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International Journal of Nursing Practice 2014; 20: 681–682
TIPS AND TRICKS
Nursing by numbers Nurses are acutely aware of numbers; they dominate much of day-to-day practice and management of the nursing workforce. It occurs in the political debates and policy machinations of elected members and public servants to preserve or increase the nurse/patient ratio. It occurs at the organizational level as directors or managers or the number of staff for a unit, ward or clinic or community centre. Clinicians and managers are acutely aware of the numbers and their implications. On one end of the scale, in many countries, nurses have gone on strike out of concern about risks to patient health and safety due to staff/patient ratios. Such events seek to raise the public profile of nurses’ concerns for public safety and well-being, as well as promote and advocate for a higher quality of care that would be possible with better ratios. Not all countries use ratio-based systems for staffing, and many countries have varied models depending on the nuances of local jurisdiction. At the other end of the scale, while numbers are just one measure of acuity, clinicians in their day-to-day practice are very aware of numbers, particularly in relation patient allocation. I have vivid recollections of agency work, arriving for a 07:00 start one particularly cold winter morning to find that the allocation had resulted in me receiving the most dependent patients, at the same ratio as those permanent staff who had patients with much lower dependency levels. Once I realized there was an ongoing pattern in the allocations at this particular hospital, I stopped offering to do shifts there. The nuances of ward culture express themselves in numbers! How many drips, drains, showers, turns, wound dressings, education sessions, transfers, discharges, medication rounds and sets of vital signs one has to do are mapped, planned in advance and factored in to the working day to help ensure an organized, structured approach to nursing care delivery. Yet there is one area where many nurses are not particularly adept with numbers that can enhance patient education and facilitate better decision making about which intervention to deliver for specific outcomes of doi:10.1111/ijn.12383
benefit to specific patient groups. I speak of course about the ‘number needed to treat’ (NNT). The NNT remains a curiously medicocentric characteristic of evidence-based health care. While I am not sure why that is the case, the provision of evidence for nursing practice is often equally characterized by a lack of an NNT calculation. Journals tell us whether an intervention is statistically significant or not, and what the confidence interval is, but NNT provides a different, some would say more patient specific, measure of effect. How to calculate and interpret the NNT has been addressed in a previous CNCF ‘Tips and Tricks’ column. However, this is not a call for all nursing care practitioners to learn how to calculate NNT. What we need are highquality sources of evidence that provide the NNT for nursing relevant interventions and for these to be widely available for the whole profession across all topics of relevance to the provision of nursing care, including policy, practice, administration and management. A number of innovations are underway right now that will assist in making NNT from good, reliable evidence more available and accessible to decision makers at all levels of policy and practice related to nursing care. This is confounded slightly by NNT not being readily available in the Review Manager software; however, as illustrated, authors of Cochrane reviews are increasingly aware of the benefits to policy and practice of providing summative data on their outcomes. We appreciate that many researchers, health practitioners, and funders might like to use, for example, an Absolute Risk Reduction (ARR), or even, despite its many associated difficulties, Number Needed to Treat (NNT). In future updates, we will aim to include tables showing the data used to calculate estimates of effect and standard errors of studies included in meta-analyses which have been conducted using the generic inverse variance option.1 The utility of these estimates of effect is not limited to reviews of the effects of interventions; overviews of © 2014 Wiley Publishing Asia Pty Ltd
682
reviews and the GRADE system provide for evidence, and tables give practical summary numbers that can be used to inform patients and policy makers as effectively as practitioners on the strength of evidence for practice. The GRADEprofiler software is used by Cochrane Review Groups to create summary of findings tables. For each outcome of interest, the GRADEprofiler software includes the pooled estimate of effect (traditional result of meta analysis), the quality of the evidence specific to the outcome, as well as an ‘assumed’ and an ‘illustrative’ comparative risk with its 95% CI. Knowing the assumed risk associated with an outcome and being able to communicate it in numbers per 1000 patients may not sound like a big change, but when you are a patient, that kind of information might just change your preferred option for treatment. For nurses, the difference is in the clarity of the evidence to support or inform decision making. Choosing between interventions for practice, or including in a guideline or patient care pathway based on a P value and a 95%CI, is not entirely intuitive. However, choosing between two preventative strategies for acute exacerbations of asthma when one has an assumed risk (or benefit)
© 2014 Wiley Publishing Asia Pty Ltd
Nursing by numbers
of 2/1000 compared with an intervention that has an assumed risk (or benefit) of 46/1000 might just provide nurses with the type of information that clearly and succinctly links evidence to practical outcomes. Collecting evidence in to online libraries such as the Cochrane Library is the first important step. Transforming those libraries into forms that help make the evidence clear and accessible is the next. If nurses want good, clear indications of the effectiveness of nursing care strategies, therapies and interventions, joining the Cochrane Nursing Care Field and identifying existing Cochrane reviews of relevance to nursing, or working with Cochrane Review Groups to enhance the utility of new reviews to nursing, are sound professional strategies with short- and longterm benefits for those involved and the nursing profession as a whole.
REFERENCE 1 Gillespie LD, Robertson MC, Gillespie WJ et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012; (9): CD007146. DOI: 10.1002/14651858.CD007146.pub3.
Copyright of International Journal of Nursing Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
International Journal of Nursing Practice 2014; 20: 681–682
TIPS AND TRICKS
Nursing by numbers Nurses are acutely aware of numbers; they dominate much of day-to-day practice and management of the nursing workforce. It occurs in the political debates and policy machinations of elected members and public servants to preserve or increase the nurse/patient ratio. It occurs at the organizational level as directors or managers or the number of staff for a unit, ward or clinic or community centre. Clinicians and managers are acutely aware of the numbers and their implications. On one end of the scale, in many countries, nurses have gone on strike out of concern about risks to patient health and safety due to staff/patient ratios. Such events seek to raise the public profile of nurses’ concerns for public safety and well-being, as well as promote and advocate for a higher quality of care that would be possible with better ratios. Not all countries use ratio-based systems for staffing, and many countries have varied models depending on the nuances of local jurisdiction. At the other end of the scale, while numbers are just one measure of acuity, clinicians in their day-to-day practice are very aware of numbers, particularly in relation patient allocation. I have vivid recollections of agency work, arriving for a 07:00 start one particularly cold winter morning to find that the allocation had resulted in me receiving the most dependent patients, at the same ratio as those permanent staff who had patients with much lower dependency levels. Once I realized there was an ongoing pattern in the allocations at this particular hospital, I stopped offering to do shifts there. The nuances of ward culture express themselves in numbers! How many drips, drains, showers, turns, wound dressings, education sessions, transfers, discharges, medication rounds and sets of vital signs one has to do are mapped, planned in advance and factored in to the working day to help ensure an organized, structured approach to nursing care delivery. Yet there is one area where many nurses are not particularly adept with numbers that can enhance patient education and facilitate better decision making about which intervention to deliver for specific outcomes of doi:10.1111/ijn.12383
benefit to specific patient groups. I speak of course about the ‘number needed to treat’ (NNT). The NNT remains a curiously medicocentric characteristic of evidence-based health care. While I am not sure why that is the case, the provision of evidence for nursing practice is often equally characterized by a lack of an NNT calculation. Journals tell us whether an intervention is statistically significant or not, and what the confidence interval is, but NNT provides a different, some would say more patient specific, measure of effect. How to calculate and interpret the NNT has been addressed in a previous CNCF ‘Tips and Tricks’ column. However, this is not a call for all nursing care practitioners to learn how to calculate NNT. What we need are highquality sources of evidence that provide the NNT for nursing relevant interventions and for these to be widely available for the whole profession across all topics of relevance to the provision of nursing care, including policy, practice, administration and management. A number of innovations are underway right now that will assist in making NNT from good, reliable evidence more available and accessible to decision makers at all levels of policy and practice related to nursing care. This is confounded slightly by NNT not being readily available in the Review Manager software; however, as illustrated, authors of Cochrane reviews are increasingly aware of the benefits to policy and practice of providing summative data on their outcomes. We appreciate that many researchers, health practitioners, and funders might like to use, for example, an Absolute Risk Reduction (ARR), or even, despite its many associated difficulties, Number Needed to Treat (NNT). In future updates, we will aim to include tables showing the data used to calculate estimates of effect and standard errors of studies included in meta-analyses which have been conducted using the generic inverse variance option.1 The utility of these estimates of effect is not limited to reviews of the effects of interventions; overviews of © 2014 Wiley Publishing Asia Pty Ltd
682
reviews and the GRADE system provide for evidence, and tables give practical summary numbers that can be used to inform patients and policy makers as effectively as practitioners on the strength of evidence for practice. The GRADEprofiler software is used by Cochrane Review Groups to create summary of findings tables. For each outcome of interest, the GRADEprofiler software includes the pooled estimate of effect (traditional result of meta analysis), the quality of the evidence specific to the outcome, as well as an ‘assumed’ and an ‘illustrative’ comparative risk with its 95% CI. Knowing the assumed risk associated with an outcome and being able to communicate it in numbers per 1000 patients may not sound like a big change, but when you are a patient, that kind of information might just change your preferred option for treatment. For nurses, the difference is in the clarity of the evidence to support or inform decision making. Choosing between interventions for practice, or including in a guideline or patient care pathway based on a P value and a 95%CI, is not entirely intuitive. However, choosing between two preventative strategies for acute exacerbations of asthma when one has an assumed risk (or benefit)
© 2014 Wiley Publishing Asia Pty Ltd
Nursing by numbers
of 2/1000 compared with an intervention that has an assumed risk (or benefit) of 46/1000 might just provide nurses with the type of information that clearly and succinctly links evidence to practical outcomes. Collecting evidence in to online libraries such as the Cochrane Library is the first important step. Transforming those libraries into forms that help make the evidence clear and accessible is the next. If nurses want good, clear indications of the effectiveness of nursing care strategies, therapies and interventions, joining the Cochrane Nursing Care Field and identifying existing Cochrane reviews of relevance to nursing, or working with Cochrane Review Groups to enhance the utility of new reviews to nursing, are sound professional strategies with short- and longterm benefits for those involved and the nursing profession as a whole.
REFERENCE 1 Gillespie LD, Robertson MC, Gillespie WJ et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012; (9): CD007146. DOI: 10.1002/14651858.CD007146.pub3.
Copyright of International Journal of Nursing Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
