The size of the problem

The clinical literature is big. Just how big is staggering. There are thousands of new studies published hourly. For example, randomised controlled trials are published at the rate of 20,000 per year. That is roughly 50–60 per day, or one every 20–30 minutes. Worse than that, randomised controlled trials represent a small proportion (less than 5%) of the research that is indexed in Medline and, as you will see in Chapter 3, it is just one of the databases that are available for you to search in to find evidence. This means that the accumulated literature is a massive haystack in which are embedded some important needles we have to find. One of those needles of information might be the difference between effective or ineffective (or even harmful) care for your client. One of the purposes of this book, then, is to help you find needles in haystacks.

Noting it down

It is important that we keep track of the questions that we ask. It is very easy to lose track of them and then the opportunity evaporates. If you cannot remember what you wanted to know when in the midst of managing a client, chances are you will also forget later.

How should we do this? One way is to keep a little book in which to write them down in your pocket or handbag. Date and scribble. A more modern way is electronically, of course, using a personal digital assistant (PDA) or computer (if simultaneously making client records). Some of us tell the client what we are doing:

In Chapter 1, we discussed the general process of looking up, appraising and applying the evidence that we find. But also remember to keep track (in other words, write it down!) of the information that you found and how you evaluated and applied it. In the end, the information that is found might result in you changing (hopefully improving) your clinical practice. The way it does this is often uncoupled from the processes you undertook, so it takes some time to realise what led you to make the changes—often systematic—to the way you do things. Sometimes the research information just reassures us that we are on the right track but this is important also.

Push: just-in-case information

In advertising jargon, the term ‘push’ is used, meaning that the information is pushed out. This is the traditional means by which information is disseminated. This is basically the function of journals. Research is undertaken and either sent directly to you, or pre-digested in some way (perhaps as an editorial, review article, systematic review or guideline). ‘Just-in-case’ information is made available when it is generated, or when it is thought (by someone other than you, the health professional) that health professionals ought to hear about it.

Figure 2.1 shows some examples of information that can be pushed. Other sources of ‘push’ information include conferences, professional newsletters, textbooks and informal chats to colleagues and other people from other professional groups.

FIGURE 2.1 How does research data get to you?

As can be seen, there are many ways that a piece of research can percolate through to you as a health professional. The picture is actually more complex than this: what is picked up for review, systematic review and so on is determined by a number of different factors, including which journal the primary data were first published in, how relevant readers think it is and how well it fits into the policy being formulated or already in existence. There are, in fact, different sorts of information that we might consider accessing and this is explained in detail in Chapter 3 (see Figure 3.1). But this is only the start. All these methods rely on the information arriving at your place of work (or home, post box, email inbox etc). Then it has to be managed before it is actually put into practice. How does this happen? There are a number of different stages that can be considered and these are explained in Table 2.2.

TABLE 2.2 The processes involved in making sure that just-in-case information is used properly to help clients

Clearly this is not an easy process. There are many steps where the flow can be interrupted. All the steps have to happen for the research to run the gauntlet through to the client. One solution is to use one of the abstracting services. One of these is the Evidence Based journal series (see http://ebm.bmj.com/). This type of service is described in depth in Chapter 3 but, in a nutshell, these journals only provide reports of previous research (that is, they contain no primary research). Papers are reported only if they survive a rigorous selection process that begins with a careful methodological appraisal, and then, if the paper is found to be sufficiently free of bias, it is sent for appraisal by a worldwide net of health professionals who decide if the research is relevant. The resultant number of papers that is reported in each discipline is surprisingly small. In other words, only a few papers are not too biased and also relevant! Happily for health professionals, there is another option.

Pull: just-in-time information

Pull is advertising jargon for the way potential customers go looking for information, rather than simply waiting for it to be pushed to them. In this context, it is information that the health professional seeks in relation to a specific question arising from their clinical work. This gives it certain characteristics. This is illustrated in Table 2.3 using the five As that were introduced in Chapter 1 as a way of simply describing the steps in the evidence-based practice process.

TABLE 2.3 Processes involved in just-in-time information: the five As

If this looks familiar to you, well, this is the essential core of evidence-based practice. How feasible is it to incorporate this way of finding information ‘just-in-time’? Again, there are a number of steps that have to be undertaken. These are not easy either—they all need mastering and practice (like almost everything in clinical care). For example, asking questions is difficult. It requires us to be open to not knowing everything. This is more difficult for some people than others (doctors were notorious for having trouble with this—perhaps because society bestowed some god-like attributes on them that made it potentially too disappointing if they admitted not knowing stuff). The truth is, most people in modern times welcome the honesty that goes with questioning the best management. It makes the health professional appear to be taking infinite and meticulous care.

How often do we ask questions? Is this something that we can aspire to realistically? Most health professionals are worried that they do not ask questions enough. Relax. You do. Studies have been undertaken in a number of settings (all to do with doctors, sadly) to show that they ask questions much more than they thought they did. For example, a study undertaken in Iowa, USA, examined what questions family doctors working in the community asked during the course of their work. Just over 100 doctors asked >1100 questions over 2.5 days, which is approximately 10 each.¹ A similar Spanish study found that doctors had a good chance (nearly 100%) of finding an answer if it took less than 2 minutes, but were much less likely to do so (<40%) if it took 30 minutes.² A study of doctors found that they are more likely to chase an answer if they estimate that an answer exists, or if the information need is urgent.³ Nurses working in a similar setting were more likely to ask someone or look in a book in order to answer their questions.⁴ Despite advances in electronic access, health professionals do not seem to be doing well at effectively seeking answers to clinical questions.⁵ If we are not able in the hurly burly of daily clinical practice to look up questions immediately, it is important (as we mentioned earlier in the chapter) to write them down.

Patient or problem

In this component, you are stating who or what the question is about. This may include the primary problem, disease or coexisting conditions—for example, ‘In children with autism …’ Sometimes you may also wish to specify the sex and age of a client if that is going to be relevant to the diagnosis, prognosis or intervention—for example, ‘In elderly women who have osteoporosis …’

Intervention or issue

The term intervention is used here in its broadest sense. It may refer to the intervention (that is, treatment) that you wish to use with your client—for example, ‘In people who have had a stroke, is home-based rehabilitation as effective as hospital-based rehabilitation in improving ability to perform self-care activities?’ In this case, home-based rehabilitation is the intervention that we are interested in. Or, if you have a diagnostic question, this component of the question may refer to which diagnostic test you are considering using with your clients—for example, ‘Does the Mini-Mental State Examination accurately detect the presence of cognitive impairment in older community-living people?’ In this example, the Mini-Mental State Examination is the diagnostic test that we are interested in. Or, if you have a question about prognosis, you may sometimes wish to specify a particular factor or issue that may influence the prognosis of your client—for example, in the question ‘What is the likelihood of hip fracture in women who have a family history of hip fracture?’, the family history of hip fracture is the particular factor that we are interested in. If you want to understand more about clients’ perspectives you may want to focus on a particular issue. For example, in the question ‘How do adolescents who are being treated with chemotherapy feel about hospital environments?’, the issue of interest is adolescent perceptions of hospital environments.

Comparison

Your questions may not always include this component. It is mainly questions about the effects of intervention (and sometimes diagnosis) that use this component. Add a comparison element to your question if you are interested in comparing the intervention component of your question to another intervention and wish to know if one intervention is more effective than another. In the example that we used above, ‘In people who have had a stroke, is home-based rehabilitation as effective as hospital-based rehabilitation in improving ability to perform self-care activities’, the comparison is hospital-based rehabilitation. Sometimes, the comparison that you are interested in may be usual (or standard) care and, sometimes, you may not wish to have any comparison.

Outcome(s)

This component of the question should clearly specify what outcome (or outcomes) you are interested in. For some outcomes you may also need to specify whether you are interested in increasing the amount of the outcome (such as the score on a functional assessment) or decreasing it (such as the reduction of pain). In the stroke question example above, the outcome of interest was an improvement in the ability to perform self-care activities. As you will see in Chapter 14, shared decision making is an important component of evidence-based practice and it is important, where possible, to involve your client in choosing the goals of intervention that are most important to them. As such, there will be many circumstances where the outcome component of your question will be guided by your client’s preferences.

The exact way that you should structure your clinical question varies a little depending on the type of question that you have. This is explained more in the relevant chapter—Chapter 4 for questions about the effects of intervention, Chapter 6 for diagnostic questions, Chapter 8 for prognostic questions and Chapter 10 for qualitative questions.