Science now more than ever

Science n o w m o r e than ever The current push by the Department of Health to promote clinical effectiveness across all areas of the National Health Service (NHS) means that nursing is now obliged to increase its understanding and use of science. Unfortunately, science seems to have a bad name in nursing. In general, a greater value is placed on knowledge derived from experience, empathy and intuition than from science amongst members of the nursing profession. This attitude exists alongside a distaste for the numerical and apparently reductionist nature of science. However, the best possible nursing practice depends on knowledge derived from a wide range of sources, and scientific research has the potential to produce the strongest and most generalizable evidence concerning which practices are the most clinically effective. The Department of Health's national Reviews and Dissemination (R&D) programme is concerned mainly with clinical- and cost-effectiveness as the basis for running an efficient and economical health service. This is obviously essential, but whether or not the rather extreme swing towards these issues is wholly positive is open to debate (see Porter 1997). However, the majority of research monies currently available are allocated to this kind of study. If we are to be pragmatic in the current climate of limited research resources, we can capitalize on these funds to address many important and useful issues. Paradoxically, the culture of the NHS (until very recently) has not been one which values research or, by implication, science. Therefore, nurses within this culture have not been imbued with an acceptance of science as an important item amongst a repertoire of skills essential to nursing. Indeed, nurses have often been highly critical of science, although in many cases their objections have been based on misconceptions. These have been dis° cussed more fully elsewhere (Closs 1994). Not all nurses need an in-depth understanding of science, and not all need to do research themselves. However, all nurses need to be able to make informed criticisms of research reports and, on this basis, be able to decide if, how and when their own practice should be changed. Therefore, a basic scientific understanding is needed across the whole profession. It is generally accepted that science is based on an iterative process o_ generating and then testing theories, and that this allows knowledge to develop Clinical Effectiveness in Nursing (1997) I, 61-63 0 1997 PearsonProfessionalLtd

and progress. Implicit in this progression is a lack of absolute certainty in theories derived from research. Some of the conclusions of research are tentative while others are reasonably certain, but science does not claim to produce absolute truths. Some lines of enquiry increase certainty concerning particular theories, while others reduce it. This conceptual cycle of repeatedly generating and testing theory is, of course, a simplistic version of what really happens. New theories may be developed in imaginative ways and do not simply disprove those currently accepted. Ideas may be borrowed from other disciplines or researchers may simply have a flash of inspiration, a 'eureka' experience. Nurses may have hunches, based on their own experiences of caring for patients, which could be developed into theories and investigated scientifically. Perhaps less desirably, research-funding bodies have the power to determine which theories are to be adopted/tested by researchers, for political, commercial or other reasons. One of the main barriers to the incorporation of science into the wider culture of nursing is its unappealing image. There is a common view that science is an abstract intellectual activity, lacking human values. This apparently inhuman property of scientific research is complete anathema to the ethos of caring within nursifig. I would argue that this is a mistaken view, and that much nursing research focusses on intensely human issues - bereavement support, pain management and supporting elderly people on discharge from hospital, to name but three. Another widespread and misleading image of science is that of some kind of infallible contemporary religion. This could not be further from the truth. Science is a rational and systematic method for trying to understand the workings of the natural world; no more and no less. It can only generate certain types of knowledge: it has no direct access to personal beliefs or private experiences and it deals with the kind of knowledge which can be made public. This is a crucial characteristic of science. It is open to the scrutiny and criticism of anyone who is interested. It can be challenged and proved wrong. The most valid objection to scientific research from the point of view of practising nurses is that it is frequently difficult to understand. Here researchers are guilty - they have to remember that it is not only their academic peers they write for

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(and defend themselves against). Rather more importantly, they must write for an audience of clinical nurses using language which is as clear and simple as possible. If those who are in a position to use the research findings are unable to understand the language in which they are couched, the whole exercise becomes pointless. The NHS Centre for Reviews and Dissemination at the University of York is taking steps towards improving this situation. Systematic reviews of the research literature on certain topics (some relevant to medicine, some to nursing) are condensed into brief, clearly-written 'Effective Health Care Bulletins'. This goes a long way towards taking the pain out of locating and reading relevant research papers, although the range of topics covered is limited at the moment. Nevertheless, this work is invaluable to workers within the NHS, provided that effective dissemination of the information can be achieved. Finally, there is still a misconception among some nurses that the many available models and theories of nursing already provide the profession with a scientific basis. Sadly, even though such models may have much to offer, most have not been subjected to the rigour of being scientifically tested. For the most part, they have been rushed into practice without any real evidence to support their effectiveness in improving patient care. It is to be hoped that any new models (and, indeed, the established ones) will be carefully tested and refined as necessary before being introduced more widely. Misconceptions about science also exist within the wider arena of health-services research. There is a view that scientific research is more or less confined to the randomized controlled trial (RCT). RCTs are commonly seen as drug or other trials run in hospitals or by GPs and are indubitably the best method of comparing clearly-defined treatments with easily identifiable outcomes. In reality, many different research designs can be used in a scientific manner, indeed, 'one of the most egregious assumptions about traditional science is that it constitutes a paradigm that disallows the use of qualitative data' (Schumacher and Gortner 1992). Nursing research addresses issues which are far more complex than simply comparing the effect of one drug with another on straightforward outcomes such as blood pressure. There is much 'involved in nursing care which simply cannot be investigated by RCTs. For example, in order to assess what

influences the successful implementation of research findings into nursing practice, many uncontrolled variables might have to be taken into account, such as nurses' educational background, motivation levels, morale, methods of ward organization, skill mix and attitudes towards research. Large survey-type studies which use multivariate statistical analyses are more appropriate methods of addressing these questions. They allow the identification of associations between variables, and may indicate which of many variables appear to be the most influential. Where very little is known about a subject, and new theory needs to be developed, qualitative research is appropriate. For example, to find out why more and more young women are taking up smoking would require in-depth interviews in order to produce useful information on which to base a theory. Such a theory might then be tested using a more experimental approach. The notion that the RCT is the 'gold standard' (and that other research designs are sub-standard) is misplaced and ignores the need to investigate the many complex clinical issues facing nurses on a day-to-day basis. This may have negative consequences for nursing, particularly in terms of obtaining funding for research where nurses have to compete with doctors and others for resources in a trial-dominated research environment. Nursing needs to use science .now more than ever. Funding bodies are favourably disposed towards clinical-effectiveness research, and the nursing profession needs the kind of information it produces. The climate is fight for nursing to develop its ~cientific base, provided that we can compete effectively with other professions for the requisite funding. Science is our most powerful method of gaining the knowledge we need to underpin best possible nursing care.

REFERENCES Closs S J 1994 What's so awful about science? Nurse Researcher 2(2): 69-83 Porter S 1997 Guest Editorial. The degradation of the academic dogma. Journal of Advanced Nursing 25:655-656 Schumacher K L, Gortner S R 1992 (Mis)conceptioas and reconceptions about traditional science. Advances in Nursing Science 14(4): l-I ! S. J. Gloss Senior Lecturer University of Hull

EDITORIAL REQUEST In Issue 1, I noted briefly that Clinical Effectiveness bz Nursing is keen, not only to receive papers, but also to recruit reviewers and commentators, particularly people in clinical practice. We are very much

hoping to have a large pool of people from which to draw when asking for commentaries and reviews, and the clinician has an important role to play in this process.

Hydration in acute stroke

Using peer review and peer commentary our journal attempts to encourage openness in science and scholarship. Peer commentary is a particularly important element of the journal, as it gives the readers an opportunity to view issues from all perspectives or benefit from the complementary approaches. An additional benefit is that the commentaries offer those who are, perhaps, not yet experienced enough to write a full paper the opportunity to, nevertheless, contribute to our understanding of a topic, and get their views into the public domain. As a result we are seeking to involve as many people as possible in the review and commentary process. In general, we offer more guidelines to reviewers than to commentators, including a checklist of issues to be addressed by the reviewer. This is because the purpose of reviewing is principally one of quality control and feedback to potential authors. Reviewing is, thus, a vital part of the journal, and we attempt, through offering guidelines, to ensure some consistency in approach amongst reviewers. The guidelines are sent to the reviewer when they

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receive a paper. A reviewer's opinions of a paper are very influential in deciding what eventually gets published. All reviews are double blind. Commentators have much more freedom to make their own contributions, and their role is essentially to amplify, complement and contextualize the original paper, with particular reference to clinical practice. This role can, of course, contain a considerable element of critical appraisal of the original paper, and we give the author the opportunity to reply to the commentary. By the time anyone is approached to provide a commentary, the paper has been accepted for publication and the commentary process is not, currently, blind. If you would like to become involved in providing reviews or commentaries for the journal, you are extremely welcome to contact me.". It will be helpful if you are able to give a list of your particular areas of interest and expertise, so that I can ensure that any papers directed to you are as relevant as possible. Rob Newell Editor