Evidence‐based practice and critical care nursing

Abstract

The buzzword of the decade is evidence-based practice (EBP), which involves the integration of research evidence with clinical expertise and patient preferences (Sackett et al., 1996). Most often, EBP is equated with research utilization in the sense that much is written about finding and implementing the external evidence and little attention is paid to eliciting patient preferences and describing the level of expertise of the clinician. Clinical expertise in critical care nursing is provided at various levels of proficiency. One reason is the constant turnover of nurses, and the other is that not all nurses eventually become experts (Benner, 1984). Moreover, many nurses are not prepared for the evidence movement. A survey in western Canada has illustrated that nurses use a broad range of practice knowledge, much of which is experientially based rather than research-based (Estabrooks, 1999). A recent Danish survey has shown similar results and suggests that intensive care nurses lack fundamental knowledge of EBP (Egerod, 2004). It was established that neither intensive care nurses nor cardiac nurses regularly read scientific journals (Egerod, 2004; Egerod and Hansen, 2005). External evidence is often introduced into the clinic by way of formal models such as clinical practice guidelines. While novices may follow guidelines ardently, often overriding patient preferences, expert nurses may find formal models unduly restraining. Patient preferences are difficult to integrate with evidence-based guidelines because patient care must be individualized and this requires clinical expertise. Many intensive care units (ICUs) have introduced clinical practice guidelines without providing additional education on how to work with guidelines. Within critical care nursing, one model has taken up the challenge of describing the effect of evidence-based practice vis-à-vis patient needs. The AACN (American Association of Critical-Care Nurses) Synergy Model for Patient Care is a model in which the characteristics of patients and families influence and drive the competencies of nurses (Curley, 1998). According to this model, nursing care reflects an integration of knowledge, skills, experience and attitudes needed to meet the needs of patients and families. The model describes nursing competencies on three levels (1, 3 and 5) ranging from competent to expert level of proficiency. An example of a nurse competency is ‘clinical judgement’, which includes ‘clinical decision-making, critical thinking and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines’ (AACN). On level 1, the nurse follows algorithms and protocols and feels uncomfortable straying from these. On level 3, the nurse makes clinical judgements based on an immediate grasp of the whole picture for common or routine patient populations. On level 5, the nurse ‘synthesizes and interprets multiple, sometimes conflicting, sources of data; makes judgement based on an immediate grasp of the whole picture, unless working with new patient populations; uses past experiences to anticipate problems; helps patient and family see the “big picture”; recognizes the limits of clinical judgement and seeks multidisciplinary collaboration and consultation with comfort; recognizes and responds to the dynamic situation’ (AACN). What we see here is how differently evidence-based guidelines are handled by nurses at various levels of competency. This aspect of clinical expertise has gone unrecognized in most studies of EBP. Integrating patient preferences in nursing practice has been a particular challenge in critical care nursing, because patients may be sedated, delirious or otherwise compromised. The current trend in critical care is towards lighter sedation, which means that nurses will be expected to communicate more with the patients in the future (Egerod et al., 2006a; 2006b). The Synergy Model describes patient and family participation in care and decision-making in ICU as ‘patient characteristics’. When the patient and family have the capacity to participate, the expert nurse ‘works on behalf of patient, family and community; advocates from patient/family perspective, whether similar to or different from personal values; advocates ethical conflict and issues from patient/family perspective; suspends rules — patient and family drive moral decision-making; empowers the patient and family to speak for/represent themselves; achieves mutuality within patient/professional relationships’ (AACN). The balance of following standardized evidence-based guidelines as well as individual patient preferences is indeed a challenge, which requires clinical expertise. More research is needed to explore the ways in which the patient perspective may truly become an integrated part of evidence-based practice in critical care nursing. Ingrid Egerod, RN, MSN, PHD 1 1 Associate Professor The University Hospitals Centre for Nursing and Care Research Rigshospitalet Department 7331 Blegdamsvej 9 DK-2100 Copenhagen O Denmark E-mail: ie@ucsf.dk