Applying Research to Interoperative Care
The theory-practice gap in nursing has been referred to, in the past, as a problem for nurses, both for those in academia and those in clinical practice (Thomson, 1998). Rolfe (1998) seems to suggest that the problem is so bad as to be putting lives at risk. He uses the example of the use of research in civil engineering to illustrate the problem. That is, that if engineers do not use research, then buildings and bridges will fall down with the result that people will die (McKenna, 1995).
The aim of research is to generate knowledge (Rolfe, 1998). Practitioner education has undergone great change as a result of research and academic practitioners are now firmly established (Mulhall, 1998). It remains the case that practitioner research has only a minimal impact on clinical practice.
If theatre practitioners are to offer care that is research-based, then it is necessary for a mechanism to be in place that allows and encourages them to do just that. The latest attempt to bridge the theory-practice gap is evidence based practice (EBP). This is happening, not just in the field of theatre practitioners but also in general nursing and the various disciplines of medicine.
Sackett et al (1996, P.71), describe evidence-based medicine as a conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual clients. Although this description makes it clear that evidence based medicine (EBM) is best practice, it is also clear to the practitioner, that the practitioner or doctor is responsible for making decisions about care. Sackett et al (1996) go on to say that EBM is an integration of individual clinical expertise and the best available external evidence from systematic research. The individual gains knowledge, not just from acquiring research, but from their own experience, clinical practice and past situations. The patient is also central to Sackett et al (1996) description of EBM. They realise that the patient has rights and preferences about their clinical journey. Sackett et al (1996) recognise that a more thoughtful interaction with clients is as important as effective and efficient diagnosis.
Royle and Blythe (1998) also describe an integration between the best evidence from research, clinical expertise, patient preferences and adds the element of existing resources. These all go together into a decision making process about individual patient health care. The introduction of available research resources into the integration is important. The author’s belief is that available resources should be influenced by evidence-based practice. If a particular environment or training is based on the evidence of best research, we can say we are offering value for money, even if that environment or training is not the cheapest option available.
Flemming (1998) suggests that evidence-based nursing (EBN) is a five stage process: ii) Information needs from practice are converted into focused structured questions,
ii) The focused questions are used as a basis for literature searching in order to identify relevant external evidence from research,
iii) The research evidence is critically appraised for validity and generalisability,
iv) The best available evidence is used alongside clinical expertise and the patient's perspective to plan care,
v) Performance is evaluated through a process of self-reflection, audit or peer assessment. Evidence-based nursing is a process, then, that should make it easier to incorporate current best evidence into clinical decision making.
Sackett et al (1996) are aware that the clinician is responsible for the decision making and that practice cannot be based purely on research. Preoperative care is not an exact science and frequently involves complex relationships between practitioner and client. I suggest it would be difficult to dissect accurately this relationship into scientifically measurable items for research. The care that we’re providing can be criticised by people looking at research and comparing the care situation to it, unless an experienced practitioner guides and complements it. However, to remain up-to-date and to use good new ideas, and to avoid becoming fixed in traditional routines, we need the best evidence from research.
If we are to promote evidence-based nursing as a useful practice for clinicians, then we have to be clear on what we mean by evidence-based nursing. Some of the new journals now appearing to promote EBN, seem to bypass any discussion as to what evidence is. They regurgitate descriptions of research, suggesting what is the most useful research; in terms of how that research is carried out. That is, they emphasise and explain randomised control trials (RCT), frequently called ‘The Gold Standard’. Few describe what theatre practitioners should be looking for in an article, to raise the level of evidence-based nursing.
Walsh (1998) attempts to describe what is meant by evidence and how an interpretation of evidence has also to take account of what we mean by a clinical decisions. When declaring they use EBN, practitioners are claiming to base their practice on truth and rightness (Walsh, 1998). If we are to implement EBN, then each practitioner claiming to do so must, therefore, know that for the client that they are dealing with, the diagnosis must be correct, the clinical plan effective, and that the evaluation is undertaken in an appropriate manner. The practitioner should also be able to provide evidence to prove that this is trustworthy and sincere (Walsh, 1998). A definition can, therefore, be given that clinical evidence consists of contestable facts, experience and information offered to support the distinct claims that a clinical course of action is intelligible, truly effective, morally acceptable and sincerely intended (Walsh, 1998).
Mulhall (1998) discusses a practitioner having different ways of knowing and different kinds of knowledge. The practitioner uses his/her knowledge of the physiological body, knowledge of the person as a social creature, and also knowledge gained from being a practitioner and performing their role. Therefore much of the evidence for what we do is not formalised in research. For some of the interactions that happen between practitioners and clients, practitioners may use very unscientific and emotional language about how they feel whilst knowing what direction they should take. To take theatre practitioners further, we need to find more accurate ways of defining “knowledge”. The task is to find effective methods of research to prove that what they do is useful (House of Lords, 1995). A. Sargant (Personal communication, August 9, 1998) explains that practitioners are expected to justify their actions to themselves, their peers, patients and the law. This may lead to some practitioners working ‘by the book’, whatever that book might be. If ‘the book’ is the only reference practitioners have, there could be the death of creativity A. Sargant (Personal communication, August 9, 1998).
Interoperative care appears to produce fewer examples of research than general nursing as have been described as contributing to EBN. In the author’s own searches on the internet, the author could find many sites dedicated to evidence-based practice in one form or another. Much of that available under the evidence-based, interoperative banner was very medical, that is, it was evidence-based medicine. Also, much of this evidence was concerned with diagnosis and prognosis.
Practitioners should be determined to provide highly individualised care where the individual is considered unique and deserving of quality nursing (Radwin, 1995). If we base practitioner care on research findings that offer the best overall care for a particular client group, we are bound to offer inferior care to those who do not fit into the group exactly.
Practitioners, who incorporate their knowledge of research evidence into practice, do so by using their own expertise (Benner, 1984). This involves a decision making process. There is an assumption that the process of making a decision is obvious (Walsh, 1998). Walsh defines clinical decisions as clinical actions aimed at mastering clinical situations.
For EBP to become a naturalised part of perioperative care, there is a need, not just for educationalists, clinicians and researchers to adopt new approaches, but also for organisations to do so. The organisation must make a commitment to provide time and staff, not only to the development of EBP, but also for its continued use. A practitioner research forum made up of practitioners from various clinical areas could raise the profile of research throughout the organisation (Mitchell, 1998). The practitioners research forum may link into a multi-disciplinary forum, but for the reasons already discussed, the author believes that it is essential that perioperative care research is promoted as an endeavour in itself. It may be useful to involve user groups in the development of practitioner research. Permanent places on the practitioner research forum could be available for representatives of user groups. Quality assurance and clinical audit should be linked to EBN (Royle and Blythe, 1998). Any form of staff development policy and job description should contain duties relating to practitioner research.
The role of a practitioner research forum would not be just to promote the use of external research findings. It would put in place the structures necessary to allow practitioners to carry out research. Instead of thinking in terms of research-based practice, we should look to practice-based research to provide knowledge of the practitioner-patient relationship. This means that if practitioners are unhappy with, or cannot find the research to support situations they find themselves in, they can do the research themselves (Rolfe, 1998). As Stenhouse, (1985) pointed out:
“if after comparing the measurement results (of external research) with your own experience, you find yourself uncertain of judgement, then basically there’s no alternative to doing your own research”.
Conclusion
Evidence-based practice is being promoted by government and academies as essential to the well-being of patients. Perioperative practitioners should not believe that they are immune to the use of research, just because they believe they work in abstract relationships. Practitioners can use EBP to show that what they do is essential for individualised care, care that leaves the patient saying they feel better because of the relationship with the practitioner. The uniqueness of the clinical encounter between practitioners and patient should become the focus of evidence-based, perioperative care. Without ignoring the usefulness of large scale, generalizable studies currently favoured by research funding committees, journals and government, practitioners must strive to redirect some research in to the clinical encounter. The practitioner handover can become a tool in which external research, individual practitioners expert knowledge and practice-based research can be shared to provide evidence-based practice. The expertise of practitioners should not be ignored; experts often know more than they can say (Benner, 1984).
Research is essential in providing the best care possible for patients. Without research that is up-to-date and specialised, we become fixed in tradition and ritual. By the use of the best and most appropriate evidence for care, we offer better care. With support from individual practitioners, educationalists, academics and organisations, perioperative practitioners can use evidence-based practice to offer high quality, individualised, patient care.
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