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). 

An ex-colleague died of a sore throat today.  It was an apparently innocuous infection that eventually affected his heart and lungs, and despite intravenous antibiotics he died.  I did not think that people died of infections any more in our medically sophisticated western world.  He was a talented and intelligent man, had just been promoted, he loved his wife and his dogs, and was younger than me.  The same day I hear that an 11 year old in my son’s year at school has died of a brain haemorrhage.  Life can be very cruel.  I start reflecting on my own mortality and end up feeling melancholy.

Today I have a day off, and enthusiastically start to look for a ‘revolutionary’ piece of evidence to introduce into the day unit.  I know that Evidence Based Nursing (http://ebn.bmj.com) and The Cochrane Library of Systematic Reviews (www.cochrane.org) are good places to look for quality evidence, but I don’t really know what I am looking for.  I notice that the majority of the reviews concern drug treatments, or the efficacy of certain surgical procedures and that as a student nurse I am not in a position to influence either.  I find an article about knee surgery.  For one awful moment I have visions of trying to confront Mr Shetland the orthopaedic surgeon with my piece of evidence.  Mr Shetland is not an easy man to work with.  He is an excellent surgeon I have no doubt, but I have watched him reduce his theatre staff to tears as he bombarded them with a sustained barrage of criticism.  Rumour has it that his reg walked out on him.  Trying to discuss my piece of evidence with him is unthinkable.  This is an ignominious start to my aspirations to spread the word of evidence based practice.  I have fallen before leaving the starting blocks.  I spend another hour scanning through endless articles about the merits of using indigenous health care workers in treating indigenous children with asthma and other esoteric topics before realising I am wasting my time.  I remember being taught at university about the necessity of a focussed clinical question, and realise that that is what I need.

‘Played centurion again last night with the medical students,’ comments fellow student Dave during a quickly snatched tea break.  I have to admit to him that I need further explanation.  ‘Oh you have to drink 100 shots in 100 minutes,’ he explains cheerfully, ‘and the last one to throw up wins’.  ‘Sounds like a good laugh,’ I comment hoping that my horror at the idea does not show.  Clearly Dave is a man who embraces all that student life has to offer.  I realise how different my outlook is as a mature student with a family than when I was Dave’s age and centurion might have struck me as being a fun sort of thing to do instead of a wet form of Russian Roulette.  We nursing students are a diverse bunch but united by the trials of juggling the academic, time and financial pressures of studying nursing.  Not only do we have to fulfil our placements hours, and cope with university lectures and assignments, the vast majority of us also hold down jobs to stave off financial ruin.  Add to this that many of my fellow students are mothers running a household and it is no wonder that nursing courses have such a high drop out rate.  My next assignment is on health promotion, and I make a mental note that Dave could be a good subject.

“He’s on the throne,” called Mrs Tonks from within the small cottage.  “On the phone.  How long will he be?” queried my mentor?”. “Not the phone, the throne.  He’s on the commode” she laughing good naturedly.  By the time we reached the living room, Mr Tonks was ensconced in his threadbare easy chair puffing like a steam train.  His blue tinged hands reached anxiously for his nasal cannula, and he sucked deeply at the meagre 2 litres of domiciliary oxygen which oozed from the concentrator behind his chair.  It was minutes before he was able to utter a word.  He looked deadbeat, like he had just finished a marathon, rather than moved a few feet from the commode to his chair.  I found this man’s desperate struggle to breath after so little excursion shocking, and resolved to find out more about oxygen therapy.  I started with  a recent article in Nursing Standard about the use of domiciliary oxygen.  I also found a Cochrane review that summarised the evidence base for domiciliary oxygen use.

The following day we visited another couple afflicted by respiratory failure.  Mr Little and his wife lived in a beautiful village house overlooking a lake, but Mr Little had pulmonary fibrosis, a serious disease where the alveoli and lung tissues become damaged and scarred.  Whilst we took a blood sample from Mr Little, his wife wheezed and coughed distressingly.  “I have emphysema,” she gasped.  Mr little was getting used to using a permanent oxygen supply, and clear plastic pipes snaked across the plush carpets.  He started telling me that he had been given conflicting advice on how long to use his oxygen each day.  One nurse had thought that it should not be used for more than 15 hours per day, whilst the GP had suggested using it 24 hours per day.  Did I know which was right?  Pre-armed with my recent reading, I prepared to explain that research had shown that mortality in patients with severe hypoxaemia was reduced if oxygen was used for more than 15 hours per day, but Mrs Little was to quick. “He won’t know – he’s only a student,” she scolded her husband abruptly.  I felt slighted.  OK I was only a student, but I had been taught to read and appraise evidence, and to try to apply it in the real world, and here I was at last doing it for real, only to be told that knowledge was the preserve of the experienced.  I felt pleased that I had looked at the research, and this empowered me to promote best practice, but was reminded that sometimes it is not what you know, but who you are that carries weight.

Notes on evidence base

The Nursing Standard Article was:-

Lynes D and Kelly C (2009) Domiciliary oxygen therapy: assessment and management. Nursing Standard. 23 (20) 50-56

The 15 hours guideline emanates from the following research paper:

Medical Research Council (1981) Report of the Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981 (1) 681–5.

A broader review of the evidence base can be found in:-

Cranston JM, Crockett A,Moss J, Alpers JH. (2005) Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001744.