In two new blogs, Professor David Richards, Professor of Mental Health Services Research and Head of Nursing at the University of Exeter, and Professor Jo Rycroft-Malone, Director, National Institute for Health Research Health Services & Delivery Programme and Pro-Vice Chancellor for Research & Impact at Bangor University, provide two perspectives on the impact of nursing research. Jo describes a range of excellent nursing research studies and their contribution to improving quality, accessibility and organisations of health and care. Summarising two new systematic reviews of nursing research in Europe, David argues that there is a lack of high-quality experimental studies in nursing research that would contribute to a strong evidence base. Both blogs emphasise the need for building the profession’s capability and capacity to contribute impactful research to more evidence-based care.
Of all the health care professions, nursing exists at the dynamic and contested interface between evidence and practice, between science and art. The rhetoric of modern health care emphasises the combination of evidence from scientific research, the experience of skilled clinicians, and the views and opinions of people actually receiving healthcare interventions. Much effort is expended in nursing toward producing skilled practitioners who use their experience to the benefit of their patients. Although ‘soft’ qualities like compassion and caring are emphasised, the primacy of science in the clinical encounter is pushed in most educational and clinical initiatives. Our students are told that in order to deliver the best care and prevent harm occurring to their patients they must study and understand the scientific method in order to deliver ‘evidence-based nursing’. But is nursing really evidence based, or are nurses still required to practice based on tradition and existing routine?
Two recent systematic reviews of the evidence base for nursing have cast severe doubt on the nursing profession’s self-identification as a member of the evidence-based health care family. In the first review , a team of more than 50 international academic nurses – doctorally qualified or PhD students – analysed all clinical research publications written by European nursing science teams published in the top 20 nursing journals. The results were stark. Fewer than 20% of reports were of experimental research designed to avoid biased (more of this later) conclusions that asked ‘what works?’ questions. Apart from around 15% of review articles synthesising existing knowledge, the remaining articles were reports of observational research (roughly divided between quantitative surveys and qualitative enquiries) that described a wide range of phenomena and that were almost entirely cross sectional and thus not able even to infer causal relationships between nursing inputs and patient outcomes. As a consequence, the authors of the review notes that, “The enquiring nurse, looking to find answers to her clinical uncertainties, must look elsewhere [other than in nursing journals] for information to aid her practice.”
Of course, one could argue that nursing, as part of a multidisciplinary health care endeavour, might find its evidence in a range of sources, not just in professional-centric journals. The second review , therefore, is even more significant. Here the research team sought evidence for the effectiveness of ‘fundamental’ nursing care interventions in the areas of nutrition, elimination, mobility and hygiene. Searching for research reporting a wide range of experimental studies (studies where researchers manipulate variables, including randomised controlled trials, nonrandomised controlled trials and uncontrolled experimental trials such as before-after trials) they found 149 such studies for analysis. Their quality appraisal found that 136 out of the 149 were significantly flawed and at risk of bias – i.e. unable to provide reliable evidence of intervention effect. Worryingly, they observed a pattern whereby the studies at greatest risk of bias demonstrated the greatest evidence of intervention effect. Better designed and conducted studies tended to produce evidence that the nursing interventions being tested were either inferior to or no better than usual care. Worst of all, even the 13 least biased studies provided little help to practicing nurses, with only one high quality study giving clear clinical guidance.
In medicine, influential clinical researchers have accused that community of presiding over a system whereby around 85% of research activity is “waste” caused by researchers asking the wrong questions, using unnecessary or poor-quality research methods, failing to publish research promptly or not at all, and reporting research findings in a biased or unusable manner from studies that are often non-programmatic, uncoordinated, and unnecessarily repetitive. Given the two recent reviews discussed above, it is difficult not to come to the same conclusion about research in nursing.
However, is it any surprise that research undertaken by researchers in nursing appears so irrelevant to nursing practice when we have no system that routinely employs clinical nursing academics to bridge the research and practice gap? In England, nursing applications for National Institute for Health Research (NIHR) applied research fellowships are the least frequent and least successful of applications from all Allied Health Care professions. Wherever one looks, rigorous applied research in nursing, and the evidence for practice it should produce, seems unfocussed, unsuccessful and largely absent.
Coming up with a specific operational solution to this problem in nursing research will not be easy, but it seems obvious that a step change in the quality and nature of research undertaken by nursing research departments is urgently required. Whether this requires additional education programmes, a mere change in stance from supervisors and research leaders, or a root and branch reform of research departments is open to debate. The recent publication from the Council of Deans of Health on clinical academic careers (or the lack of them) and two proposed initiatives from NIHR on a nursing research ‘incubator’ and a ‘Senior Nurse and Midwife Research Leaders Programme’ demonstrate that at the very least this problem is on research funders’ radar. However, rather like a super-tanker attempting to change direction, from the evidence reviewed above, it may take some time yet for the good ship Nursing Research to turn itself around.
Guest blog by David Richards
Professor of Mental Health Services Research and Head of Nursing
University of Exeter College of Medicine and Health
- Richards DA, Hilli A, Pentecost C, Goodwin VA, Frost J. (2018) Fundamental nursing care: A systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene. J Clin Nurs. 27 (11-12):2179-2188.
- Richards, DA, Hanssen, TA, Borglin, G. (2018). The second triennial systematic literature review of European nursing research: impact on patient outcomes and implications for evidence based practice. Worldviews on Evidence Based Nursing. Online first. doi 10.1111/wvn.12320.