the 46th patricia chomley memorial oration 2012 - Royal College of ...

suggest that both these professions have made a very significant contribution to broadening theconcept from that adopted by medicine with its focus on effectiveness of treatments assessed, quiterightly, by randomised controlled trials (RCTs). Given the scope of nursing and midwifery practice,we had other clinical questions that required answers in terms of available evidence and these canbe best answered by research designs other than RCTs. Australia, through organisations such as theJoanna Briggs Institute and its international network of collaborating centres now numbering wellover 60 across all continents, has provided international leadership and practical support in thisdevelopment. This isn’t because other health care professions haven’t taken up the concept, but itseems to be taking longer to embed across the board or they have been later adopters than us.The most measurable evidence of the extent of the uptake of evidence-based practice by nursingin this country lies in its widespread incorporation into nursing policies and the modification ofprotocols to align with current evidence. These policies and protocols have translated the evidenceto facilitate its application. But the key question is: Is this evidence being applied to meet individualsituations and needs? Evidence-informed practice has a triangular base: the best evidence currentlyavailable, professional judgement and expertise, and, at the peak of the triangle, the individualreceiving the care. To my knowledge we don’t yet have a solid base of evidence that indicates theextent to which individualised application is happening, although I’m sure we could all provideanecdotal evidence either in support or otherwise.What follows is an example of individualised application in practice. But first, some contextualinformation. Despite laboratory evidence that fever aids the body’s response to fighting infection,24the medical research literature is replete with references to the objective of ‘fever clearance’ inchildren. 25, 26 Therefore fever must be ‘treated’ as if it was the disease i.e. all efforts must be made toget the child’s temperature down to normal. That is not to say that all medical practitioners hold thisview, but judging by the advice and prescriptions given by GPs, many do. A number of course mayfeel pressured by parents influenced by very cleverly targeted advertising, to prescribe antipyretics,as with antibiotics. Epidemiological evidence is also now appearing that exposure to acetaminophen(paracetamol) in the intrauterine environment, infancy, childhood and adolescence is associated withan increased risk of asthma. 27, 28 So the currently available evidence is telling us to minimise as muchas possible the administration of antipyretics. This advice is, however, complicated by the fact thatthese febrile children may well be in pain or in real discomfort associated with their illness and soneed analgesia – managed by the same drug – along with other non-pharmacological care.A two year old boy is admitted to hospital following a diagnosis of pneumonia. He is miserable, noteating, doesn’t want to be cuddled, etc. He is ordered, among other medications, analgesia. Thegraduate nurse administers the medication and then takes time to explain to the mother that thishas been given to relieve her child’s pain/discomfort, not to bring his temperature down. She furtherexplains, in non-technical terms, the role of fever in fighting his infection and why the hospital had10 RCNA The 46th Patricia Chomley Memorial Oration 2012