Research Working Group - Updates from 2014

December 2014: Reflections on evidence based oncology nursing

For this month’s Research News Update Ulrika Östlund of the EONS Research Working Group reflects on evidence based oncology nursing.

Part of my job as a lecturer at Karolinska Institutet in Stockholm, Sweden is teaching at the specialist nursing program on oncology nursing. In one course the students have just finished a study assignment in which they choose a nursing problem related to treatment for cancer. Topic covered were nausea and vomiting, oral mucositis, taste and smell changes, bowel problems such as diarrhea and constipation, malnutrition, pain, fatigue, peripheral neuropathy and erectile dysfunction. They continued with searching the international research literature for nursing actions to be used, in collaboration with patients and their significant others, for preventing, alleviating and/or coping with the “problems”. They had to include at least five studies, any kind of design. Finally they judged the evidence base for these nursing actions from the studies they had found (at least one had to be graded for its research quality) and reflected over how the specialist nurses can work based on what they found. They presented their results in a written report and at a seminar in which they acted as expert groups presenting their results to the rest of the students and took questions.

We, the students and teachers, are aware that the work they did does not fulfil criteria for reviews using systematic principles for concluding on the available research evidence. Still I think what they found can give an indication on the evidence base for nursing actions in oncology nursing. Based on what they presented I would say that for some specific nursing actions the evidence base has improved but for others the research evidence is weak or even non-existent. Some students also searched evidence for specific nursing actions they use in their clinical work and, for some, found no evidence supporting them and reflected on the need to change their practice. If my students could achieve what they did, searching for and reflecting on evidence for nursing actions, during a couple of weeks when accomplishing a study assignment, what cannot be done in collaborations between researchers and clinicians aiming to strengthening the research evidence where needed, make available evidence “implementable”, and finally to implement it in practice?

In 2009 Hallberg in an IJNS editorial raised the question how far the expansion in nursing research has produced knowledge relevant to the work of clinical nurses and with direct benefits for patients? In this thought provoking editorial she argue that nursing research studies not having immediate clinical implications may inform further studies and have enhanced clinical practice given priority to the perspectives and needs of patients and their families, but more can be done. The outcome of different interventions and its feasible in clinical nursing settings need to be studied. As part of my engagement in the EONS Research Working Group I am currently reading applications for the EONS Research Grant and most applications can be described as intervention studies, this was not the fact some years ago. This may be an indication that the research within oncology nursing develops in such a way suggested by Hallberg.

Hallberg highlighted in the editorial that not only new ideas need to be evidenced but also current practice have to be studied, as also obvious in my students study assignments. Moreover, to develop our knowledge base and implement findings broadly we need to collaborate across countries. This also requires exploring the validity in different contexts. When reporting findings from an intervention study the authors have to be clear about what the intervention researched actually is, sufficient detail has to be described so the intervention can be replicated. Sometimes, to be able to make recommendations for practice, chains of studies with different designs are needed. Critical reflection on the designs traditionally used to study effectiveness is also required because they are, for example, not always feasible in clinical nursing settings and external validity may be limited as inclusion criteria do not fit clinical reality. Qualitative methods applied within an experimental study may shed light on why an intervention is effective or why it is not. Furthermore analysis of interventions and the outcomes of these, from a theoretical perspective, can contribute to theory development (Hallberg, 2009). A couple of years ago I conducted a methodological review on mixed methods research designs together with colleagues (Östlund, Kidd, Wengström, & Rowa-Dewar, 2011). We concluded using triangulation as a methodological metaphor, as exemplified in the paper, can facilitate the integration of qualitative and quantitative findings and help researchers to clearly present both their theoretical propositions and the basis of their results. Furthermore support a better understanding of the links between theory and empirical findings, challenge theoretical assumptions and aid the development of new theory.

Hallberg (2009) also reflect on the value of reviews that address well defined research areas and are conducted in a systematic manner and providing guidelines for clinical problems. EONS have recently developed and published guidelines on breakthrough cancer pain and a summary can be found in the article by (Wengström, Geerling, & Rustöen, 2014). The EONS Breakthrough Cancer Pain Initiative is a nurse-led project designed to help oncology nurses identify and manage breakthrough pain. It is the hope of those developed the guidelines that if implemented in clinical practice the understanding and management of BTCP will improve assessment and overall management of breakthrough pain in cancer patients. They conclude that nurses play a key role in translating research into clinical practice as oncology nurses have a unique interaction with patients and significant others. I would like to add that researchers need to develop interventions that are implementable and key for doing this is co-producing knowledge from the engagement of researchers, clinical nurses and not to forget the “end-users” patients and their significant others.

Implementing guidelines and changing practice based on new evidence is a challenge. Within the community of oncology nurses, as in EONS, I am sure that we can make a difference if being aware of the evidence base for nursing actions used or new nursing interventions being implemented. If working together using our different experiences and expertise within research, clinical practice, management, cultural context and other relevant knowledge, oncology nursing will continue to improve. To support such initiatives the EONS Research Working Group, at their meeting in October, agreed to take further a discussion on developing a resource pack for EONS nurses to use in their own countries, covering the fundamental aspects of research in cancer nursing. It was anticipated that the resource would cover the following key areas: understanding the research process in cancer nursing; using and implementing evidence for cancer nursing practice and; reading and critiquing research papers.

References

Hallberg, I. R. (2009). Moving nursing research forward towards a stronger impact on health care practice? Int J Nurs Stud, 46(4), 407-412. doi: 10.1016/j.ijnurstu.2009.02.005

Wengström, Y., Geerling, J., & Rustöen, T. (2014). European Oncology Nursing Society breakthrough cancer pain guidelines. Eur J Oncol Nurs, 18(2), 127-131. doi: 10.1016/j.ejon.2013.11.009

Östlund, U., Kidd, L., Wengström, Y., & Rowa-Dewar, N. (2011). Combining qualitative and quantitative research within mixed method research designs: a methodological review. Int J Nurs Stud, 48(3), 369-383. doi: 10.1016/j.ijnurstu.2010.10.005


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