Evidence-Based Practice in ADULT NURSING

Evidence-based practice is a requirement of the Nursing and Midwifery Council (NMC) (2018) Code, so incorporating these activities into practice is vital for nurses. This essay critiques a research study carried out by Sawer et al. (2020) with the title, Is shame a barrier to sobriety? A narrative analysis of those in recovery. Subsequent to critiquing the research, two of the findings will be analysed critically to consider these in the light of the broader evidence base. Finally, the discussion will evaluate how evidence-based research can enhance or affect practice before arriving at conclusions on this topic.

The study of Sawer et al. (2020) was critiqued utilising a critical review form for qualitative studies developed by Letts et al. (2007). The findings for each of the sections of this form can be seen in the Appendix. It should be noted at the outset that the type of research undertaken was in this case, qualitative. According to Grove and Gray (2022, p. 21) “Qualitative research is a systematic subjective approach used to describe life experiences and situations and give them meaning.” This helps to understand the perspectives, perceptions and worldviews of participants (De Chesnay, 2016). It differs very significantly from quantitative research paradigms which are typically based on gathering numbers and testing theory. Given that the authors wished to understand experiences in depth, the approach of Sawer et al. (2020) may be considered suitable for this study. The research design itself was a narrative inquiry – also suitable because this seeks to understand participants’ own stories in their own words  and comprehending lived experience (Blessinger and Carfora, 2015). Sawer et al. (2020, p. 79) clearly articulate their research questions which were: “In what ways do participants tell their stories of shame? And how is shame experienced and/or understood by those in recovery from alcohol dependence?” This helps demonstrate study reliability as the research questions are suited to the research design and type of research.

Sawer et al. (2020) gathered their sample of participants from Alcoholics Anonymous, including five males and three females within the study, and using a snowball sampling-based approach. Sampling is the process of selecting participants from the total population to take part in the study, aiming to include representative individuals from the wider group (Cernat et al, 2022). Snowball sampling is a technique that is usually used to access difficult to access populations, through asking participants for referrals to other potential participants (Terry, 2017). While it is very useful for this purpose, it also has the risk of sampling bias creeping into the process because people may potentially refer others that have similar experiences or worldviews, meaning that the research may narrow in its findings (Fain, 2017). This ultimately can lead to issues of reliability, trustworthiness and validity in research. Typically, in quantitative research, researchers seek to achieve saturation of data (Boswell and Cannon, 2022) which occurs when researchers are gathering data, and no new information is being found. Another key problem with the study of Sawer et al. (2020) is that the researchers do not refer to this within their study. This leads to further questions about reliability and trustworthiness of the findings, and the extent of academic rigour applied overall.

On data collection, the authors used interviews with a view to encourage the telling of stories in some detail, with one initial question used asking about the participant’s story of recovery, followed up by further prompts to gain more data from participants (Sawer et al., 2020). Though the authors did not use the word “shame” in the interview, they did in the participant information sheet (Sawer et al., 2020). The use of semi structured interviews in this way is well-aligned to a qualitative research approach (Holloway and Galvin, 2016). It is not clear from the research why other techniques such as focus groups were not considered, since these can gather a greater depth of information when used at the right times (Dingwall and Staniland, 2020), however, this may be due to the nature of the topic and a possible reluctance to discuss shame in front of others. From the perspective of academic robustness, discussion of why not focus groups could have been helpful. On data analysis, Sawer et al. (2020, p. 80) carefully detail out their five step approach adopted from Crossley, which included reading and familiarising, identifying narrative tone, identifying imagery and themes, weaving a coherent story and cross analysis to synthesise themes. From a trustworthiness and validity perspective, noticeably missing from the Sawer et al. (2020) study is any reference as to how their own worldviews and beliefs may have shaped the data collected, its analysis and findings, since as Dewing et al. (2021) point out, this could have a significant influence. Holloway and Galvin (2016) argue that it could also draw in the potential for bias, leading to validity and reliability concerns.

Finally, the study was conducted according to ethical principles, and this is seen throughout the documentation of the research of Sawer et al. (2020). Sawer et al. (2020) describe how they sought ethical approval at the outset, and the use of informed consent forms to help ensure that harm did not come to participants (Llahana et al., 2019). They also anonymised names to ensure that participants could not be identified (Williamson and Whittaker, 2019) which might be considered particularly important on the topic of shame relating to alcohol misuse. One possible area for improvement might have been to signpost participants to extra counselling services, or having a counsellor present, since it is possible to imagine that the content may have been distressing for some, potentially.

One of the main findings of the Sawer et al. (2020) research was that participants had a deep seated negative view of self, present well before they were dependent on alcohol. Critiquing this finding, a few other studies were identified on undertaking a search, which support this point. In particular, the study of Kougiali et al. (2021) on mechanisms and processes involved in women’s pathways into alcohol dependence and towards recovery also highlights this point. The research of Kougiali et al. (2021) was a qualitative meta-synthesis of other studies undertaken in this field, identifying 23 research papers of relevance. Kougiali et al. (2021, p. 437) showed that there was a link between difficult situations in childhood and how this impacted on the person’s sense of self. Shame and stigma was seen to be present long before alcohol dependence, and sometimes it was found to delay seeking recovery, however, once recovery began, the authors showed that this helped revise the concept of self (Kougiali et al., 2021). This mirrors the findings of Sawer et al. (2020, p. 83) which showed that participants felt they had faults and that they had a “fault with self” which alcohol could relieve. Sawer et al. (2020) also pinpointed the concept that shame was likely to delay going to start the recovery process. Furthermore, while on the subject of offending and prison rather than alcohol dependence, Flood (2018) found that being able to recover and transform self-required shedding underlying feelings of shame. While the subject is somewhat different, the same overall process of deep seated shame can be seen to impact on change for a person (Flood, 2018) further adding some weight to the findings of Sawer et al. (2020).

Importantly, the research of Kougiali et al. (2021) might be considered higher up on the hierarchy of evidence than the research of Sawer et al. (2020). This is because the work of Kougiali et al. (2021) can be seen to be a robust and comprehensive review of other qualitative studies already existing in this specific area of research (Greenhalgh, 2019). Meanwhile, the study of Sawer et al. (2020) is lower down on the hierarchy of evidence because it represents just one small scale study into this topic. While there are various different hierarchies of evidence that have been proposed, as can be seen from the analysis of Melnyk and Fineout-Overholt (2018) in all cases, meta synthesis of qualitative studies are always considered more academically robust than a single qualitative study. Of course, this does depend on how the meta synthesis was conducted, since if the methodology was not academically robust this might affect validity of the Kougiali et al. (2021) findings, a point which does also challenge the hierarchy of evidence as a concept overall (Houser et al., 2016). Nonetheless, the study of Kougiali et al. (2021) does appear to be reliable, trustworthy and valid, so this is not the case in this scenario.

A second key finding of the Sawer et al. (2020) study was that participants’ recovery was enabled through being able to discuss and make sense of personal shame arising from experiences. On searching the literature, no one study was identified that outlined this exact finding, though there were some similar and related findings within the literature base. For example, research undertaken by Romo and Obiol (2021) that carried out interviews of 22 adults in alcohol recovery found that the way in which participants handled stigma and associated shame influenced their recovery. This lead Romo and Obiol (2021) to outline the importance of Alcoholics Anonymous and other treatment centres to use communication to break down stigma to lower barriers to recovery. Moreover, other research undertaken showed that one key stage in recovery was discussing shame with others and developing accountability which helped as a commitment to overcome drinking (Chambers et al., 2017).

However, the Chambers et al. (2017) study was based on the use of an online help group/network rather than in-person AA-style recovery, which means that the findings could diverge from those of Sawer et al. (2020) as a result of this. This is particularly pertinent given the point of Chambers et al. (2017) that online networks give people control over how they choose to present themselves – which may not necessarily align with the reality.

When considering this second finding of Sawer et al. (2020) it is helpful to consider analysis undertaken by Lund (2017) in a study which examined qualitative data drawn from interviews with 21 former substance abusers, examining their recovery process. Importantly, Lund (2017) links guilt and shame in recovery to the Christian faith, and highlights that these types of self-conscious emotions are partially socially constructed through this religion. While this highlights the importance of shame in recovery when considering those that identify as Christian or who have been brought up within Christian mindsets/worldviews, it does question the transferability of the findings to other different kinds of cultures. With this in mind, it should be noted that Sawer et al. (2020) gathered their data from participants at Alcoholics Anonymous, itself known to be a group based on Christian tradition (Douglas, 2013). Therefore, it cannot and should not be assumed that the findings of the Sawer et al. (2020) research will necessarily apply to other people who have different worldviews and beliefs based on different religious and spiritual perspectives, necessarily.

According to Abu-Baker et al. (2021) evidence-based practice is an approach that utilises both the best and latest available research, working alongside clinical expertise and drawing in the patient’s situation and values to determine the course of action for care/practice. Evidence-based research has benefits to bring to nurses in their practice (Linsley et al., 2019). Linsley et al. (2019) argue that this is more the case than ever before, as nursing roles are increasingly being expanded, requiring that they have greater knowledge. As Linsley et al. (2019) point out, this means that nurses need to be able to question their practice and interrogate the research to continually improve care. This is supported within the NMC (2018) Code, which requires that nurses offer care on the basis of the best available evidence relating to this. As argued by Ellis (2018) the drawing in evidence can help update practice and the provision of care so that it improves outcomes for service users.

As Abu-Baker et al. (2021) outline, incorporating evidence-based practice into nursing has a number of advantages for practice, which have been evidenced to show lower cost, improved quality of care, improving patient outcomes and enhancing safety. These are all good reasons for incorporating evidence into practice for nurses.

As Pooler (2014) outlines, evidence based practice is not something that is done once and then assumed to be complete. Rather, it is a continual process of working to improve practice and care (Pooler, 2014). This is important, given that a nurse’s career could conceivably span 40 or more years, and the evidence on best practice may very well change during that timeframe. Questioning what is being done and why is therefore something that needs to be done with regularity, which Pooler (2014) specifies must include identifying evidence, appraising it, acting on it and reflecting on the outcome, for the best results. However, this is not straightforward to do due to barriers that can exist hampering the use of evidence-based practice. For example, research by Li et al. (2019) on community nurses showed that while practitioners may have a positive attitude to adopting evidence-based practice, they may not necessarily have good knowledge of how to go about it. Furthermore, a lack of time and resources can make it to actually implement evidence-based practice into care, and these are further barriers that can be experienced (Li et al., 2019). Fry and Attawet (2018) also identified evidence that obstacles to evidence-based practice for nurses and midwives include a lack of time and a need for organisational and management support of this process. However, as has been demonstrated, evidence-based practice has a multitude of important benefits to bring, particularly in terms of positives for patient outcomes. Therefore, arguably nurses need to follow the NMC (2018) Code and ensure that time is made available for evidence-based practice so that these benefits can be realised for service users. Nurses should also reflect on their own knowledge and capabilities and work on personal development in this area as highlighted by Pooler (2014) to ensure that the best outcomes do indeed result from taking an evidence-based practice approach to care.

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This critical analysis of a qualitative study by Sawer et al. (2020) has shown that the research undertaken does have some flaws in terms of reliability, trustworthiness and validity. These issues arise out of the recruitment, sampling and data collection processes as well as a lack of reflection on how the authors’ own beliefs might have influenced the findings overall. Nonetheless, some support can be pinpointed for the findings elsewhere in the body of literature, meaning that the work of Sawer et al. (2020) may still be considered of use in building the evidence in this area. This is important given that evidence based practice can improve the quality and safety of care provided by nurses. Nurses may need to work to ensure that barriers to implementing evidence-based practice are overcome to ensure that these benefits can be realised in providing care to service users.

 Reference List

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Chambers, S.E., Canvin, K., Baldwin, D.S. and Sinclair, J.M.A. (2017) Identity in recovery from problematic alcohol use: A qualitative study of online mutual aid, Drug and Alcohol Dependence, 174 (1) 17-22

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Houser, J. (2016) Nursing Research, 4^th edition, London: Jones & Bartlett Learning

Kougiali, Z.G., Pytlik, A. and Soar, K. (2021) Mechanisms and processes involved in women's pathways into alcohol dependence and towards recovery: a qualitative meta-synthesis, Drugs: Education, Prevention and Policy, 28 (5) 437-453

Letts, L., Wilkins, S., Law, M., Stewart, D., Bosch, J., & Wes-Morland, M. (2007) Critical Review Form – Qualitative Studies, Hamilton: McMaster University

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Lund, P. (2017) Christian faith and recovery from substance abuse, guilt, and shame, Journal of Religion and Spirituality in Social Work, 36 (3) 346-366

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Appendix: Critical Review Form

Critical Review Form-Qualitative Studies (Letts et al., 2007)