Editor’s Note

Welcome to the thirty-seventh edition of the NEDC e-Bulletin. It is well into the New Year already, and for the National Eating Disorders Collaboration this means several new projects are on the horizon. Evidence-based practice forms the basis of all NEDC projects and research. This month’s edition explores the meaning of evidence-based practice and reflects on its importance in the prevention and treatment of eating disorders.

Contents

1. Feature Article: What is Evidence-Based Practice?
2. Interview: Evidence-Based Practice in Nursing
3. Implementing Evidence-Based Practice – Guidelines and Research Databases
4. Become an NEDC Member in 2016

Evidence-based medicine has ancient origins, but has been proving a contemporary topic of debate for clinicians, researchers, public health planners and the public. A movement towards evidence-based practice (EBP) has been gaining momentum in the field of psychology and across all major health disciplines that emphasise the importance of basing clinical practice on scientific foundation. Evidence-based Medicine, Treatment and Practice (EBM) are terms that are commonly used in discussions of best placed practice and treatment for eating disorders.

A common misconception in the application of evidence-based practice is that it is simply having knowledge of the most current research. According to a key piece of literature (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996), EBM is defined as the conscientious, explicit and judicious use of the best evidence in making decisions about the care of the patient. The American Psychological Association, continues on to describe it as “the best available research with clinical expertise in the context of patient characteristics, culture and preferences” (2006, p. 273), cited in (Levant et al., 2006).

In breaking down the meaning of these descriptions, EBM is the integration of 3 pillars; gathering of the best available research and evidence, clinical experience and expertise as well as the response and experience of the individual patient. These 3 pillars combine to create a foundation for shared decision making, meaning that the clinician and the patient jointly participate in making a health decision after discussing benefits, risks and options as well as considering the experience of the individual (Hoffmann, Montori & Del Mar, 2014). In the absence of shared decision making, medical tyranny can result.

In collating the most relevant research, the quality and strength of a piece of research is key to sound EBM. In working through the process of discerning evidence and research, challenges may arise around research reliability (Wilton & Slim, 2012). The majority of guidelines draw to a consensus on using a grading system, with the aim of guiding clinicians about the strength and current recommendations of a therapeutic approach. The strength of evidence in descending order;

Multicenter methods

• randomized
• double-blind
• placebo controlled trails

Single-centre

• randomised trial
• open label or placebo

Systematic Review

• prospective or observational studies that address patient outcomes

Physiologic Studies

• in the absence of clinical trials
• published opinions of experts and case series

(Guyatt,Haynes & Jaeschke 2000).

The next pillar, clinical experience and expertise, is key within the field of eating disorders. There is often much discussion on the importance for an individual to have access to experienced practitioners in the treatment of eating disorders. This is primarily due to the complex nature of the disorder, an understanding expertise in treatment is key to the recovery of an individual.

The combination of these aspects helps to provide high level patient care through a holistic and person-centred approach. The importance of working with the individual needs of a client is commonly reflected on in treatment of eating disorders literature. This overlaps with the importance of taking into consideration the experience of the patient, which in application is one of the more poorly mapped out and most challenging steps to apply (Montori, Brito & Murad, 2013). The development of patient-centred communication skills is an area that could further advance best patient care, thus additional research on this pillar could be beneficial to the treatment of eating disorders.

References

Guyatt, G.H, Haynes, R.B & Jaeschke, R.Z (2000) Users’ guides to the medical literature: XXV. Evidence-based medicine: principles for applying the users’ guides to patient care. JAMA 2000;284:1290Y1296. Cited in Wilton, N. K., & Slim, A. M. (2012). Application of the principles of evidence-based medicine to patient care. Southern Medical Journal, 105(3), 136–43.

Levant, R. F., Barlow, D. H., David-, K. W., Hagglund, K. J., Hollon, S. D., Johnson, J. D., … Directorate, P. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285.

Montori, V,M., Brito, J.P & Murad, M.H.(2013) The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA

Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: What it is and what it isn’t - It's about integrating individual clinical expertise and the best external evidence. British Medical Journal, 312(1), 71–72.

Wilton, N. K., & Slim, A. M. (2012). Application of the principles of evidence-based medicine to patient care. Southern Medical Journal, 105(3), 136–43.
 

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We spoke with Elaine Painter about the implementation of evidence-based practice in the field of nursing. Elaine is a valued member of the NEDC with a wealth of knowledge and experience. Elaine has a general and mental health nursing background and a Masters in Primary Health Care. Since 2002, Elaine has held the position of Queensland’s statewide team manager for the Eating Disorders Outreach Service.

Evidence-Based Practice is implemented across a range of health disciplines. How do you apply EBP within the field of nursing?

A primary goal for nurses is to keep patients medically safe, whilst maintaining a therapeutic relationship. The clinical team use evidence-based medical literature to inform the safe management of refeeding and medical stabilisation. Nurses play a key role in the team during this stage, by skillfully monitoring physical parameters, assisting in the safe provision of nutrition and maintaining the rights of patients in order to preserve the established therapeutic relationship.

Nurses have a responsibility to up-skill themselves on current literature, to assist with their understanding of the medical and psychological impacts of starvation on an individual. The Minnesota Starvation Experiment, conducted from 1944-45 gives an excellent overview of starvation on the healthy brain and is essential reading for health practitioners working in this area. Nurses also benefit from stories of recovery and the types of therapeutic interventions that are most likely to help the person to engage in recovery.

What are the benefits of EBP in nursing?

Evidence- based knowledge forms the basis of established protocols in Queensland and allows nurses to medically treat and safely manage eating disorder patients in an inpatient setting. There are several benefits to implementing evidence based practice in nursing. Evidence based practice:

• Enables treatment interventions to be tailored to individual needs, whilst maintaining medical safety
• Establishes a good understanding of eating disorders, minimising the incidence of counter transference and stigmatisation, and paving the way for the development of therapeutic relationships
•  Encourages nurses to keep abreast of constantly updated evidence and best practice.

Based on your experience, what do you perceive to be the challenges faced when implementing EBP?

A major challenge faced when implementing evidence-based practice in the treatment of eating disorders is the balance between a patient’s right to autonomy and a nurse’s duty of care to keep patients safe. At times, these ideals can conflict. To ensure best practice, I always encourage nurses to consult with their team and nurse manager when making difficult decisions.

We have spoken a lot about treatment, do you think EBP has its roots in prevention as well?

Evidence-based practice certainly has relevancy in both the prevention and treatment of eating disorders. Nurses are definitely in a position to identify an eating disorder early on. It is quite common that patients are admitted to hospital for a separate diagnosis, but also present with eating disorder symptoms. The perinatal period is recognised as a particular trigger for disordered eating behaviours. Having knowledge of these symptoms can be invaluable to the early identification of an eating disorder.

Nurses are in contact with patients across a broad spectrum of health settings – community care, dental practices, general practices and hospitals. This extensive interaction provides several opportunities for nurses to recognise early signs and symptoms of eating disorders in patients. An early identification can enable early intervention and treatment of an eating disorder.

Shared decision making between a patient and health professionals is a key aspect of EBP, what is your experience with this?

Shared decision making between a patient and health professionals is essential. When a patient with an eating disorder is admitted to hospital, they are considered at risk and safety is the primary focus. Because of this, initial decisions are often made by the medical team, with the view of moving towards shared decision making. It is important that nurses adopt a ‘narrative approach’ in communicating with patients, where their rights are made clear throughout the treatment process.

Adopting a shared decision making approach enables individuals with an eating disorder to feel a part of a team and somewhat in control of their treatment. Dependent on circumstances, families should be kept informed and involved in the decision making process. Hence, shared decision making should be a balance between the patient, their family and health professionals.
 

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Evidence-Based Practice is an interdisciplinary approach to patient care that is being increasingly implemented across a range of health disciplines. EBP encourages the use of current and best available research, whilst also applying clinical experience and considering individual patient needs. Given such, implementation can pose several challenges (Wilton & Slim, 2012).

Access to reliable evidence has been recognised as a challenge faced by health professionals (Wilton & Slim, 2012). The scope and complexity of research available is often overwhelming and difficult to appraise, making this a common barrier to implementing EBP (Nelson, Steele & Mize, 2006; Spruce, 2015). The development of evidence-based clinical guidelines and increased awareness of research databases may support professionals in implementing EBP (Deane, Crowe, King, Kavanagh & Oades, 2006).

Based on the above findings, the NEDC have identified reputable guidelines and evidence databases to assist health professionals in discerning eating disorders evidence.

Guidelines

• Australian Clinical Practice Guidelines – This is an Australian portal providing access to current evidence-based guidelines. In 2014, the Royal Australian and New Zealand College of Psychiatrists published clinical practice guidelines for the treatment of eating disorders. This publication can be accessed through the search portal.
• National Guideline Clearinghouse - This is an American based tool providing access to clinical practice guidelines on a range of disorders, including eating disorders.

Research Databases

• The Cochrane Library – The Cochrane Library is considered ‘gold standard’ in regards to its level of evidence. This database provides peer reviewed systematic reviews.
• Journal of Eating Disorders – This journal provides open access to peer reviewed research articles on the epidemiology, prevention and treatment of eating disorders.

References

Deane, F. P., Crowe, T. P., King, R., Kavanagh, D. J., & Oades, L. G. (2006). Challenges in implementing evidence-based practice into mental health services. Australian Health Review, 30 (3), 305-9.

Nelson, T. D., Steele, R. G., & Mize, J. A. (2006). Practitioner attitudes toward evidence-based practice: Themes and challenged. Administration and Policy in Mental Health and Mental Health Services Research, 33(3), 398-409.

Spruce, L. (2015). Back to basics: Implementing evidence-based practice. Association of Operating Room Nurses, 101(1), 106-14.

Wilton, N. K., & Slim, A. M. (2012). Application of the principles of evidence-based medicine to patient care. Southern Medical Journal, 105(3), 136–43.
 

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Becoming a member is free, but the participation and support of our members is invaluable! If you are not yet a member, we would love to have you involved.

The NEDC has just finished a productive and successful 2015 and has another exciting year ahead. As we enter 2016, it is the perfect time to become a member of the NEDC.

Here is a snapshot of some of our members’ experiences with the NEDC to date:

“As someone who is both a scientist, and managing with a chronic eating disorder, I am constantly searching for information that helps me (and my support team) to understand and manage my health. The NEDC website is a fantastic online platform that allows me to have access to the latest evidence-based information and thinking on how and why eating disorders develop and how best to treat them. I'm reassured to know that a significant amount time, effort, and funding is being invested into ED research and practice” - Lauren

 “I’ve been fortunate to have been involved with the NEDC over the past 6 years and have been truly impressed by the way the dialogue seems to have evolved during that time. Clinicians, carers and consumers now seem to have a greater understanding of one another’s perspective and experience, which has led to some collaborative approaches and innovation that was desperately needed in this sector. Personally, I have found that my lived experience has been valued and my expertise appreciated, I have had the opportunity to contribute to some interesting projects, expand my networks and access some great information.” - Kathy Logie

“NEDC is a rich resource for those of us with an interest in eating disorder awareness, prevention and intervention. The NEDC website is often my first-stop for information on events, resources for projects, access to current research news and connection to colleagues.” - Elysa Roberts

Why join?

The NEDC membership is a mutually beneficial relationship providing access to a collaborative environment. Becoming an NEDC member enables shared learning, networking and access to evidence-based research. NEDC members are valuable partners and key contributors to the development of improved approaches to prevention and treatment of eating disorders in Australia. With the assistance of our members, it is the aim of the National Eating Disorders Collaboration (NEDC) to help ensure:

1. Eating disorders are a priority mainstream health issue in Australia
2. A healthy, diverse and inclusive Australian society acts to prevent eating disorders
3. Every Australian at risk has access to an effective continuum of eating disorders prevention, care and ongoing recovery support

To become a member, simply fill out our online application form.

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