clinical Practice Guideline No. 9 (Agency for Health Care Policy and Research Publication No. 94-0592). Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service. Jones, S. G., & Holloman, F. (2000). Continuous quality improvement project: Decreasing the potential for the development in the inpatient setting of drug resistance by improving nursing practice. Journal of the Association of Nurses in AIDS Care, 11, 76-86. Kaplan, L. D., & Northfelt, D. W. (1997). Malignancies associated with AIDS. In M. A. Sande & P. A. Volberding (Eds.), The medical management of AIDS (p. 413). Philadelphia: W. B. Saunders. Krueger, J. C., Nelson, A. H., & Wolanin, M. O. (1978). Nursing research: Development, collaboration, and utilization. Germantown, MD: Aspen. Mitchell, G. (1999). Evidence-based practice: Critique and alternative view. Nursing Science Quarterly, 12, 30-35. Munhall, A. (1998). Nursing, research and the evidence. Evidence Based Nursing, 1, 4-6. Newshan, G. (1998). Is anybody listening? A phenomenological study of pain in hospitalized persons with AIDS. Journal of the Association of Nurses in AIDS Care, 9, 57-67. Nightingale, F. (1859). Notes on nursing. Philadelphia: J. B. Lippincott. Nolan, M. T., Larson, E., McGuire, D., Hill, M. N., & Haller, K. (1994). A review of approaches to integrating research and practice. Applied Nursing Research, 7, 199-207. Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31, 317-322. Sackett, D. L., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (1998). Evidence-based medicine: How to practice and teach EBM. Edinburgh: Churchill Livingstone. Scully, C., & Epstein, J. B. (1996). Oral health care for the cancer patient. European Journal of Oral Oncology, 32B, 281-292. Valanis, B. (2000, April). Thinking downstream: Research to guide evidence-based practice in managed care. Paper presented at Building on a Legacy of Excellence in Nursing Research Conference and WIN Assembly, Denver, CO.