I recently taught a health promotion course to graduate nursing students. We reviewed many issues including the implementation of evidence in practice. We were reminded that evidence based practice includes the use of data from well conducted research studies, but also includes the clinical experience of the practitioner and, most importantly, input from the patient. It is from this context that we discussed childhood immunizations. Once again, the news is full of information about measles outbreaks and the anti measles vaccine campaign that was started instigated by a doctor in the UK that spread across the world and has lasted over a decade. My class looked at the issue from the perspective of evidence based practice and I was reminded of my own experiences.
The first step in EBP is to review the evidence. The research (article now retracted) that was used to support the assertion that the MMR vaccine is a factor in the development of autism had many flaws. Among many other things, the sample was very small with only 12 participants. The research question did not include a review of the effect of the MMR vaccine. Rather, the data collected about vaccines and association with autism came from a number of sources including parental recall, physician anecdote or chart audits, mostly years after the MMR had been given. Compared to the large, epidemiological studies that did not demonstrate a link between MMR and autism, the class couldn’t help but conclude that the small research study was very flawed and the conclusions false.
Next in the evidence based practice process is clinical experience. We discussed the impact of the subsequent campaign against the MMR vaccine. Un-immunized children in my practice did not contract measles. However, parents who refused to immunize against MMR often chose to refuse all immunizations. I cared for several cases of avoidable pertussis in the subsequent years and none of the children that I did immunize suffered ill effects. At the same time, there were older patients in my practice who had developed polio when they were children and suffered paralysis in various forms because of it. These patients were astounded at the thought that anyone would refuse an immunization to prevent a terrible disease. To summarize my clinical experience, I saw the benefits of immunizations first hand.
Now…the final and most important part of evidence based practice, the patient. Despite the research evidence and my clinical experience that supported immunizations, there were many parents in my practice that refused to immunize their children. Underlying all the debate about immunizations was the intense fear that developed in parents. No parent wants to do something that will harm their child. However, the dilemma in evidence based practice is what happens when there is conflict among any of the key elements of evidence based practice (research, clinician and patient perspectives). The class explored options for the clinician. Should patients be discharged from a practice if they refuse to immunize their children? Should the clinician simply accept the parent’s choice? Perhaps a readjustment of evidence based practice needs to happen. For example, a parent education session to ensure that they are fully informed about the issue and the implications of their decision followed by non-judgmental care that demonstrates an understanding for the patient’s perspective. This was the way I chose to work with families who refused immunizations. Even though the children did not receive their shots, the therapeutic relationship was maintained.
Evidence based practice is a complex, constantly evolving phenomenon. Even if we follow all the steps, ultimately the path of care may be determined by unforeseen factors. Yet, it seems to me that respect and empathy are the most important features of any patient interaction and this care will always be evidence based.