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Evidence based practice: Taking the pressure off
International Journal of Orthopaedic and Trauma Nursing xxx (2017) 1e2
Contents lists available at ScienceDirect
International Journal of Orthopaedic and Trauma Nursing journal homepage: http://www.journals.elsevier.com/internationaljournal-of-orthopaedic-and-trauma-nursing
Editorial
Evidence based practice: Taking the pressure off
Over the past few decades there have not only been concerted efforts to drive patient care towards evidence-based practice (EBP), but copious discussion about the fact that the practice of nursing care is not yet fully evidence-based. Quite recently, Saunders et al. (2016) found that Finnish nurses at university hospitals were familiar with the concept of EBP, but lacked the ability to integrate best evidence into care. Yet that paper, and others, seem to fail to appreciate how much EBP has moved forward from a time, in the 1970s, when most nurses had never heard of research let alone read a research paper. Nursing research is in a very different situation today than it was even 25 years ago; increasingly being applied to practice where it is available. More nurses than ever before know about and understand it. Even medicine, which has been developing its evidence base since the time of Hippocrates, is still developing its own scientific foundations. There are still, however, many areas of health care practice that are not yet based on evidence and which require both the conduct of further research and efforts to apply such evidence to practice. The barriers are well known; including lack of evidence, lack of knowledge of the evidence and lack of attention to the implementation of evidence in practice. In 1989 Walsh and Ford published their seminal book; “Nursing Rituals. Research and Rational Actions”. At the time it had a significant impact on the way many nurses thought about practice. The main tenet was to address the commonly believed myths and rituals of nursing and to ask if they were research based. The authors argued that many routine nursing practices were based on little more than tradition and habit and questioned many things that had been common practice since the early days of nursing. Some of these were clearly ridiculous looking back: painting egg white onto a pressure ulcer whilst drying it out with piped oxygen and putting salt in patients' baths - both, reputedly, to aid wound healing. I have always been troubled by the idea that everything that isn't based on research should be thrown out. Take, for example, something we used to call the ‘back-round’- a long standing practice, that disappeared in many hospitals around 1990. A trolley stacked with bed linen, a wash bowl and various items for washing and caring for patients' skin was pushed around the ward approximately every 2 hours by two nurses or health care assistants who interacted with each patient and gave ‘pressure area care’ if it was required. The practice was also used as an opportunity to make contact with patients to check if they needed anything and whether incontinent patients, for example, needed washing, skin care and a change of linen. The tradition stopped largely because it was
believed that it was ritualistic practice and not based on individual patient need or research. If we take a closer look at this, however, we can see several problems. It is a commonly held belief that the idea of the 2-hourly back-round began during the second world war in spinal injury units. The story goes that care assistants were employed to work in pairs, changing each patient's position. It took them 2 hours to get around the wards and no one sustained a pressure ulcer. Hence the 2-hourly back-round was born. There was no research evidence for this in those days; just a hunch that regular changes of position had to be a good idea. I am convinced that when my own unit stopped back-rounds in the late 1980s, the incidence of pressure ulcers increased (mainly because it was easier to forget something that was no longer a ritual) and patients interacted less often with staff. This is now recognised in the development of ‘intentional rounding’ as a way of ensuring that every patient receives proactive contact at some point every 2 hours or so. Since that time, there has been a growing body of evidence available about the causes and prevention of pressure ulcers and it is widely agreed that most pressure ulcers are preventable and that regular changes of position, between 2 and 3 hourly, is an important preventive strategy amongst the options. Manual repositioning is used to re-distribute pressure between the body and the surface the patient is lying or sitting on. Many clinical guidelines recommend routine repositioning of at risk patients, often 2-hourly so this remains common practice. Not everything that looks like evidence, however, is good evidence. Gillespie et al.'s (2014) Cochrane Systematic Review highlights a lack of robust studies of positions and repositioning frequency for pressure ulcer prevention. This leads to uncertainty, but it does not follow that position changes constitute ineffective practice as the studies included in the review are few, at risk of bias and lack statistical power. The review authors state that: “There is currently no strong evidence of a reduction in pressure ulcers with the 30 tilt compared with the standard 90 position or good evidence of an effect of repositioning frequency”. Despite this Gillespie et al. (2014) remind us that position changes have a sound theoretical rationale for the prevention of PUs and that just because the research evidence is weak, there is no reason to assume that the practice does not work. Just because we don't have scientific evidence for something, doesn't mean it is wrong. Ford and Walsh's (1994) second book warned of replacing the old rituals with new ones and unquestioningly implementing
http://dx.doi.org/10.1016/j.ijotn.2017.02.001 1878-1241/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Santy-Tomlinson, J.Evidence based practice: Taking the pressure off, International Journal of Orthopaedic and Trauma Nursing (2017), http://dx.doi.org/10.1016/j.ijotn.2017.02.001
2
Editorial / International Journal of Orthopaedic and Trauma Nursing xxx (2017) 1e2
new ideas without understanding the benefits and outcomes. A case in point may be the use of ‘tools’ to identify patients at risk of pressure ulcers. Johansen et al. (2014) found that undertaking risk assessment did not necessarily result in the planning and implementation of appropriate pressure ulcer prevention initiatives. When such a risk assessment tool becomes an “end in itself” and does not necessarily lead to management of that risk through useful action, then it could be argued that it has become a new ritual without focus on individual patients and lacking evidence to support it. Bringing back the back-round probably isn't the answer e nurses and other health professionals are much more able to innovate these days and have larger quantities of better evidence available to help them decide what the best approach to the problem might be. As long as we continue to strive to be critical of what we do and how we do it and search for ways for it to be more effective, care will be going in the right direction.
References Ford, P., Walsh, M., 1994. New Rituals for Old. Nursing through the Looking Glass. Butterworth Heinemann, Oxford. Gillespie, B.M., Chaboyer, W.P., McInnes, E., Kent, B., Whitty, J.A., Thalib, L., 2014. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst. Rev. Apr. 3 (4), CD009958. http://dx.doi.org/10.1002/ 14651858.CD009958.pub2. Johansen, E., Moore, Z., van Etten, M., Strapp, H., 2014. Pressure ulcer risk assessment and prevention: what difference does a risk scale make? A comparison between Norway and Ireland. J. Wound Care 23 (7), 369e378. €inen-Julkunen, K., 2016. Nurses' readiness for Saunders, H., Stevens, K.R., Vehvila evidence-based practice at Finnish university hospitals: a national survey. J. Adv. Nurs. 72 (8), 1863e1874. http://dx.doi.org/10.1111/jan.12963. Walsh, M., Ford, P., 1989. Nursing Rituals. Research and Rational Actions. Heinemann Nursing, Oxford.
Julie Santy-Tomlinson, Editor E-mail address: [email protected].
Please cite this article in press as: Santy-Tomlinson, J.Evidence based practice: Taking the pressure off, International Journal of Orthopaedic and Trauma Nursing (2017), http://dx.doi.org/10.1016/j.ijotn.2017.02.001
Contents lists available at ScienceDirect
International Journal of Orthopaedic and Trauma Nursing journal homepage: http://www.journals.elsevier.com/internationaljournal-of-orthopaedic-and-trauma-nursing
Editorial
Evidence based practice: Taking the pressure off
Over the past few decades there have not only been concerted efforts to drive patient care towards evidence-based practice (EBP), but copious discussion about the fact that the practice of nursing care is not yet fully evidence-based. Quite recently, Saunders et al. (2016) found that Finnish nurses at university hospitals were familiar with the concept of EBP, but lacked the ability to integrate best evidence into care. Yet that paper, and others, seem to fail to appreciate how much EBP has moved forward from a time, in the 1970s, when most nurses had never heard of research let alone read a research paper. Nursing research is in a very different situation today than it was even 25 years ago; increasingly being applied to practice where it is available. More nurses than ever before know about and understand it. Even medicine, which has been developing its evidence base since the time of Hippocrates, is still developing its own scientific foundations. There are still, however, many areas of health care practice that are not yet based on evidence and which require both the conduct of further research and efforts to apply such evidence to practice. The barriers are well known; including lack of evidence, lack of knowledge of the evidence and lack of attention to the implementation of evidence in practice. In 1989 Walsh and Ford published their seminal book; “Nursing Rituals. Research and Rational Actions”. At the time it had a significant impact on the way many nurses thought about practice. The main tenet was to address the commonly believed myths and rituals of nursing and to ask if they were research based. The authors argued that many routine nursing practices were based on little more than tradition and habit and questioned many things that had been common practice since the early days of nursing. Some of these were clearly ridiculous looking back: painting egg white onto a pressure ulcer whilst drying it out with piped oxygen and putting salt in patients' baths - both, reputedly, to aid wound healing. I have always been troubled by the idea that everything that isn't based on research should be thrown out. Take, for example, something we used to call the ‘back-round’- a long standing practice, that disappeared in many hospitals around 1990. A trolley stacked with bed linen, a wash bowl and various items for washing and caring for patients' skin was pushed around the ward approximately every 2 hours by two nurses or health care assistants who interacted with each patient and gave ‘pressure area care’ if it was required. The practice was also used as an opportunity to make contact with patients to check if they needed anything and whether incontinent patients, for example, needed washing, skin care and a change of linen. The tradition stopped largely because it was
believed that it was ritualistic practice and not based on individual patient need or research. If we take a closer look at this, however, we can see several problems. It is a commonly held belief that the idea of the 2-hourly back-round began during the second world war in spinal injury units. The story goes that care assistants were employed to work in pairs, changing each patient's position. It took them 2 hours to get around the wards and no one sustained a pressure ulcer. Hence the 2-hourly back-round was born. There was no research evidence for this in those days; just a hunch that regular changes of position had to be a good idea. I am convinced that when my own unit stopped back-rounds in the late 1980s, the incidence of pressure ulcers increased (mainly because it was easier to forget something that was no longer a ritual) and patients interacted less often with staff. This is now recognised in the development of ‘intentional rounding’ as a way of ensuring that every patient receives proactive contact at some point every 2 hours or so. Since that time, there has been a growing body of evidence available about the causes and prevention of pressure ulcers and it is widely agreed that most pressure ulcers are preventable and that regular changes of position, between 2 and 3 hourly, is an important preventive strategy amongst the options. Manual repositioning is used to re-distribute pressure between the body and the surface the patient is lying or sitting on. Many clinical guidelines recommend routine repositioning of at risk patients, often 2-hourly so this remains common practice. Not everything that looks like evidence, however, is good evidence. Gillespie et al.'s (2014) Cochrane Systematic Review highlights a lack of robust studies of positions and repositioning frequency for pressure ulcer prevention. This leads to uncertainty, but it does not follow that position changes constitute ineffective practice as the studies included in the review are few, at risk of bias and lack statistical power. The review authors state that: “There is currently no strong evidence of a reduction in pressure ulcers with the 30 tilt compared with the standard 90 position or good evidence of an effect of repositioning frequency”. Despite this Gillespie et al. (2014) remind us that position changes have a sound theoretical rationale for the prevention of PUs and that just because the research evidence is weak, there is no reason to assume that the practice does not work. Just because we don't have scientific evidence for something, doesn't mean it is wrong. Ford and Walsh's (1994) second book warned of replacing the old rituals with new ones and unquestioningly implementing
http://dx.doi.org/10.1016/j.ijotn.2017.02.001 1878-1241/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Santy-Tomlinson, J.Evidence based practice: Taking the pressure off, International Journal of Orthopaedic and Trauma Nursing (2017), http://dx.doi.org/10.1016/j.ijotn.2017.02.001
2
Editorial / International Journal of Orthopaedic and Trauma Nursing xxx (2017) 1e2
new ideas without understanding the benefits and outcomes. A case in point may be the use of ‘tools’ to identify patients at risk of pressure ulcers. Johansen et al. (2014) found that undertaking risk assessment did not necessarily result in the planning and implementation of appropriate pressure ulcer prevention initiatives. When such a risk assessment tool becomes an “end in itself” and does not necessarily lead to management of that risk through useful action, then it could be argued that it has become a new ritual without focus on individual patients and lacking evidence to support it. Bringing back the back-round probably isn't the answer e nurses and other health professionals are much more able to innovate these days and have larger quantities of better evidence available to help them decide what the best approach to the problem might be. As long as we continue to strive to be critical of what we do and how we do it and search for ways for it to be more effective, care will be going in the right direction.
References Ford, P., Walsh, M., 1994. New Rituals for Old. Nursing through the Looking Glass. Butterworth Heinemann, Oxford. Gillespie, B.M., Chaboyer, W.P., McInnes, E., Kent, B., Whitty, J.A., Thalib, L., 2014. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst. Rev. Apr. 3 (4), CD009958. http://dx.doi.org/10.1002/ 14651858.CD009958.pub2. Johansen, E., Moore, Z., van Etten, M., Strapp, H., 2014. Pressure ulcer risk assessment and prevention: what difference does a risk scale make? A comparison between Norway and Ireland. J. Wound Care 23 (7), 369e378. €inen-Julkunen, K., 2016. Nurses' readiness for Saunders, H., Stevens, K.R., Vehvila evidence-based practice at Finnish university hospitals: a national survey. J. Adv. Nurs. 72 (8), 1863e1874. http://dx.doi.org/10.1111/jan.12963. Walsh, M., Ford, P., 1989. Nursing Rituals. Research and Rational Actions. Heinemann Nursing, Oxford.
Julie Santy-Tomlinson, Editor E-mail address: [email protected].
Please cite this article in press as: Santy-Tomlinson, J.Evidence based practice: Taking the pressure off, International Journal of Orthopaedic and Trauma Nursing (2017), http://dx.doi.org/10.1016/j.ijotn.2017.02.001