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This chapter recounts the emergence of orthodox medicine. Medical care and medical education emerged as a scientific enterprise in the last quarter of the nineteenth century, with the help of the advances in germ theory, anti-septic techniques, hygiene, anesthesia, and surgery. By the turn of the twentieth century, orthodox medicine succeeded in eliminating a number of unconventional therapies, challenging philosophy-based practices through “evidence-based medicine” (EBM). Biomedicine treated disease as a biochemical phenomenon that could be classified into discrete categories of causation using standardized, objectified, and technologically validated biochemical treatments and mechanisms. This led to the evolution of clinical trials, such as the blind or masked (placebo) assessment; the double-blind, placebo-controlled randomized clinical trial (RCT); and the so-called Cochrane Collaboration, which incorporated meta-analysis to support RCT's predictions.

Evidence-based medicine is clinical care guided by the best-available scientific evidence generated from clinical research linked with the clinical acumen of the individual physician. It is built upon the principles of clinical epidemiology, and requires the physician to collect valid, reliable, and complete data from the patient, and in turn, use external evidence from clinical research to guide the patient’s care. Ways have been developed to help doctors deal with the explosion in the volume of clinical literature, evaluate the quality of individual studies, synthesize evidence from multiple studies addressing the same clinical question, and judge the applicability of the literature to the individual patient at hand. Methods have also been developed for the creation of clinical practice guidelines, but such guidelines can be undermined by financial conflicts of interest. The greatest challenge, however, is in getting physicians and patients to apply the evidence in clinical practice.

This chapter deals with the development of knowledge which is to be applied in order both to understand what works and to show what has worked — with the improvement of practice and policy and with claims for competence in the development of solutions to the problems of contemporary life — the policy domain, and in the implementation and execution of those policies, the practice domain. It refutes the arguments presented in particular by the Cochrane Collaboration for health, but also with some qualifications endorsed by the Campbell Collaboration in relation to general policy, that is meaningful to construct a hierarchy of modes of production of evidence with the meta-analyses of randomized controlled trials occupying the highest position in that hierarchy. It then considers the issue of variables versus cases by taking forward the complex realist methodological arguments developed in Chapter One.

By the end of this chapter, you should understand… ● The range of possible sources of information about medicines ● Their positive and negative characteristics ● Some trustworthy sources of evidence ● The role of medicines information departments ● Some basic principles of critical analysis of evidence ● How the British National Formulary (BNF) is structured ● How to read a BNF monograph ● A selection of terms used in the literature about medicines…. While nurses will not usually be selecting medicines, they still need information to make the best use of the medicines prescribed for their patients. Information of all kinds is much more readily available today than it was a generation ago when the authors were students, but much of it is of low quality and today’s student must learn to test the quality of the evidence offered to see if it can be relied upon. In all fields of healthcare it has become usual to insist that practice must be evidence based. This is very desirable, but it begs the question—what is evidence? This chapter will examine some of the sources of evidence about medicines that are available and give some guidance on their reliability. Later, there will be an introduction to critical analysis of sources, and a description of some of the key terms used in evaluating clinical evidence about medicines. Sources of information may be conveniently divided into two main types—people and publications. It is natural that many healthcare professionals should rely upon their mentors and instructors to supplement the knowledge they gain in formal teaching. Indeed, for many years much of the practical information about medicines that junior doctors received came from participation in ward rounds under the tutelage of a consultant. In medical school they learned some general pharmacology, but the actions of many drugs were learned following graduation (Maxwell and Walley, 2009 ) The same will be true for nurses, and it will continue to be true throughout their careers. New medicines will come into use, and nurses will have to learn about them. It is therefore important to realize that pharmacology will be a lifelong study and does not end with registration as a nurse.

Healthcare delivery has been transformed over the past decades with a rapid expansion in the demand for care driven by demographic changes, technological innovation, and increasing consumer expectations. This transformation has in turn had a profound impact on the roles of health professionals in general and nurses in particular. The number of patients with multiple pathologies and complex long-term nursing care needs has also escalated, with pressure for rapid throughput in acute hospital care settings resulting in shorter lengths of stay and greater emphasis on care in the community. To meet growing demand, boundaries between the roles of health professional have blurred, with nurses now undertaking activities previously performed by doctors, and unqualified staff undertaking activities previously performed by registered nurses. These changes are all taking place in the context of economic turbulence. The shift of nursing to an all-graduate profession reflects the recognition that the future role of a registered nurse will carry greater responsibility and autonomy than ever before. The expectations of every student and qualified nurse must therefore also change in relation to the knowledge and skills that they need to deliver expert nursing interventions and clinical leadership. The next generation of nurses will increasingly lead and coordinate the care of a range of patients and clients, supervising and supporting unqualified or lay carers and referring patients to other health professionals when appropriate. As one of this new generation of qualified nurses, it is important that you are able to demonstrate expertise in the fundamentals of nursing practice. You must be equipped with the knowledge and skills needed to enable you to:…● understand the common health conditions that can affect adults; ● understand the pathophysiology of these common health conditions, and the physical and psychosocial needs and problems that result from them; ● recognize your key role in managing the problems and challenges that patients face; ● ensure that your nursing interventions are evidence-based; ● demonstrate competent assessment skills, critical thinking, and problem-solving skills to make informed clinical nursing decisions in collaboration with the patient and other team members; ● adopt an enquiring and questioning approach, and be confident in accessing and interpreting evidence to inform your choice of nursing interventions….