Nursing Voices

Thursday, January 18, 2007

A Nose for Research

Some nurses are big fans of something called evidence based nursing. According to this school of thought, nurses should not make any patient care decisions without at least having two research references in their hip pocket to backup their plan of care. I, on the other hand, subscribe to “old school” nursing. Sometimes these two schools of thought collide.

Don’t get me wrong, I think evidence based nursing is valid, that is, until it gets in the way of patient care. One of my patients went ballistic one day while I was working as the unit charge nurse. She was yelling and screaming as she scratched her wrist with a paperclip. I walked over to the patient, told her to stop, and escorted her to her room. The patient and I had a brief discussion about what constitutes appropriate behavior on the unit, and how she could ask for help the next time she had the urge to act out. As far as I was concerned, the incident was over.

When I returned to the nurse’s station, my boss and one of my colleagues were busy developing a patient treatment plan based on evidence based nursing. They were talking about what to do next, and they were blaspheming my approach with the patient. My boss said that, according to research data, the patient needed to be watched 1 on 1 by a nurse due to her impulsive behavior, and he questioned what research theories I used when I took my patient to her room. Say, what? I giggled to myself, paused, and then started sniffing the air like a hound dog tracking his prey. My boss peered at me from over his glasses and asked me what I was doing. I told him I was doing research. I said that I theorized that I could smell an out-of-control borderline personality that needed limits set on her behavior, and that I had concluded that watching the patient 1 on 1 would give the patient positive reinforcement for negative behavior. I told him that I wasn’t rewarding the patient’s bad behavior by providing her with a private audience. End of discussion.

An anonymous reader responding to my post about Clara Barton observed that you can’t be a good nurse without caring, but neither can you be one without knowing a lot, and that new knowledge is derived from research. The reader went on to say that theory is supposed to lead to better nursing practice, but that falling in love with theories isn’t anymore helpful than falling in love with our patients. I couldn’t agree more.

Sometimes common sense trumps a hypothesis.


Blogger Serial Filler said...

Bravo! Chalk up three points for common sense. You know, you have a way of taking all the fun out of mental illness. That patient might recover just to get away from you!

In cases like this Dr. Ursa simply makes up spurious scholarly references as required. If a quotation is authoritative enough, few people are inclined to admit that they have never heard of it.

10:18 PM  
Blogger Digi Rebel said...


10:21 PM  
Blogger Digi Rebel said...


10:21 PM  
Blogger kario said...

Almost always, common sense trumps a hypothesis. Unfortunately, common sense is one of those things you either have or don't have - I don't think you can teach it.

10:27 PM  
Anonymous sean said...

I just had an image...

My patient's blood pressure is dropping, she can't breath, her heart rate is 184. Oh look! No urine output for 5 hours!!!

I better run..... the computer and sit down for an hour looking up research on how to proceed.

Experience and "gut instinct" should be recognized as valid, along with research.

On a side note...I miss psych/mental health...*sigh*

11:21 PM  
Blogger Bohemian Road Nurse... said...

You are so right. In fact, I've seen some very respectable "sources" who decree that 1:1 would actually be contraindicated for such borderline acting-out behavior...

11:46 PM  
Blogger Stephanie said...

LOL wow they wanted you to sit one on one with her and give her attention? That's exactly what she wanted. There was nothing wrong with her other than the fact that she has borderline personality disorder and craves attention because of it. I'm not a nurse or a nursing student, I'm a pharmacy technician, and even I could come up with that one.

4:17 AM  
Blogger Spirit of 1976 said...

I'm mostly in favour of evidence-based nursing, but then the research they were citing brings into question the whole issue of reliability and validity.

Was the research they were citing with reference to BPD patients? I suspect not. I also suspect that with a bit of digging on Google Scholar, you could find a paper somewhere that says your approach was the correct one.

I certainly agree with you though, that with borderline PD clients, it's absolutely vital to set firm boundaries.

5:04 AM  
Blogger jaz said...

You took the paperclip away, right?

6:27 AM  
Blogger scalpel said...

If an intervention works, that's evidence enough for me.

9:10 AM  
Blogger apgaRN said...

Can you hear my applause across the wires? I've been trying to find the words to write a well-formed opinion on this same topic for some time... you said it so well! I'll probably link to this one if I ever get around to finishing mine. :)

10:28 AM  
Anonymous N=1 said...

Well - you both are right.

Evidence-based practice does indeed seek to develop professional practice based on valid and reliable evidence. However, professional judgment is an integral component of practice. A novice nurse would have more cause to pause and read the recnet research becasue she hasn't had the practice hours to build confidence in choosing nursing interventions. An expert nurse will be able to (as you did) to integrate the assessment of the individual patient's history and behavior with the established mechanisms of immediate and short-term interventions. Whether or not one can cite the applicable research on the fly isn't germane. What is germane is that you can find the apllicable research when and where you need it.

The tone of your post, though seemed to this N=1 to be dismissive of nursing research. Rather, my argument would be with the people who are mandating the use of research in a spurious - and professionally restrictive - way.

Commenters who speak of old school vs. new school are distressing, as that argument serves to keep the divides between nurses ongoing.

Let's work toward professional autonomy and collegial consensus instead.

2:44 PM  
Anonymous N=1 said...

Egads and little fishes - sorry for the typos in the previous comment! Preview is my friend.
Preview is my friend.
Preview is my friend....

2:46 PM  
Blogger The Curmudgeon said...

"In cases like this Dr. Ursa simply makes up spurious scholarly references as required. If a quotation is authoritative enough, few people are inclined to admit that they have never heard of it."

This happens in court, too....


"Counsel, your opponent cites five Illinois Supreme Court cases in his brief that appear to be right on point. What do you say to this?"

"Well, your honor, he's left out the Smith case which surely is the leading case on this issue. There must be hundreds of cases that follow it. Smith states the rule -- and counsel's merely cited the exceptions to the rule."

It is bad form at this point to turn red in the face and jump up and down and say that your learned opponent is making Smith and its progeny up out of whole cloth. Shouting "liar, liar, pants on fire!" is almost a sure method of pushing the court into following Smith.

If the attorney "citing" Smith has enough gray hair and the other advocate is a wispy youth, the court is likely to follow Smith anyway. Right down the primrose path.

4:21 PM  
Blogger ~Autumn said...

I just wonder, and maybe I hope that I get more 'real job' training once I'm out of school and into my career. They cram theory and evidence based practice so far down our throats in nursing school now it comes out undigested (ew).

7:08 PM  
Blogger Gerbil said...

Lots of psychologists, too, are peeing themselves with joy over EBM (or empirically supported treatments, as they tend to be called). I'm not one of them... because not all studies agree with each other. So how do you know which is the most empirically supported of the ESTs?

And then there's the problem of measurement. Some therapies (like cognitive-behavioral therapy) lend themselves really well to measurement, while others (like psychodynamic therapies) don't. You can't support a therapy empirically without measurement, so of course the ones that can't easily be measured don't get EST status.

I go for the dodo bird verdict myself. It doesn't matter what you're doing, as long as it's helping, and the benefits outweigh the risks. Just don't do group therapy for adolescents with conduct disorder.

8:52 PM  
Blogger etaoin shrdlu said...

You mean the torture doesn't stop after nursing school? It's still more reams of nursing diagnoses, care plans and rationales?

Seriously, I can appreciate what N=1 is saying, too. There is an art and a science to nursing. But as a newbie, I'm not worried about becoming learned or technically proficient . . . I just hope that the art part isn't elusive.

12:18 AM  
Blogger Jean-Luc Picard said...

Common sense defeats all ridiculous rulings.

3:19 PM  
Blogger RX850 said...

It's too bad that common sense isn't a requirement to be a nurse...

8:39 PM  
Blogger The Angry Medic said...

...or that common sense isn't very common, either.

You go, Momma Jones! I miss those good ol' days when medicine was practised with common sense like that. You socked it to em good.

And this is random, but I like how you used the word 'Trump' in the last sentence ;)

9:26 PM  
Blogger marachne said...

I have to second a lot of what N=1 is saying. And to provide some evidence that not all nursing research agrees that EBP is the be-all and end-all of what nursing involved.

For starters, if you‘ve read Patricia Benner's "From Novice to Expert: Excellence and Power in Clinical Nursing Practice” you get a very different sense of how some are looking at nursing and clinical practice. Seriously, if you’re a nurse, you should read it. Another great source of this concept of Clinical Judgment is presented by Christine Tanner, most recently in:

Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. Journal of Nursing Education. 2006 Jun; 45(6): 204-11.

Tanner's definition of Clinical Judgment is "an interpretation or conclusion about a patient’s needs, concerns or health problems and/or the decision to take action (or not), and to use or modify standard approaches, or to improvise new ones as deemed appropriate by the patient's response."

Nowhere in there is there anything about spending hours "looking things up." Yes, abstract and generalizable knowledge, derived from science and theory has its place, but Tanner also talks about "the kind [of knowledge] that grows with experience," and "the kind that is highly local, individualized, drawing from knowing the individual patient and shared human understanding." She also talks about "recognition of a pattern, an intuitive clinical grasp, or a response without evident forethought."

Chris Tanner is also one of the best nurse educators around.

I do have to say, it somehow shouldn't come as a surprise that she a qualitative and not an empirical, quantitative researcher.

Nurse education goes through phases and fads, like so many things. Many now see that a strict adherence to EBP becomes mechanistic and formulaic: using a “cookbook” doesn’t work any better then doing things “because that’s the way we’ve always done it.” Also, new nurses, novice nurses need to use a more methodical approach to a situation. Experienced and expert--you can be a nurse a long time and still not be a really good nurse--nurses don't have to think things through in such a linear fashion, because they have a whole wealth of knowledge to bring to the situation.

Which doesn't mean one shouldn't read the literature, because that too is (can be) valuable knowledge. The thing is one has to learn how to read research critically--just because it's published doesn't mean it's true. Also, one study does not mean one should change one's practice.

OK, enough rant. Dang, if I stopped posting long things like this on other people's sites, I'd finally get something posted on my own! :)

11:52 PM  
Blogger marachne said...

oh, and response to the angry medic -- I see a lot of common sense being used by a lot of really excellent nurses....even a few docs.

11:55 PM  
Blogger Shrinked Immaculate said...

I cant say i totally agree with the premise of your argument. EBM is here to stay and is a step in the right direction. That however, is not to say that experience counts for nothing. Instinct though I would be more circumspect about. Cheers. Hi, I am so glad you like my little efforts at picture taking. I took these pics mostly with a Canon A700.

5:41 AM  
Blogger Mother Jones RN said...

This comment has been removed by a blog administrator.

6:14 AM  
Blogger Mother Jones RN said...

I want to thank everyone for their comments to my post. It's good that we can have an open and frank discussion about medical/nursing research, and how it is used in the workplace. If you sensed any anger in my post, let me assure you that it was not leveled at researchers per say, but at the educated idiots that misuse information in the workplace. Common sense isn't an old fashion concept.


Citation: My approach to dealing with the patient was based on the research conducted by B.F. Skinner.


7:07 AM  
Blogger Fresh Hell, Texas said...

Most nurses I know have both book smarts and common sense, with a talent for knowing which one to go with in the moment.

It's an enviable, and somewhat rare, combination of skill sets.

5:14 PM  
Anonymous Anonymous said...

Hi MJ and Marachne:

Chris Tanner is one of my favorite reads, too. I studied qualitative research methods under Patricia Munhall, who is/was a close research associate of Tanner's. You're right about the qualitative aspects, as well as the varying uses (and misuses) of research.

Common sense is rarely entirely intuitive and "gut-based". It's usually an integrative form of study, practice and repetition.

In MJ's story, if she had been a nurse on a medical surgical unit, perhaps, I'll betcha that she would have acted very differently (see my rant at Universal Health blog on the absence of mental health nursing standards of care and practice for patients in non-behavioral health settings - atrocious) with that patient. As MJ said, she didn't just pull out those interventions from a hat - she used her experience, her mental health knowledge and her repertoire of nursing therapeutic interventions to determine the immediate intervention, its intended outcome and her follow-up assessment of the patient's response.

I agree that if EB Nursing and Medicine are applied as documentation requirements, that this will defeat their purpose.

However, EB Nursing is finally coming of age, and a quick tour around the nursing research world demonstrates how much is being accomplished and how much patients stand to benefit.

Thanks for writing this, MJ. Great reading - lots of food for thought!

2:46 PM  
Blogger poody said...

Let me guess the theroy based nurses are BSNs right?

4:52 PM  
Blogger ERnursey said...

I like your approach, sometimes dealing with people is like dealing with your kids. You have to be firm, set limits and follow through.

11:56 AM  
Blogger The Mental said...

Silly me! I have been hearing of "Evidence Based Practice" for almost a year now and I thought that Evidence = clues, appearances, behavior, vital know, the clinical picture. What a wonderful idea! Base the medical practice on the clinical picture--but look real hard instead of going so fast! I was so happy! Now, I feel a bit embarrassed and skeptical.

[Note that I am NOT a healthcare provider!]

My cynical side says...if the emphasis is becoming more pronounced on practice based on research and publications, then that creates a greater demand for such. Which means more research grant opportunities...which means more money to universities through the research being there a DMS-IV code for Reality Paranoia: beliefs that the bottom line to everything is...the bottom line...somewhere to some entity or person? Add another to my chart! LOL

8:49 PM  
Anonymous Anonymous said...

Marvelous! I couldn't agree more!!

10:44 AM  
Anonymous Anonymous said...

There is a lot to be said for common sense and the part it plays in patient care. I will earn my MSN in a few weeks, and I am no more theory based now than when I graduated from a diploma program 40 years ago.

Nursing has forgotten it is practice that makes a perfect nurse, not how many theories that can be cited on a moment's notice. I want a nurse who knows what to do and how to do it before even considering the theory behind the action. I could die waiting for the theory to be developed.

6:15 PM  
Blogger Fyrdawg said...

Before I was a nurse, I was a firefighter, worked my way up to captain. We had a new deputy chief that wanted to see me "calculate" how much water to put on a fire to put it out. Seems someone had developed a model for "theoretical" fire area and how much water to use to extinguish the fire. Told him I had no clue: if the fire is till burning, I keep putting water on it. If it gets bigger, I get more hoses and put more water on it. And I keep putting water on it until the fire goes out.

I feel the same applies to Evidence-Based Nursing. Some situations demand immediate action. Patient stops breathing, call a code, bag the patient, then try to figure out why he or she isn't breathing.

Someone starts hollering evidenced based whatever: firefighting, nursing: come show me how.

7:10 AM  

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