Evidence-based nursing interventions warrant rigorous development methods

Abstract

Quality improvement, service and practice development aim to move services and practices in the direction of delivering the best care and achieving the best outcomes possible for patients. This process requires that clinicians take the best available evidence, meld it with information reflecting patients’ experiences and preferences, and with staff’s views on what is feasible and acceptable into services that are workable for delivery within available resources and other constraints of routine care. This sounds straightforward – and sometimes it can be. All too often, however, nursing care addresses complex, multi-component topics underpinned by variable quality research derived from specific patient groups. This poses challenges for service development. Additionally, services are more often developed and reconfigured in response to particular problems than as systematic processes of tailoring evidence for the local context. A separate but related issue is the importance of planning for evaluation alongside service development, so that rigorous methods can demonstrate the outcomes of innovation. Too often evaluation is an afterthought, restricted to retrospective methods and ad hoc analysis. This is increasingly recognized, whilst shortfalls in the rigour of methods of innovation remain relatively invisible. Van Hecke et al. (2011) present an exception to this. They describe in their paper in this issue of JAN (pp. 662–676) several structured development frameworks and explain the rationale for their choice. Their systematic approach revealed, firstly, a paucity of information on patients’ experiences and a consequent failure to engage and consider consumers’ perspectives on the topic. This is important for most interventions, but crucial for one requiring sustained consumer behaviour change. Secondly, they used qualitative enquiry processes to understand patients’ experiences and information needs, and nursing staffs’ perspectives, current practice and what would be required to promote patient adherence to evidence-based leg ulcer management (wearing compression, performing leg exercises, physical activity and leg elevation). Finally, a series of test runs with patients enabled both real-world testing and fine-tuning of the intervention, and built nurses’ confidence in their ability to deliver it and the likelihood of a positive response from patients. This paper illustrates the integration of research-based evidence, underpinning theory, patient perspectives and staff engagement in the development and fine-tuning of innovation. It describes a comprehensive process based on recognized frameworks to develop a nursing theory-based intervention to promote adherence to evidence-based lifestyle advice, with a patient user group notorious for non-compliance and a staff user group with good knowledge of the evidence but few skills in engaging patients with it. It shows the value of spending time to understand the meaning ascribed to an intervention by its users to achieve success. The authors acknowledge the time commitment this entailed but contend this was justified by achievements. Detail supplied in the tables not only enables readers to adopt this intervention but also to replicate the process in development of other nursing interventions. This paper is essential reading for nurses who care for patients with leg ulcers and is equally valuable for those involved with innovation, service and practice development.