實證護理之系統性文獻查證

「實證護理」的內涵與實證醫學在定義上有某種程度的關聯性，其強調要具有臨床專 家的實務經驗，並運用適當的資源以及了解病人的個人喜好，加上經系統性文獻查證 而得到有證據的研究知識，最後，能將實證研究結果回饋到臨床上，產生以研究為基 礎的臨床實務，以提昇病人的照顧品質，其中系統性文獻查證扮演著極重要的角色。 系統性文獻查證有清楚的九個步驟，其與傳統敘事性文獻查證不同，對於研究品質的 評量，可以從「研究品質的優良程度、研究結果於臨床的適用性以及研究結果對病人 的意義」等三方面進行批判性評價，其中研究品質可依證據的強度而分為五個層級， 所以，實證護理最好顧及隨機控制試驗之系統性文獻查證及統合分析。由於護理研究 的典範，包括量性與質性研究，量性研究重視隨機對照試驗，並對一系列之研究文獻 進行統合分析；而質性研究品質的批判，不似量性研究有一定的評量標準，而應依其 研究的哲理、目的及知識植根的基礎作判斷，並從質性研究文章的『確實性、推廣性 、信賴性以及確認性』的嚴謹度去批判質性研究的品質，因此，實證護理應顧及質性 研究與量性研究對護理專業發展的價值，此是實證護理未來發展的一項反思與挑戰。 In practicing evidence-based nursing, a nurse has to decide whether the evidence is relevant for the particular patient. The incorporation of clinical expertise should be balanced with the risks and benefits of alternative treatments for each patient and should take into account the patient's unique clinical circumstances including preferences. Systematic review of literature is an important element of evidence-based nursing. There are nine explicit steps in the procedure of systematic review. Systematic review differs from the traditional narrative review in that systematic, explicit methods are used to identify, assess and synthesize the information obtained. Systematic reviews use rigorous methods to reduce bias and can provide reliable summaries of relevant research evidence. The hierarchy of evidence used has five levels and emphasizes the evidence about the effectiveness of interventions. Therefore, it is better that evidence-based nursing should be based on systematic reviews of randomized controlled trials, as well as meta-analysis. Critical appraisal is necessary in systematic reviews to ensure that they are conducted to rigorous standards. The purpose of critical appraisal for evidence-based practice is to decide whether the quality of a research study is good enough for the results it provides to be used to answer a question posed by a health care practitioner or patient. Critical appraisal can be broken down into three distinct but related parts which: (1) Whether the quality of the study is good enough; (2) The application of the study result in my setting; (3) What the results mean for my patients. The paradigms of nursing research are qualitative and quantitative research. Meta- analysis is a statistical technique used in systematic reviews and it must be a rigorous process in quantitative research. It can answer two main questions about an intervention: “ Does this intervention have a beneficial ( or harmful) effect?” and if so, “ What is the size of that effect?” No algorithmic criteria can be produced that can unproblematically judge the quality of qualitative research. It is necessary to avoid a checklist approach to evaluating qualitative research. The quality of qualitative research is assessed based upon a critical assessment of how well the issues of credibility, transferability , dependability and confirmability are addressed. Therefore, by combining qualitative and quantitative approaches, the ability to produce applicable clinical evidence is greatly increased in future.