Development of evidence-based guidelines in midwifery and gynaecology nursing

Development of evidence-based guidelines in midwifery and

gynaecology nursing Joan Webster, Wendy C. Lloyd, Margo A. Pritchard, Christine A. Burridge, Lorraine E. Plucknett and Amanda J. Byrne Objective: to develop an effective and efficient method for basing nursing practice on research evidence. Setting: the Royal W o m e n ' s Hospital, Brisbane, Australia. Method: nurses and midwives from various clinical areas were invited to participate in an evidence-based practice project. Standard procedures for retrieving relevant articles and evaluating their quality were observed. W h e r e possible, raw data from studies with similar methods were summarised using appropriate statistical tests.

Findings: several guidelines have been developed, staff involved with the project have become 'research literate' and the project is contributing to the hospital-wide quality improvement activities.

Joan Webster BA, RN, RM Assistant Director of Nursing (Research). Wendy C. Lloyd RN. RM, BNurs Clinical Nurse Consultant, Central Sterilising Department Margo A. Pritchard BA, RN, RM, Cert Adv Neonatal Nsg Clinical Trials Coordinator, Christine A. Burridge B Health Scieece(Nurs). RN. RM Clinical Nurse, Operating Rooms Lorraine E. Plucknett RN, RM, Cert Perioperative Nsg. Cert OR Mgnt Clinical Nurse Consultant, Operating Rooms

Amanda J. Byrne B Nursing. DipApplSci(Nurs). RN. RM Clinical Nurse Consultant, Special Care Nursery. Royal Women's Hospital and District Health Services. Bowen Bridge Road, Herston QId 4029. Australia (Correspondence to JVV) Manuscript accepted 6 April 1998

Conclusions and implications for practice: it is possible to translate research findings into practice when small groups use systematic reviews to develop practice guidelines.

INTRODUCTION Midwifery is a discipline in which levels of ambiguity exist about the effectiveness of many common routines. Consider variations in practices such as flexing the head during normal delivery, routine post-caesarean observations or management of breast engorgement. This is especially apparent when moving from one organisation to another or even between wards in the same institution. Although such differences are rarely of clinical significance, the impact on the woman, her baby or on the budget, may be considerable (routine suction at delivery is one example). In addition, the midwife may be criticised or seen as inadequate for performing a routine which elsewhere may have been an accepted policy. Recent emphasis on evidence-based practice (EBP) in health care offers an approach to dealing with such ambiguities and, at the same time, creates a potential for change based on scientific knowledge. Moreover, the process of EBP is acceptable to clinicians because it is an intuitively sensible approach. Steps involve: (1) identifying an information need or problem and translating that problem into an answerable question, for example, 'Does Midwifery (1999) 15.2-5

© 1999 Harcourt Brace

double gloving reduce needle-stick injuries during surgical procedures?'; (2) seeking out the best evidence with which to answer the question (evidence may range from systematic reviews of randomised controlled trials to expert opinion or even compelling empirical observations); (3) critically appraising the evidence in a systematic way; (4) incorporating the evidence into guidelines for clinical practice; and (5) evaluating the change (Sackett 1997). Although this approach appeals in theory, in practice, implementing EBP has been complicated. Many organisations are not linked to easilyaccessible search devices, such as periodical data bases (Medline, CINAHL) and the Intemet. Even where they are, time is a huge constraint for busy clinicians. Another problem is a lack of expertise or skill in critical evaluation of reported research. In addition, there is a serious deficit of randomised controlled trials of midwifery and nursing interventions (let alone systematic reviews or meta analyses of such trials) in the midwifery and nursing literature. Finally, it is sometimes difficult to refine a nursing practice issue into a tight research question (White 1997). Consequently, acceptance of a broader approach to what is admissible as 'evidence' for

Evidence-based guidelines in midwifery and gynaecology nursing nursing has been proposed (Hicks & Hennessy 1997). Despite these difficulties, developing practice guidelines for midwives and gynaecology nurses based on an EBP approach has been the focus of our Continuous Improvement Based on Evidence and Research (CIBER) project at the Royal Women's Hospital (RWH), Brisbane. A central philosophy in the project's development was the involvement of midwives and nurses in the process. Skills in research and data retrieval were not criteria for group membership, enthusiasm and a willingness to learn through active participation was the only stipulation. Getting the project off the ground has not been without difficulties, but the rewards have been far reaching.

METHOD Development of EBP groups was included in the annual business plan for the Hospital's Centre for Nursing & Women's Health Research. Identifiable targets, key performance indicators and an action plan were prepared and accepted by the Nursing Executive. The project was explained at staff meetings and expressions of interest sought. Four groups were formed representing specialty areas of the hospital: (1) delivery suite and operating room; (2) gynaecology; (3) postnatal and birthing centre; and (4) neonatal intensive care. To ensure acceptance and ownership of outcomes by management, membership of each group included the Assistant Director of Nursing, the Nurse/Midwifery Educator and the Nurse/Midwifery Manager responsible for each of the group's area of practice as well as interested clinical midwives and nurses from ward areas. Other individuals such as the Infection Control Nurse, the Clinical Nurse Consultant from Central Sterilising, a representative from the Breast Screening Clinic and a midwife from the RWH's Perinatal Research Centre joined a group of their choice. The aim of the project was to develop practice guidelines based on scientific evidence through a participative process. Initial meetings focussed on group cohesion and skill development. The concept was very new for most members and, at the start, quite frightening. There was enthusiasm for the project, but concern about ability to meaningfully participate. Visits to the library to develop search and retrieval skills, ensuring on-line access to Medline and CINAHL in work areas, breaking the process down into manageable tasks, working together when critically appraising articles, and having a simple framework to record findings, all helped to allay fears and improve the knowledge levels of participants. One of the first steps was to nominate clinical problems for investigation. It was decided to limit questions or problems to those within our jurisdiction to address. For example, even though there is

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strong evidence to suggest restricting ultrasonography in pregnancy, midwives have little control over policy development in this area. Group members were asked to consider the following to help their decision. Should practices issues be chosen because: there is variation in practices among clinicians (for example, insisting on feeding babies within 24 hours of birth) there are significant cost benefits in changing practice (for example, routine suction at delivery or use of double or single drapes) - it is an issue of current concern (for example, double gloving for surgical procedures) - there is uncertainty about appropriate practice (for example, number of 'counts' done during an operation or how often should meatal cleansing occur in a woman who has an indwelling catheter in situ for longer than 48 hours) - the problem may be severe (for example, the prevalence of MRSA colonisation amongst premature neonates) the issue has been prioritised by staff as a whole through strategies, such as a Delphi technique. -

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At the outset, questions relevant to CIBER group members were selected. This turned out to be a useful strategy, it made the process more meaningful and kept enthusiasm high. A number of practice issues of concern to individual participants were identified, but only one was chosen by each group for review. The issue was used as a pilot question, a learning tool to develop skills and techniques, and to test the process. The process contained a number of parts: 1. Once the topic was nominated, searches of the Medline, CINAHL and Cochrane data bases were conducted. In addition, policies or guidelines from other institutions or organisations were sought where appropriate. 2. Abstracts were selected and printed if they reported original research, meta analyses or systematic reviews. Care was taken at this stage to include all valid articles to reduce possible bias. 3. Printed abstracts were distributed equally amongst group members who were asked to retrieve the original articles (those with limited skills were buddied with another group member). 4. Working in a group, studies were critically appraised and, depending on the quality and focus of the research, decisions were made about which articles to include in the review. 5. For each report, the strength of evidence was assessed according to standard criteria (NH&MRC 1995a) (Figure 1). 6. Raw data from randomised controlled trials, which employed similar methods, were reanalysed and summarised using the pooled relative risk for adverse event statistic (Table 1).

4 Midwifery

• Levell

Evidence o b t a i n e d f r o m a systematic r e v i e w o f all r e l e v a n t RCTs

• Levelll

Evidence f r o m at least o n e p r o p e r l y designed r a n d o m i s e d c o n t r o l l e d trial Evidence f r o m well-designed c o n t r o l l e d trials w i t h o u t r a n d o m i s a t i o n

• Levellll-I • Levellll-2

Evidence f r o m well-designed c o h o r t o r case c o n t r o l studies, p r e f e r a b l y f r o m m o r e than o n e c e n t r e o r research g r o u p

• Level 111-3

Evidence f r o m m u l t i p l e time-series w i t h o r w i t h o u t f r o m u n c o n t r o l l e d studies c o u l d also be included)

• Level IV

Represents the o p i n i o n s o f respected authorities, based on clinical o p i n i o n , descriptive studies o r r e p o r t s f r o m e x p e r t c o m m i t t e e s

Fig. I

the i n t e r v e n t i o n (dramatic results

Rating system used to classify strength of evidence

T a b l e I Relative risk esdmate for glove integrity when either single or double gloves are worn (n= 1801)

Case control Single glove use Matched holes in inner and outer glove when double gloves worn

Relative risk

95% Confidence Bounds

6.46 5.32 0.82

4.40 to 9.50 3.71 to 7.63 0.79 to 0.85

Barrier protection is approximately 5 times more likely to be compromised when single latex gloves are worn when compared with wearing double latex gloves

7. Finally, the guideline was developed using a simple format which identified both the level of evidence and areas for future research (Figure 2).

FINDINGS

AND

DISCUSSION

Using small groups to develop scientifically-valid clinical guidelines has a number of advantages for a health facility. First, the process is an excellent method for teaching research principles. Partly

because steps in the research process (i.e. identifying and limiting the question, conducting a literature review, developing a research design, collecting the data, and analysing and presenting results) are intrinsic to the method used to develop guidelines, and partly because studies chosen for critical appraisal had meaning to participants. Thus, learning about research was interesting and relevant. Two practice guidelines have been finalised, a further two are nearing completion and several more are being researched. Momentum is expected to increase as groups become more skilled and self-sufficient. Negotiations with the Information Technology Unit for a hospital-wide 'Clinical Guideline Data Base' is underway. This will provide easy access for midwives, nurses and others to current evidence-based guidelines. Until then, guidelines will be published in the RWH Policy & Procedure Manual. The importance of such a data base cannot be overestimated in an increasingly information literate and litigatious society (Shorten & Wallace 1997). We must know not only what we are doing, but also why we are doing it and be able to support our decisions with credible data. Grimshaw et al. (1995) noted that although there may be considerable cost attached to the development of evidence-based guidelines, the outlay can be easily recouped through changes in

Guideline - use of double gloves

Level of evidence

References

Double gloving offers a measure of protection against damage to the inner glove Double gloving reduces the incidence of blood contact during pelvic surgery Needle stick injuries are not reduced when double gloves are worn Wound sepsis is not increased by glove perforation nor reduced by double gloving Use of double gloves impairs comfort, sensitivity and dexterity

II

Gani JS (1990)

I I I-I

Quebbemann et al. (I 992) Tokars et al. (I 995)

II

Quebbeman EJ et al. (1992)

I I I-I

Dodds RD et al. (1990)

II

Wilson SJ (I 996)

Implications for research More information is needed about the effect of double gloving on needlestick injuries Recommendation The practice of wearing double gloves when performing surgical procedures confers increased projection against exposure to blood and body fluid Key points: use of double gloves Glove barriers on the non-dominant hand are more often perforated The risk of perforation and exposure increases with length and complexity of operation Although initially impermeable to viruses, the porosity of surgical gloves increases with duration of use Fig. 2

Example of guideline format

Evidence-based guidelines in midwifery and gynaecology nursing practice. We have already begun to see examples o f such savings as clinicians from the group take back information to colleagues and begin planning for change. Examples include a reduction in the number o f babies routinely suctioned at delivery ($2.21/baby) and a move towards an 'event-related' rather than a 'date-related' basis for determining shelf life o f sterile articles. Significant savings have been demonstrated when other hospitals adopted this policy (Lamb et al. 1996). Other advantages o f the project include the development o f a very useful literature resource. All articles retrieved during the course o f a review are retained, grouped and filed under topic headings. Staff may access the holding at any time, either for their own information or for research purposes. Finally, the review identifies areas requiring further investigation. Despite the usefulness o f resources such as the Cochrane data base, which contain numerous systematic reviews o f interest to midwives and nurses (Renfrew 1997), there remain vast areas o f practice where such reviews are lacking (Castledine 1997). This provides a useful starting point for students looking for clinically-relevant topics for research study. In addition, identifying gaps in the literature will also be one consideration in the ongoing development o f the Centre's research agenda.

Limitations The project has been affected by two constraints. First, it has been difficult to find time for busy clinicians to meet together. This has been overcome, to some extent, by the process outlined earlier and by using informal communication between monthly meetings. E-mail contact is also maintained between group members. The second problem has been the paucity o f useable literature. Many o f the topics we have begun to review have had to be abandoned because o f the quality o f available data. Original research is still rare in midwifery and nursing, and rarer still are studies which may be combined when investigating a specific research question.

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Involving midwifery/nursing staff in this project has resulted in an increased interest in research and ownership, and commitment to change based on scientific evidence. In addition, the project has directly contributed to hospital-wide quality improvement activities. REFERENCES Casteldine G 1997 Evidence-based nursing: where is the evidence? British Journal of Nursing 6:290 Dodds RD, Barker SG, Morgan NH et al. 1990 Self protection in surgery: the use of double gloves. British Journal of Surgery 77:219-220 Gani JS, Ainseline PE Bissett RL 1990 Efficacy of double gloves verses single gloving in protecting the operating team. Australian & New Zealand Journal of Surgery 60: 171-175 Grimshaw J, Eccles M, Russell l 1995 Developing clinically valid practice guidelines. Journal of Evaluation in Clinical Practice 1:37-48 Hicks C, Heunessy D 1997 Mixed messages in nursing research: their conlribution to the persisting hiatus between evidence and practice. Journal of Advanced Nursing 25:595-601 Lamb 3",Foster S, Henderson E et al. 1996 Significant savings achieved by implementing event related outdating. Canadian Operating Room Journal 14:12-14 NH&MRC 1995 Guidelines for the development and implementation of clinical practice guidelines. Quality of Care and Health Outcomes Committee, National Health & Medical Research Council, Australian Government Publishing Service, Canberra Quebbeman EJ, Telford GL, Wadsworth K, Hubbard S, Goodman H, Gottlieb MS 1992 Double gloving. Protecting surgeons from blood contamination in the operating room. Archives of Surgery 127:213-216 Sackett DL 1997 Evidence-based medicine. Seminars in Perinatology 21:3-5 Shorten A, Wallace M 1997 Evidence based practice: the future is clear. Australian Nursing Journal 4:22-24 Renfrew MJ 1997 Influencing the development of evidencebased practice. British Journal of Midwifery 5:131-134 Tokars JL, Culver DH, Mendelson MH, Sloan EP, Farber BF 1995 Skin and mucous membrane contacts with blood during surgical procedures: risk and prevention. Infection Control Hospital Epidemiology 16:703-711 White SJ 1997 Evidence-based practice and nursing: the new panacea? British Journal of Nursing 6(3): 175-178 Wilson SJ, Sellu D, Uy A, Jaffer MA 1996 Subjective effects of double gloves on surgical performance. Annals of the Royal College of Surgeons of England 78:20-22