It is well recognised that many students and qualified nurses alike struggle to get their heads around statistics.  Confidence intervals are essential to understanding nursing research, but can instil feelings of blind panic in the uninitiated.  Like so many technical concepts they are intimidating when you don’t understand them, but not so difficult once you do.  So what does it mean when a study reports that those receiving a treatment are twice as likely to be cured as those in a control group who do not receive the treatment CI95% 1.7 – 2.2 ?.  Nursing studies take place in the real world, and the way individuals respond to a particular treatment or the precise way it is applied will vary.  Researchers try to minimise the differences, but these so called ‘sampling errors’ are still inevitable.  In a study including few participants this could result in a confusing spread of results.  The treatment might work for individual A, but not for individual B.  So what is the true effect of the treatment?  When large numbers are recruited to a study, we might begin to expect that the average treatment effect represents this true effect.  In fact the larger the number of participants, the more certainty we can have about the accuracy of the result.  So how accurate does a study need to be before we are prepared to claim that the results found are valid.  Most researchers consider a finding to be statistically valid if they can be 95% certain of the result.  In practice this means that, rather than quoting a single figure for the effect of a treatment, the authors of studies specify an interval within which they are 95% certain that the true figure lies.  In this case they claim that they are 95% certain that the true figure lies somewhere between 1.7 and 2.2.  As the lower estimate of effectiveness of 1.7 is still well above 1 (if it were 1 the treatment would be of no benefit; if it were below 1 it would be harmful) we can say that we are pretty confident that the treatment is effective. 

So I think I understand confidence intervals, and I am 95% confident that my own explanation above is more or less what it is all about.  But perhaps one of you statistically minded people can explain to me what is so special about the 95% CI that has made it so standard across nursing studies.  This de-facto acceptance of an apparently arbitrary figure troubles me.  The community seems to be happy that an odds ration of 1.1 – 1.4 95%CI demonstrates a result that favours treatment, whereas the same study could show say 0.9 – 1.5 97%CI and it would presumably be rejected on the basis that it includes values of 1 and below.  So why is 95% so pivotal and should we feel happy to jump out of an aeroplane 95% sure that the parachute will open?

It would be easy to conclude, as I come to an end of my community placement, that the majority of people over the age of 75 have at least one venous leg ulcer.  Mr O’Leary was no exception – in fact his was particularly painful and had so far resisted all attempts to heal.  Like so many of the older folks in the community, he suffered the pain stoically.  As he squelched his way into his living room for the daily bandage change, I glanced at the exudate stained leather of his shoes and the soggy mass of  bandaging and was reminded of the embarrassment endured by these patients.  Mr O’Leary smiled warmly, gently rolling his fingers in Parkinsonian rhythm as he enquired after my health in a soft Irish lilt.  I desperately wanted to find a way to promote healing, and started searching for any hints in the research literature.  It surprised me to find that until the 1990s, although the UK Department of Health knew that a major proportion of community health expenditure went into treating leg ulcers, it was not known how much that was, neither was the prevalence of leg ulcers known, nor what treatments were being used and whether they worked.  In fact little was known at all.  A systematic review of available research was commissioned for the first time to try to answer these and other questions about leg ulcers.  The results were not encouraging.  The majority of the questions remained unanswered or where there were answers those answers were unclear.  I realised that nursing research has a place in identifying further research needs as well as answering clinical questions.  Fortunately what has been described as an ‘evidence desert’ spurred the NHS into funding a suite of systematic reviews of wound care in 1997.  It is now widely accepted that compression bandaging is the main treatment for venous leg ulcers (Cullum et al 2001), and that no conclusive evidence favouring any particular dressing beneath the compression bandaging has emerged (Palfreyman et al 2006).   Unfortunately Mr O’Leary was not able to tolerate significant compression, and seldom remembered to elevate his legs to aid venous return.  I had no Panacea to help him, and it was clear that we still need further research into this area.  ‘I’ll see you at the same time tomorrow Mr O’Leary’ I said having completed the dressing.  What was my next visit?  Oh yes, another venous leg ulcer.

Cullum N, Nelson EA, Fletcher AW, et al.. Compression for venous leg ulcers. Cochrane Database Syst Rev 2001;(2):CD000265

Palfreyman SJ, Nelson EA, Lochiel R, et al. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev 2006;(3):CD001103

It is hard to ignore the politics in nursing.  Every time a qualified community nurse leaves, they are replaced by an untrained Health Care Assistant.  What is going on here?  I do not want to do HCAs down, as many of them do a superb job, but if the job can be done as well by an HCA as a staff nurse, then what is the point in spending three years studying and living on a student grant.  Are the accountants taking over primary care?  Do ‘they’ not realise that carrying out nursing interventions requires more than mechanistically following a care plan.  A few days ago we all trooped to the hospital to listen to the senior manger explain how primary care is moving to a commissioner -  provider model.  Now having been a manager myself in a previous life, I have more sympathy than most for these unfortunate, overpaid individuals, but their talk of corporate identity, metrics and strategic positioning was a real turnoff for us clinicians.  “Tesco,” lectured the speaker, “can sell holiday insurance, mobile phones, in fact almost anything.” The bewildered nurses gazed at each other as the quagmire of mutual misunderstanding between speaker and audience widened.  They had signed up to care for sick patients, were they to sell insurance?  “We must all review our strategic marketing position,” burbled the manager from another planet, but it was too late, the audience was lost.  “We must leverage our core competencies to create a paradigm shift,” she pleaded faintly. To be fair, she had little hope from the start.  The majority of nurses, I believe, nurse because they care about patients, and have no wish to become business savvy; it is incompatible with their approach to patient care.  If we must run like a business, so be it, but nurses should focus on what they are trained for and do best, and accountants should allow them to do so.

This morning I am starting my placement in the community; working with district nurses in local rural villages.  I am really looking forward to it, and it makes me realize that I have actually been a bit disappointed with some of my previous placements.  Like any good nursing student, I have reflected on this surge of renewed enthusiasm, and this is what my introspection has revealed; I have a horror of ‘doctor’s handmaid’ nursing, and it appears that despite the modernisation of the nursing profession, there is still a fair bit of it going on.  I feel that evidence based nursing has the potential to help guide the occupation away from this approach to become an independent, and mature profession.  What excites me about district nursing is the long tradition of autonomy and independence in decision making.  Perhaps I will miss the buzz of a busy ward, but I am relishing dealing with one patient at a time, seeing them in their true environment, and getting to know them as people.  No doubt the reality will not turn out as I hope, but for the moment allow me to enjoy feeling positive, and to savour getting away from the interminable assignments, and get my suitably gloved and decontaminated hands dirty doing the real job of caring for people.

My placement comes to an end.  As ever, I have encountered many interesting people and situations and experienced a wide range of emotions from elation through to despair.  I have learned a lot and realised how much more I need to learn.  The kindness and patience of the majority of staff have made the difficult task of adapting to a new placement a pleasure, only marred by a few who seem to have forgotten that they too were once students.  And what of my quest to back up my practice with nursing research?  I have tiptoed like a child into the boxing ring of evidence based healthcare and come out after round one with a bloodied nose before even swinging my first punch.  But I am still on my feet and will hopefully be a little wiser when I return for round two.

‘Ring for the paediatric nurse,’ bellows Christine trying to make herself heard over the top of the heartfelt screams of 5 year old Thomas.  Thomas has had 5 teeth removed, and has just woken up in the recovery area spitting blood metaphorically and literally.  We are amazed at his strength as an anaesthetist and 3 nurses’ combined efforts only just manage to stop him from launching himself off the trolley.  I rather pride myself on having a way with children, so on finding Thomas’s favourite teddy bear on the trolley  I confidently approach the angry and frightened child. ‘Look Thomas, it’s Barney bear,’ I say in my most soothing voice.   Thomas fixes me with a glare of stunning malevolence and yells ‘I WANT MY MUMMY’.  Helen, the children’s nurse arrives to a combined sigh of relief, and in seconds Thomas morphs from demon in child form to the embodiment of peaceful angelic vulnerability. 

During a quiet period in the day surgery list I take the opportunity to continue my search for more recent evidence about postdural headaches.  Charlotte, a recently qualified nurse, looks over my shoulder.  ‘I suppose you have some reason for looking at that?’ she says accusingly.  I quickly mutter something about needing it for a college essay.  Why do I feel so embarrassed to be caught looking up nursing research?  Despite the emphasis on evidence based care in nursing courses and within the UK nursing code of conduct, even those recently qualified often regard it as an assignment to be passed at university but not really relevant to practice.  I still believe that as nurses we can and should be putting evidence at the core of our practice, but there is clearly a hill to climb in empowering, educating and changing attitudes to achieve this.

Today I try to engage nurses with my research findings regarding bed rest after lumber puncture.  I am aware that this might not be the most riveting of conversational openings, but I am still quite disappointed with the result.  Some of nurses I speak to are not at all sure why they ask patients to lie down after their procedure, whilst others reply that they think it is something to do with getting headaches, but are unable to give any more details.  I wonder who is dictating this care plan, and am told that it’s just what everyone does, and they expect it is documented in some procedure somewhere.  I am assured that it will be the consultant who will have ultimately specified the requirement.  Several nurses admit that they do not know much about evidence based practice, and would not know how to go about finding relevant evidence.  I am left with the impression that nurses are not expected to question practice; our role is to carry out procedure and process as laid down by the greater system over which we seem to have little influence.  I can see the logic in this.  If every nurse were to develop their own protocols, then the standard of care delivered would be even more of a lottery than it is now.  It makes sense that there are proper pathways for incorporating relevant evidence into practice.  Perhaps I need to need to find out more about how this process operates.

I arrive in the day unit to see Dave limping down the corridor.  ‘What happened,’ I ask.  ‘I got knocked down by a car and spent the night in the emergency department,’ he grins.  He denies that centurion was in any way connected and nonchalantly hobbles off down the corridor.

I have a focussed clinical question!  Whilst working on the pain list, I note that patients receiving epidural steroid injections in their spine have to lie down for 20 minutes after their injection.  I am told that this is to reduce the chances of them developing a headache following their procedure and that they used to lie down for much longer.  I decide to look to see if there is any evidence to back this up.  My question is “For patients undergoing lumbar puncture does bed rest result in reduced incidence of headache compared with no bed rest?”.  Searching for “lumbar puncture and bed rest and headache” in Evidence Based Nursing (http://ebn.bmj.com/search.dtl), I find an article that seemed to answer the question “McArthur J (2002) Longer bed rest does not prevent more postpuncture headaches than immediate mobilisation or short bed rest. Evidence Based Nursing. 5;87”.  I am pleased to find this article because I know that only quality research is summarised in this journal.  In addition, the title of the piece answers the question immediately, and the article itself consists of an easily read synopsis of the relevant research (in this case a systematic review of randomised controlled trials) without too much unnecessary detail.  The article also includes a commentary which provides a simple explanation of the research and its application to practice.  The conclusion appears to be that contrary to the previously perceived wisdom on the subject, there is no evidence to suggest that bed rest after lumbar puncture reduces incidence of headaches.  Flushed with success I print both this article and the longer systematic review to which it refers in order to examine them more carefully, and resolve to search for further more recent evidence perhaps in some of the bibliographic databases (for example Medline).