During a regular checkup, my internist and I discussed practice trends in our respective fields. "For the past decade, medicine has been obsessed with evidence-based practice," my doctor asserted. "Now, there is a new emphasis on "contextually based, patient-centered care," a classic approach which is thankfully reemerging." I replied that the same emphasis on evidence-based practice was prominent in nursing but that a holistic focus on the patient and family in context had not dramatically faded to the background. We agreed that evidence is powerful in shaping practice but that the evidence base is often not robust enough to enhance the care of individuals, especially those living in contexts that may not be health enhancing.
This conversation lingered with me all day. Can the application of evidence that may not be statistically powerful compromise rather than enhance patient care? Does published evidence preclude or enhance experience and good clinical judgment? And so I turned to David Sackett, MD, whom many consider to be the father of the evidence-based medicine practice movement. I found the following statement in his groundbreaking 1996 article1(p72):
Good practitioners (paraphrased from doctors) use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.
Conversely, without some understanding of the available evidence, practice can be tyrannized by ideologies and pet practices that may have little validity or may not fit the patient's context and style. The patient's health beliefs and behavior combined with evidence and good clinical judgment are essential ingredients in the recipe for effective care.
Each week as I taught my class in nursing theory and research to a group of RN-BSN students, Mark would exit the classroom at 6:55 PM and return 5 minutes later. I decided to change the break time to coincide with this pattern. When the class broke, I watched Mark walk to a corner and take out his cell phone. When his call was completed, I approached and asked if everything was alright. "I have noted your pattern of leaving the class at this time every week and could not help but wonder why." Mark replied,
I am a home health nurse and I have a patient with pretty severe hypertension. The doctor has her on a special regimen that has great promise according to the research. My concern is that her memory is fading a bit so I call her twice a day to make certain she takes her medication. We also have a brief, casual talk so that I can assess how well she is doing. On two occasions I had to call her son to take her to the ER, but things worked out. The phone calls seem to help keep her on track.
The perfect recipe, an evidence-based treatment, a nurse who understands the patient's context and behavior and who uses great clinical judgment to gently encourage adherence and to monitor progress. This is the essence of holistic care.
-Gloria F. Donnelly, PhD, RN, FAAN
Editor
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