Utilising Evidence Based Care

UTILISING EVIDENCE BASED CARE – Module Assignment

The following essay aims to critically appraise a range of sources of research evidence pertaining to the management of violence and aggression within an inpatient mental health setting, and also to discuss and explore the limitations of the research, and its implications for clinical practice.

Incidents of a violent and aggressive nature are frequently reported in healthcare settings (Secker et al, 2004 and Walker and Seifert, 1994). Delaney et al (2001) state that violent and aggressive incidents present unquestionable risks to the safety of both staff and patients, which must be addressed; furthermore, the potential for tragedy in this arena is highlighted by the BBC (2004) reporting of a recent incident of extreme violence in a French mental health hospital, which culminated in the “horrific” murders of two nurses. The subject of violence and aggression in mental health is the source of much debate, and it is widely acknowledged that the management of violent and aggressive incidents presents an increasing problem in the field of healthcare (Bowers et al, 2006; Dudley-Finnan, 2002; Duxbury, 1999; Duxbury and Whittington, 2005; Delaney et al, 2001; Ng et al, 2001; and Saverimuttu and Lowe, 2000). It is also interesting to note that according to Duxbury (1999, p.107) similar problems with violence and aggression exist in both “acute inpatient general and mental health settings”. During past clinical experience I have witnessed a number of incidents of a violent and aggressive nature, and it is for these reasons that this area has been chosen for the focus of this essay.

In order to proceed further it may be beneficial to define some key terms. Polit and Beck (2006) describe the term ‘research’ as a systematic approach in seeking answers to questions or solutions to problems, through the use of scientific methodology; and according to Hek and Moule (2006, p.8) research is only “one form of evidence amongst many other types of evidence”.

Thompson (2003) describes the term ‘evidence-based nursing’ as a process in which nurses utilise “the best available research evidence, their clinical expertise and patient preferences” in order to make good clinical decisions, “in the context of available resources”; the aim of this process is to apply professional knowledge and scientific evidence to the treatment of patients, with the intention of improving outcomes (Sackett et al, 1996 and Hamer, 1999). The evidence-based healthcare movement is driven by, derived from, and underpinned by medical practice and philosophy (Bradshaw, 2000; Clarke, 1999; Dale, 2005; Estabrooks, 1998; Fitzgerald et al, 2003; Ingersoll, 2000; Jennings and Loan, 2001; and Kitson, 1997); however, Bilsker and Goldner (2004) report that evidence-based practice is now demanded in all “health-related disciplines”.

Dale (2005) states that evidence is categorised and placed within a “hierarchy of evidence”, which determines the most “relevant” and the “best” evidence for practice by examining and scrutinising the “integrity and scientific validity” of the research methodology; Jennings and Loan (2001) add that the hierarchy exists as a tool for professionals to “rank” evidence according to its “quality”. However, it is widely implied throughout much of the literature that “research is the strongest form of evidence” (Dale, 2005).

Evidence-based healthcare is at the forefront of numerous “current government policy initiatives” (Page and Meerabeau, 2004); and furthermore Bradshaw (2000) reports that healthcare providers in the United Kingdom are “being urged” to incorporate evidence-based practice into their “routine activities”. However, this concept is not new; Nightingale (1946) first acknowledges and advocates the importance of knowing the outcomes of different interventions, if nurses are to plan and provide care that is effective. In addition, the NMC (2004, p.10) dictates that registered nurses possess a “responsibility to deliver care based on current evidence, best practice and, where applicable, validated research”.

In order to collect the subject material for this assignment a literature search was performed through the British Nursing Index, CINAHL and MEDLINE electronic databases (accessible online via http://gateway.ovid.com), as these databases are most pertinent to the research needs of the subject. The search included the terms “inpatient”, “violence and aggression”, and “mental health”; duplicate results were removed from the search, and an example of primary research, secondary research, and professional opinion were then selected from the results to be critically appraised. Dale (2005), Geanellos (2004), Jennings and Loan (2001), McGovern and Whitcher (1994), Page and Meerabeau (2004), Stuart and Sundeen (1995), and Thompson (2003) all report that the ability to perform effective literature searches and then critically appraise the literature is now considered a crucial and requisite skill, which nurses must possess.

The following piece of primary research was selected from the search results:

Bonner, G., Lowe, T., Rawcliffe, D. and Wellman, N. (2002) Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing 9(4) p.465–473.

The critical appraisal framework to be used here is taken from:

Hek, G. and Moule, P. (2006) Making Sense of Research. An Introduction for Health and Social Care Practitioners. 3rd ed. London: Sage Publications Ltd.

Bonner at al (2002) present a qualitative pilot study aiming to explore the “subjective experience of restraint” and to establish factors which were deemed “helpful and unhelpful, during and in the aftermath of restraint”, through the use of semi-structured interviews with the patients and staff involved; this is important as Hek and Moule (2006) state that the purpose of the research must be clear, adding that there must be a worthwhile reason to undertake the research.

Bonner et al (2002) provide a comprehensive literature review detailing the history of restraint and the development of modern restraint techniques. The discussion provides an extensive rationale for conducting the study and also reveals a lack of existing research into the subjective experience of restraint for both staff and patients, providing further impetus to conduct the research; additionally, a previous study by Duxbury (1999) also advocates the need for research into this specific area. Hek and Moule (2006, p.133) report that there should be an extensive search of existing literature, as the knowledge “sought” by the research should not be “already available”; this would reduce the value of the research, unless it adds to the previously available knowledge. Another positive aspect of the study by Bonner et al (2002) is that the research questions are derived directly from the aims of the study (Hek and Moule, 2006). Bonner et al (2002) use a wide range of supporting literature, provide an extensive reference list and present opposing arguments in a balanced manner; but despite this no search strategy detailing databases or search terms is included, as is recommended by Hek and Moule (2006).

The methodology of the study is clearly described by Bonner et al (2002), using a non-probability convenience sample of patients and staff; however, it is worth noting that due to the use of a convenience sample there may be elements of bias, which influence the findings (Hek and Moule, 2006). However, Bonner et al (2002) does acknowledge that the study is not representative of the whole population due to the use of a convenience sample, stating that generalisations cannot be made due to the use of “such a small sample”. Interestingly, Meehan et al (2000) and Whittington (2000) both argue against the use of psychiatric patients as research participants. However, Bonner et al (2002) obtained approval to conduct the study, in advance, from the “relevant NHS Local Research Ethics Committee”; Hek and Moule (2006) assert that this adds credibility to the study, as researchers must be mindful of ethical issues throughout the duration of their studies.

Hek and Moule (2006, p.134) emphasise the importance of linking the “results and analysis” of the study to the “original research questions”; a criterion that the study by Bonner et al (2002) easily fulfils, as throughout the analysis and following discussion the findings are repeatedly connected to the aims of the study. Hek and Moule (2006, p.134) suggest that it is important for researchers to “acknowledge any limitations” of their studies; this too is achieved by Bonner et al (2002) who propose a need for “further research” and “wider studies”. I feel that this piece of research displays significant integrity against the framework of Hek and Moule (2006); therefore, this study may have considerable implications for practice.

The following example of secondary evidence cites the study by Bonner et al (2002) as a supporting reference:

NICE (2005) Violence. The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. London: Royal College of Nursing.

The critiquing framework to be used here is taken from:

AGREE Collaboration (2001) Appraisal of Guidelines for Research and Evaluation – [online]. Available from: http://www.agreecollaboration.org/pdf/agreeinstrumentfinal.pdf [Accessed 25th September 2007].

Jennings and Loan (2001) state that “practice guidelines” are “fundamental” to the process of evidence-based practice; a view supported by both Bradshaw (2000) and Stuart and Sundeen (1995) who suggest that clinical guidelines can help to bridge the gap between theory and practice. The need for clinical guidelines in the management of violence and aggression is also highlighted by a preceding study by Delaney et al (2001), and it is for these reasons that the clinical guidelines of NICE (2005) have been selected as an example of secondary evidence.

Cheater and Closs (1997) and Richens et al (2004) both report that guidelines should be founded on the basis of research findings and evidence produced by studies such as that of Bonner et al (2002); this is clearly achieved by NICE (2005), and is conducive to ensuring that evidence is incorporated into practice. Geanellos (2004), McGovern and Whitcher (1994) and Page and Meerabeau (2004) all stress the importance of this, reporting that there can be difficulties in applying evidence to practice.

The guidelines of NICE (2005) are thorough and extensive, covering all aspects of the management of violence and aggression in detail; the objectives are also clear, and this, according to AGREE (2001) is significant, as it allows the reader to quickly ascertain the relevance of the guidelines to their needs. NICE (2005) incorporates a plethora of supporting evidence, providing a brief summation and evaluation of each source; details of the search strategy, which was used to collect the evidence, are also provided, along with the rationale for including or excluding sources. Therefore, one may safely assume that these guidelines are evidence-based, and furthermore AGREE (2001) and Hek and Moule (2006) both argue that this adds credibility to the guidelines. The recommendations of guidelines should be “specific and unambiguous” (AGREE, 2001, p.14), and again this is accomplished by NICE (2005); the guidelines present detailed explanations of how to manage specific incidents, whilst taking into consideration all possibilities.

Following the use of the critiquing framework of AGREE (2001) I feel that these guidelines display significant integrity and would be a useful tool in the management of violence and aggression for every mental health nurse working in an inpatient environment.

The following example of expert opinion has been selected:

Hardy, J. (2006) Stay calm under fire. Nursing Standard 20(23) p.69.

A range of sources will be employed in order to appraise this evidence.

Dale (2005) states that nurses are required to employ a range of evidence in their practice including “professional consensus”. According to Jennings and Loan (2001) such knowledge is “derived from intuition” and is a source of important evidence in nursing”. Hardy (2006) presents a reflective piece of anecdotal evidence, which describes an incident of aggression witnessed by a nurse in clinical practice. Hek and Moule (2006) state that the purpose and intended audience of evidence should be made clear by the author; Hardy (2006) achieves this within a brief abstract and short introductory paragraph, discussing an increased need for student nurses to possess abilities to “defuse confrontational situations”.

Hek and Moule (2006) report that professionals must make connections between the aims and outcomes of their evidence; Hardy (2006) does this by concluding that there is a need for a “more proactive approach to teaching techniques for conflict resolution”, which echoes the original aims of the article.

Significantly, Thompson (2003) highlights that professional opinion is widely considered to be the “least reliable and valid form of evidence”; a view reiterated by Geanellos (2004). However, there exists a strong counter-argument, which stresses the importance of experiential evidence in the field of nursing (Bradshaw, 2000; Dale, 2005; and Hek and Moule, 2006). It is suggested by both Bilsker and Goldner (2004) and Franks (2004) that research evidence must be balanced against experiential evidence, in order to ascertain what constitutes acceptable evidence for individual aspects of practice. Dale (2005) state that nurses must consider all available evidence, “not just research evidence”; furthermore, the ability to make good clinical decisions is reliant on experiential knowledge and professional intuition (Bradshaw, 2000).

Hek and Moule (2006, p.14) assert that there are numerous situations where the “application of intuition and tacit knowledge is essential”, and although there may be limitations to the evidence provided by Hardy (2006), I feel that it does contain some useful thoughts and suggestions to inform practice.

The following section of this essay aims to explore factors, which may influence the use of evidence in practice.

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