Looking back at when I started out nursing, in the days when Breakfast TV was new, shoulder pads were fashionable and those at the cutting edge stored their personal data in Filofaxes, it all seemed so simple. We quickly mastered the first rule of nursing, which was Looking the Part. This included taking a rectangle of white linen, a pack of Kirby grips, a can of spray starch and a tin, to create our particular model of nurse’s hat, to decorate our off-the-collar hair. The shameful truth is I really don’t remember much about learning to engage with research, though my finals papers confirm that we did have to write about the application of research to practice. A glance at the few photos I have reveals some practices which research has since shown were less than helpful and others for which I’m pretty sure there was never any evidence base. Note the sherry on the tea trolley!
How much we used research, and how we were equipped for that, is now lost to me, but certainly today the Nursing and Midwifery Council requires every nurse to ‘deliver care based on the best available evidence or best practice’ and to ‘ensure any advice you give [about healthcare products or services] is evidence based‘. Nurses must also keep their knowledge and skills up to date. This is very reassuring for all those receiving their care and very challenging for the nurses themselves. It requires both time and special skills and knowledge to infiltrate a world that is dominated by language largely unfamiliar to most. Frankly, it can be time-consuming, overwhelming and pretty scary. This needs to change. I’ve been pondering what nurses are up against and what those of us at the research end can do to help.
Social media enables me to be part of a vast community of people who share an interest in discussing evidence in healthcare. I got chatting to Anne Cooper, a nurse of the same vintage as me, who has a particular interest in using information technology to help patients through excellent nursing practice. With others, we talked about accessing research and she went on to write a great blog about some of the hurdles nurses have to clear if they are going to fulfill the NMC’s requirement to deliver care based on best evidence. I’ve also been talking to a nurse friend, Ruthie, who echoed some of the points Anne made in telling me about the challenges she faces in trying to ensure her practice is best practice.
Ruthie is a nurse clinician, working in the community as part of a ‘hospital at home’ team. A typical afternoon shift sees her getting details of her workload on the computer system before arriving at the Team HQ, possibly visiting a patient on the way in if staff shortages require it. Morning and afternoon nurses meet then and in theory this is an opportunity not just to hand over information about their patients but to share relevant research or training undertaken. In reality, there’s rarely time for this; they do their best to share useful stuff by email, in their own time. The shift should end at ten but might not. A morning shift should start at eight but the team communicate by email before it begins. The reality, says Ruthie, is that they get very tired and it can be pretty hard to find the energy to engage with research on those precious days off.
Compounding the lack of time is a problem we can all relate to – information overload. The sheer volume of research is overwhelming; how can anyone ever hope to keep up, even with just the most important and most relevant stuff?
I asked Ruthie how, and when, she looks for research. She told me she works practically. Questions are raised in the course of her work or someone, a patient or colleague, asks a question which prompts her to look. She might get help from an information specialist to find relevant evidence but more often will ask colleagues with specialist expertise, as well as casting around in the ways we all tend to when looking for information – YouTube, websites, wherever might throw up fertile ideas and useful leads to follow.
This is very much the kind of process Neal Maskrey, Director of the National Prescribing Centre, described at our recent Symposium, where we were debating how we might make evidence more usable. He reminded us that, in order to get evidence into practice, we need to recognize how people make decisions. Brief reading and talking to other people dominate normal decision-making, and we tend to gravitate to the familiar; we have to work much harder to embrace things we don’t recognize. We need a certain amount of information to get us to the point of making a decision. As fellow speaker Karl Claxton pointed out, in health we don’t have the luxury of perfection – decisions have to be made. This was something Ruthie flagged up, the need to deal with information quickly and to be able to decide how much (and what) information is enough, the point at which you say “I’m going to settle for this!” If nurses, and other health professionals, are able to do this, there’s a good chance that their practice will bring together those three important elements: best evidence, clinical expertise and the patient’s preferences and values.
Of course, nurses aren’t going to find themselves with more time on their hands, but other obstacles can be tackled. Cochrane’s mission has always been to produce high quality, trustworthy evidence to improve health and we’ve been pretty good at the research end of it. The bit we’ve been slower to sort out, now a big focus of our efforts, is how to share it effectively with the very wide range of people for whom it’s relevant and help them use it. Damn it, we ought to be able to make the whole thing less scary and less difficult.! We really do want people to use our lovely, gold standard research! So we’re very keen to find ways to help.
Last week, Ruthie came to the UK Cochrane Centre for a pilot workshop for health professionals on ‘Understanding Research for Decision Making’, a joint enterprise with The Critical Appraisal Skills Programme (CASP) and led by CASP’s Sally Crowe. With its sister workshop for members of the public, these free sessions are being held at locations across the country with the aim of helping people develop skills in using research evidence. Ruthie told me she already uses the reputation of the source of evidence in making judgements about whether to trust a piece of research, but found CASP’s simple screening questions, to help decide whether a research paper is worth looking at in more detail, really useful. The workshop also included guidance on looking for quality in research methods and interpretation of results. For Ruthie, the language of research papers isn’t a barrier, though we know it is for many. What she most valued about it was the time to spend looking at research with some guidance on hand to help her hone her skills of reading critically and how to read the graphic representations of evidence, not just the text. It raised a lot of questions, she said, and made her look properly. She also really appreciated looking at evidence with others, with different skills and professional backgrounds. Ruthie’s only regret was that she couldn’t stay for the session for members of the public, stressing the value of patients and health professionals sharing expertise and knowledge.
Anne talked about the increasing need for knowledge management and researchers enabling their findings to be quickly turned into knowledge by practitioners. I couldn’t agree more. Our blogs aim to give you key information from Cochrane reviews packaged up with some context and, increasingly, some expert commentary, like a patient perspective, or practitioner’s view. I also tweet about research and it’s clear that there’s a really responsive community out there, which I see through daily exchanges and also in more intensive debates, such as the fabulous tweetchat we co-hosted with #WeNurses about evidence questioning the value of risk assessment for pressure ulcer prevention (catch up on all that here).
Ruthie remarked that she finds nurses very open to research and to new ideas and highly motivated to ensure their practice is evidence-based, but day-to-day it’s easy to default to whatever is routine practice and nursing folklore still gets in the way. I’m sure the kind of access we have to each other through social media, and the sharing of information and expertise that this allows, is making it easier for nurses and researchers to engage with each other. As the NMC reworks its Code and considers its stance on social media, we must hope that its role in promoting best practice will be recognized. As for us, we’ll keep doing what we’re doing and looking for more and better ways to help you get the evidence you need in ways that are quick and easy for you. We have lots of plans afoot, so watch this space! Meanwhile, for an irreverent take on nurses and research, read David Barton’s blog and find out what Matron at St Twitters has to say on the matter!
You can follow us on Twitter @ukcochranecentr. I also tweet as @SarahChapman30.