Editor’s Note: The opinions expressed in this blog post are solely those of the author.

“Everyone needs a place of safety-somewhere that bathes us in warmth and reassurance. Somewhere – where the door is always open and when it can be closed to keep us secure and safe from harm. Sometimes a smell or a taste will take us back to childhood. A simple dish can become a talisman - warding off the perils of the world outside. We all find ways to build our strongholds. Life can be so bleak without the venison of shelter.”

This episode dealt with Lucille having a library search done regarding Mrs. Patricia Williams health issues, Sister Hilda and Dr. Turner try to help a young woman in a mental health crisis, a new curate pastor boards at Nonnatus House, Sister Julienne becomes aware of Sister Monica Joan’s struggles with her faith, Shelagh takes on a tutoring role of student nurse-midwives and sees a potential funding source that could benefit Nonnatus House, Sister Francis’ tooth ache derails Cyril’s romantic gesture of a picnic by the water for Lucille but they have an alternate date and end up taking a new step towards committing their love.

What I want to focus my post on stems from Lucille’s search for evidence. As a modern day midwife in the time of uncertainty with issues surrounding the pandemic, climate change, rising morbidity with health issues such as weight, blood pressure, diabetes—I see science as our shelter and it is my stronghold. I teach in two different graduate level courses that help guide our nurse practitioner and doctoral practitioners: Evidence Based Practice (EBP) and Epidemiology and Biostatistics (Epi & Biostats).

In EBP we talk about the triad of a) searching for the current best evidence, b) integrating clinical expertise, and c) inclusion of patient preferences based on their values and expectations in a shared decision making model of care. In the show I smiled as Lucille was doing exactly what we discussed that week in our course. The Fall term was just beginning and Lucille along with our students were on a mission to use their skills to assess the relevance, quality, and application of evidence to clinical practice in an effort to improve the safety and quality of healthcare.

Many people talk about the Evidence Pyramid which thinks of the exploration of information within a hierarchical strategy. There can be many complexities within clinical decision making and I have at times found the pyramid too simplistic – instead I like the Evidence House as in their strategy the knowledge is placed in relationship to each other and the audience being served. It links the method to the goal of the primary audience. You want to think did the researcher use the right design to answer their question.

In Call the Midwife they have done a fabulous and realistic job of showing the exploration of information/research. The characters have used varied study designs. Dr. Turner is a good example from the thalidomide storyline of reading about a case study and this week Lucille is exploring descriptive epidemiological study designs. A descriptive epidemiological study design is used to describe the distribution of health-related states and events. The designs focus on describing the person, time, and place of a health-related state or event. They do not test hypotheses, but they can identify relationships between variables and generate hypotheses that can be tested with more rigorous study designs.

Descriptive epidemiological studies include case reports, case series, cross-sectional, and ecological studies. Case-reports describe in detail a single case of a health-related state or event. They describe an unusual or a new type of disease or injury. Case-series describes a small number of cases of a disease, illness, injury, or symptoms. This is how we began to read about COVID 19—it began with exploring a cluster of patients who suffered from, at that time, a mysterious infection. Cross-sectional studies describe the characteristics of a group of people and variables such as health conditions, health behaviors, and risk factors assessed at the same time. Cross-sectional studies provide important information about the prevalence of diseases, risk factors, and health behaviors. They also identify potential relationships between risk factors, behaviors, and health outcomes, and generate hypotheses that can later be tested in more rigorously designed studies.

Then there are analytic epidemiology studies which explore the 'why' or 'how' of health-related events and they are classified into three categories: A) experiments, B) observational studies, and C) systematic reviews.

• A) Experiments include randomized and nonrandomized experiments. In randomized controlled trials (RCTs) there is an intervention and there is always a comparison group. A key feature of an RCT is that study participants are randomly assigned to the study groups. Nonrandomized experiments are similar to experiments but lack the important feature of the randomization of participants to the study groups.
• B) Observational studies cohort and case-control studies. In cohort studies, a group of people are followed over a period of time to determine who develops the health-related events that are being studied and the risk factors for the disease or condition. Case-control studies compare a group of people who already have experienced a health-related event or disease (the 'cases') and compare them to people who have not experienced the event or disease (the 'controls'). The groups are compared to determine whether certain exposures or risk factors are associated with the health-related event or disease. In case-control studies we look backwards—or retrospectively. They are a lower level of evidence but they are so important as you explore potential causes of outbreaks and epidemics.
• C) Systematic reviews are studies of studies and they combine and synthesize the results of multiple studies. This process entails exploring for similar studies on a clearly defined question and then appraising that research and summarizing the effects of that intervention—commonly by using something called meta-analysis techniques. Meta-analysis is a statistical calculation to combine the results of several studies about the same outcome, to explore the overall impact of that intervention or treatment. Systematic reviews are considered to be at the top of the evidence pyramid and to be the strongest level of evidence. A systematic review can be qualitative or quantitative. A quantitative review involves including studies that have numerical data while a qualitative review involves including studies or data from observation, interviews, or verbal interactions and focuses on the meanings and interpretations of the participants. These can include focus groups, interviews, observations and diaries.

So thank you Call the Midwife for showing multiple examples of varied designs for our students to watch and enjoy!! We can pull the show into classes and discuss and learn.

“The world is not as bleak or as vast as we imagine. We are stronger than we think and less alone. Other people are our armor and our barricades -- they are our place of safety. Too often we say ‘we are only human’ as though humanity is a small thing, a frail state, something feeble and constrained. But to be human is to embrace all the power that there is. It is not always easy but it can be so very beautiful. And so we grow and we nurture … we protect and we accept. We listen, we witness, we learn, and we love.”

RESOURCES

Davies, B., & Logan, J. (2022). Reading research: A user-friendly guide for health professionals, (7th ed.). St. Louis, MO: Mosby. ISBN: 978-0-323-75924-3

Melnyk, B., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer Health.