Using action research to construct national evidence-based nursing care guidance for gerontological nursing

Aim. This paper explores the development of a low‐cost, involving methodology for constructing nursing‐focused evidence‐based national care guidance, known as Best Practice Statements, the intended users of which are gerontological nurses practising throughout Scotland. Design. The Best Practice Statement construction methodology forms one cycle in a five‐year longitudinal action research study that aims to achieve evidence‐based nursing, facilitate professional networking to support practice development and promote the principles and practice of gerontological nursing. Achieving these aims involved designing a virtual Practice Development College. Methods. A Community of Practice comprising practising gerontological nurses, expert advisors, academic teaching and research nurses collaborated in face‐to‐face meetings and in the virtual Practice Development College to delineate and refine the procedural model for Best Practice Statement construction. Focus groups, telephone interviews, analysis of on‐line archives and documentary outputs formed the analytic dataset. Results. Qualitative analysis indicated that, from the perspective of the community of practice, the emerging methodology facilitated the melding of knowledge sources reflecting the dominant evidence hierarchy with other forms of evidence valued by gerontological nurses, in the Best Practice Statement. Relevance to clinical practice. Current methods of care guidance construction rarely address the concerns of nurses and the evidence from which guidelines are developed is narrowly defined with regard to inclusion and acceptability. In contrast this model focuses on nursing issues, embraces a wider definition of evidence and ensures that the published Best Practice Statements are credible and achievable in gerontological practice, where they are tested and refined as an inherent aspect of the development process.     

Recipe for success: stories of evidence-based practice implementation

Through a collaborative partnership with administrators at a university, nurse leaders at a local hospital worked to create a culture in which nurses could provide evidence-based practice (EBP). The Best Practice Series was started, and two participants' experiences of implementing EBP in their units are described with encouraging results.     

Implementation of evidence‐based nursing practice for diabetic patients: An Iranian experience

Evidence‐based nursing is recognized as an indicator of quality in nursing practice, a basis for accountability and the gold standard of professional nursing care. The aim of this study was to explore nurses’ experiences and perceptions about evidence‐based nursing practice in giving care to patients with diabetic foot ulcers. A qualitative research design was adopted, and content analysis was used to analyse data. Semistructured interviews were held with 19 bachelor‐degree nurses working in a teaching hospital in an urban area of Iran. During data analysis, two main themes developed: ‘structural backgrounds of the organization’ and ‘empowerment’. Accordingly, it was concluded that successful implementation of evidence‐based nursing requires the reconfiguration of the administrative structure in the hospital. In addition, it requires the support of nurse leaders to facilitate the implementation of evidence‐based nursing in the practice.     

Admiral nursing competency project: practice development and action research

Aims and background. Admiral Nurses are specialist dementia care nurses working in the community with carers of those who have a dementia. The aim of the competency project (2000–2003) was threefold. Firstly to work collaboratively with these specialist nurses to facilitate the development a competency framework that reflects the needs of the Admiral Nursing Service. Secondly, to provide a way to structure evidence demonstrating evolving competency. Thirdly, to specifically enable the nurses to demonstrate evidence of achieving the UK Nursing and Midwifery Council's Higher Level Practice standard. Design and methods. The two complementary approaches of emancipatory action research and systematic practice development were adopted. Methods were taken from action research and systematic practice development approaches with an emphasis on promoting and enabling enlightenment, critical reflection, ownership and creating the best conditions for long‐term commitment to the competency framework. Results. The main outcome from this project was the development of a specialist nursing competency framework. The Admiral Nurses’ Competency Framework is made up of a set of eight core competencies with three levels of competency statements, loosely structured around the Higher Level Practice standard, and guidance documentation to illustrate how work‐based evidence can be generated to demonstrate competence. There were also process‐derived outcomes associated with combining systematic practice development with emancipatory action research that had an impact on the culture. The main outcomes here were that practitioners engaged in and experienced learning about how to research their own practice and the consequences of doing this. They also learnt about specialist nursing practice more widely than Admiral Nursing. Finally, there was some increase in awareness about the culture within their teams and organizations. The final competency framework reflects the needs of the service, is owned by the majority of practitioners and project commissioners and this has had a positive impact on implementation. Conclusion. In this paper, we report on combining systematic practice development with action research to achieve immediate project aims. In addition we show how a project of this nature can contribute to developing skills in practitioners necessary for cultural changes in practice and contributes to wider issues of modernization within nursing and health care. Relevance to clinical practice. This competency framework will enable Admiral Nurses to demonstrate their level of specialist practice, as individuals and collectively as a service and it also promotes the principles of nurses as life long learners. This may have relevance to other groups of specialist nurses. The project has widespread relevance for two reasons. Firstly, it shows that nurses can be involved in designing and testing a competency framework as collaborators. Secondly, that to achieve this within the spirit of approaches, such as systematic practice development and action research, can be testing for all collaborators even were there is a shared or espoused aim.     

Implementing research findings into mental health nursing practice: exploring the clinical research fellowship approach

ABSTRACT:  The lack of research utilization within nursing practice has been extensively discussed in the literature. The Clinical Research Fellowship (CRF) program was developed to assist nurses to change practice on the basis of high-quality research evidence. This paper presents the results of a qualitative study examining the experiences of four CRF participants and three of their unit managers in completing the program and implementing changes within the clinical setting. The major themes to emerge from the data were: experience of the program, outcomes, implementation, assistance from the Centre for Psychiatric Nursing Research and Practice, Victoria, Australia, benefits and drawbacks to the program and whether it would be recommended to others. The findings indicate a positive view of the program itself although problems with the implementation stage were clearly evident. Further support following completion of the program is required to achieve maximum benefit from the program.     

Factors influencing evidence‐based nursing utilization intention in Korean practice nurses

The purpose of this study was to describe Korean nurses' perceptions, attitudes and utilization intention for evidence‐based nursing (EBN), and to explore what factors influence utilization intention. We conducted a cross‐sectional survey in 2012. Registered nurses directly involved in clinical practice were recruited at a medical centre in Korea. A total of 420 nurses completed a self‐report questionnaire. Results showed that participants reported moderate scores regarding their perceptions and attitudes towards EBN, and rated themselves as higher than the median for utilization intention. Furthermore, this study revealed that perceptions of and attitudes towards EBN, occupational view and previous EBN education were significant factors affecting utilization intention. Nurse educators and managers should encourage nurses to have better attitudes towards EBN, help them be more satisfied with their work and provide them with appropriate education for EBN to establish evidence‐based practice as a part of daily nursing care.     

Predictors and enablers of mental health nurses’ family‐focused practice

Family‐focused practice improves outcomes for families where parents have a mental illness. However, there is limited understanding regarding the factors that predict and enable these practices. This study aimed to identify factors that predict and enable mental health nurses’ family‐focused practice. A sequential mixed methods design was used. A total of 343 mental health nurses, practicing in 12 mental health services (in acute inpatient and community settings), throughout Ireland completed the Family Focused Mental Health Practice Questionnaire, measuring family‐focused behaviours and other factors that impact family‐focused activities. Hierarchical multiple regression identified 14 predictors of family‐focused practice. The most important predictors noted were nurses’ skill and knowledge, own parenting experience, and work setting (i.e. community). Fourteen nurses, who achieved high scores on the questionnaire, subsequently participated in semistructured interviews to elaborate on enablers of family‐focused practice. Participants described drawing on their parenting experiences to normalize parenting challenges, encouraging service users to disclose parenting concerns, and promoting trust. The opportunity to visit a service user's home allowed them to observe how the parent was coping and forge a close relationship with them. Nurses’ personal characteristics and work setting are key factors in determining family‐focused practice. This study extends current research by clearly highlighting predictors of family‐focused practice and reporting how various enablers promoted family‐focused practice. The capacity of nurses to support families has training, organizational and policy implications within adult mental health services in Ireland and elsewhere.     

Reflections on a 'virtual' practice development unit: changing practice through identity development

Aims. This paper draws together the personal thoughts and critical reflections of key people involved in the establishment of a ‘virtual’ practice development unit of clinical nurse specialists in the south of England. Background. This practice development unit is ‘virtual’ in that it is not constrained by physical or specialty boundaries. It became the first group of Trust‐wide clinical nurse specialists to be accredited in the UK as a practice development unit in 2004. Design and methods. The local university was asked to facilitate the accreditation process via 11 two‐hour audio‐recorded learning sessions. Critical reflections from practice development unit members, leaders and university staff were written 12 months after successful accreditation, and the framework of their content analysed. Findings and discussion. Practice development was seen as a way for the clinical nurse specialists to realize their potential for improving patient care by transforming care practice in a collaborative, interprofessional and evolutionary manner. The practice development unit provided a means for these nurses to analyse their role and function within the Trust. Roberts’ identity development model for nursing serves as a useful theoretical underpinning for the reflections contained in this paper. Conclusions. These narratives provide another example of nurses making the effort to shape and contribute to patient care through organizational redesign. This group of nurses began to realize that the structure of the practice development unit process provided them with the means to analyse their role and function within the organization and, as they reflected on this structure, their behaviour began to change. Relevance to clinical practice. Evidence from these reflections supports the view that practice development unit participants have secured a positive and professional identity and are, therefore, better able to improve the patient experience.     

Implementation of evidence‐based practice by nurses working in community settings and their strategies to mentor student nurses to develop evidence‐based practice: A qualitative study

The aim of the study was to explore how community nurses apply the best available evidence to their practice, and how they mentor student nurses to conceptualize and implement evidence‐based practice in community settings. In the UK, the expansion of health‐care provision in the community has supported the development of highly skilled community nurses. However, there is limited literature regarding the strategies used by community nurses to implement evidence‐based practice and mentor student nurses to conceptualize evidence‐based practice in community placements. An exploratory qualitative approach applying inductive reasoning to focus group data was used. As a result, nurses working for a community NHS Foundation Trust in South England with a mentor qualification were invited to participate in one of the seven focus groups, 33 nurses participated. Data were analyzed with thematic analysis. The themes discussed in this paper are: ‘our practice is evidence‐based’ as guidelines and policies provided structure, but occasionally stifled autonomous clinical decision‐making, and ‘time’ as a barrier and facilitator to mentoring student nurses in community settings. In conclusion, nurses need to develop the ability to incorporate patients' needs and wishes within evidence‐based care. Time was a facilitator for some community mentors, but protected time is required to complete the necessary practice documentation of student nurses.     

Exploring ethics in practice: creating moral community in healthcare one place at a time

Examining everyday ethical situations in clinical practice is a vital but often overlooked activity for nursing leaders and practitioners, as well as most other healthcare professionals. In this paper, we share how a series of practitioner-led Ethics in Practice sessions (EIPs), which originated within a busy urban teaching hospital, were adapted and translated, first into home care and more recently, into an EIP session for public health nurses. The success of EIP sessions rests with their focus on issues that are selected by practitioners. The aims of EIPs are to foster ethical leadership within communities of practice, create safe places to share concerns, use relevant research evidence and other literature to support informed discussion, and generate stories that deepen our understanding of the ethical situations we encounter in our work. We hope our experience inspires nursing leaders, nursing colleagues and fellow healthcare professionals to consider using the EIP approach to build moral community and the idea of moral imagination with their clinical colleagues, one place at a time.     

Clinical practice of doctorally prepared nurses

This study describes the clinical experiences of doctorally prepared nurses whose primary professional role is providing care as advanced practice nurses. Telephone interviews were conducted with 20 participants who lived and practiced in 13 states. Practice settings for these nurses included inpatient acute care and various outpatient/community health settings. Several themes describe the nature of the participants' practice: management of patient care, interwoven partnerships, leadership, and practice values. Major themes relating to the contribution of doctoral education to practice were abilities gained and changes in image and status. The findings of this study demonstrate that doctorally prepared nurses are actively involved in nursing practice by affecting patient outcomes, promoting cost-effective care, and using clinical research.     

Developing evidence-based practice: experiences of senior and junior clinical nurses

Title. Developing evidence‐based practice: experiences of senior and junior clinical nurses Aim. This paper is a report of a study to compare factors influencing the development of evidence‐based practice identified by junior and senior nurses. Background. Assessing factors influencing the achievement of evidence‐based practice is complex. Consideration needs to be given to a range of factors including different types of evidence, the skills nurses require to achieve evidence‐based practice together with barriers and facilitators. To date, little is known about the relative skills of junior and senior clinical nurses in relation to evidence‐based practice. Method. A cross‐sectional survey was undertaken at two hospitals in England, using the Developing Evidence‐Based Practice Questionnaire administered to Registered Nurses (n = 1411). A useable sample of 598 (response rate 42%) was achieved. Data were collected in 2003, with comparisons undertaken between junior and senior nurses. Findings. Nurses relied heavily on personal experience and communication with colleagues rather than formal sources of knowledge. All respondents demonstrated confidence in accessing and using evidence for practice. Senior nurses were more confident in accessing all sources of evidence including published sources and the Internet, and felt able to initiate change. Junior nurses perceived more barriers in implementing change, and were less confident in accessing organizational evidence. Junior nurses perceived lack of time and resources as major barriers, whereas senior nurses felt empowered to overcome these constraints. Conclusion. Senior nurses are developing skills in evidence‐based practice. However, the nursing culture seems to disempower junior nurses so that they are unable to develop autonomy in implementing evidence‐based practice.     

Nurses' perceptions of health beliefs and impact on teaching and practice: a Q‐sort study

Aim

To understand Chinese nurses’ perceptions of health beliefs, their content, origin and the influence of sociocultural factors, as a basis of their evidence‐based practice. This study contributes to a larger study to establish the health beliefs of Japanese, Australian, Chinese, South Korean and Thai nurses.

Background

Registered nurses teach patients and students about maintaining or attaining health are subject to the same range of influences and their health beliefs may be antithetical to current health evidence.

Methods

Q‐method design using q‐sort and interview was used to explore the perspectives on a range of health beliefs of 60 nurses in four cities in China.

Findings

Three factors arose from the perceptions of the participants about health and accounted for 50.2% of the total variance: (1) social impact, (2) ‘the importance of evidence’, and (3) beliefs rooted in culture.

Discussion

Influence on nurses’ health beliefs was explored in terms of the internalized and frequently unconscious beliefs, values and norms tying them to their communities, reflecting the need for nurses to be aware of their health beliefs and behaviours.

Conclusions

Education for nurses in practice needs to acknowledge that individual practitioners’ beliefs strongly influence health teaching for patients and families. In order to implement evidenced‐based practice and teach in line with current evidence nurses need to critically examine and reflect on the impact of culture, society and the media on their own health beliefs.

Implications for nursing policy and health policy

Education policy needs to consider that culture and societal pressures affect nurses’ health beliefs and practice. Critical thinking, reflective and evidence‐based practice need to be emphasized in clinical training and nurse education. China also needs to develop policies to allow nurses to be able to assess the reliability of health information on the Internet and to make quality health research more available.     

Reflective practice and daily ward reality: a covert power game

Background. The concept of reflection is propounded in the literature as an epistemology for practice that enables practitioners to solve their daily problematic situations through conscious thought processes which eventually leads to practice‐based knowledge. Hence, reflection became a central tenet of both theory development and educational provision in nursing. Furthermore, this centrality of reflection was reinforced by statutory nursing bodies and service providers by adopting it as the means for carrying out adequate professional practice. Although this may be the case, issues of implementation of reflection within the daily reality of practitioners are frequently overlooked within the literature. Moreover, little consideration appears to be given on the impact that the organizational culture and the politics of power may exert on the implementation of reflective practices within daily ward reality. Aims. This paper explores how reflection is viewed by nurses within their daily reality in the medical wards, examines the relationships between the organizational culture of these wards and the practitioners and investigates whether reflective methods of practice were being implemented when the study was conducted. Methods. An interpretative ethnographical methodology was implemented and the data collecting methods used were observation, interviews and qualitative content analysis with a group of 16 practising nurses from four medical wards of one NHS Trust in England. Two interviews were conducted with each nurse within 3‐week intervals. The content of these interviews evolved from the analysis of episodes of practice observed when the nurses were giving nursing care. These data were supplemented by narratives from the nurses’ in the form of written reflective accounts that were analysed via qualitative content analysis techniques. Findings. Four themes were generated: (i) relationships between nurses and doctors; (ii) relationships between nurses and managers; (iii) nursing practice; and (iv) nurses’ input in the outcome of a clinical situation. Conclusions. The concept of reflection appears to be invalidated by the organizational hierarchy of the wards on the basis of a power struggle game. The ward structure portrays reflection as an abnormal method of practice and knowledge development. This belittlement of reflection does not mirror the practitioners’ reality. Instead, it is an intelligent and intentional act on behalf of the dominant professional groups in the wards to create an illusionary picture of ward reality to allow them to survey and define nursing practice and thus maintain and remain in power. This is explicated by using Foucault's analysis and critical social theory framework. Hence, reflective processes are constrained by this covert power game; reflection, where used, is confined to nurses’ personal time and space. Relevance to clinical practice. The realization of this covert power game by individual clinical nurses can become the incipient point for formally using reflective methods in the practice setting.     

Nurses’ experiences of guideline implementation: a focus group study

Aims. The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines? Background. The implementation of clinical guidelines seems to be dependent on multiple context‐specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation. Design. Qualitative interview. Methods. Data were generated by four focus group interviews involving nurses working in out‐patient services in primary health centres in Finland. Purposive sampling was used to select health centres. Inductive content analysis was used to identify themes emerging from the data. Results. Four main groups of factors were identified from the analysis of data: (i) factors related to the organisation, (ii) factors related to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses’ awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines to local circumstances, seems to be crucial for successful implementation. Conclusions. Clinical guidelines can be promising tools in enhancing evidence‐based nursing practice, as nurses see them as practical work tools in patient care and so are willing to adopt them. However, support from management and physicians is needed to ensure the successful implementation of guidelines into nursing practices. Relevance to clinical practice. Based on the findings of this study and previous knowledge of guideline implementation some practical recommendations are suggested. Select the most relevant guidelines to clinical practice, organise the adaptation of guidelines to local circumstances, inform all practitioners involved in treatment and give clear instructions for the adoption of the guidelines.     

Collaborative practice: a critical theory perspective

The purpose of this critical theory study was to investigate the observed failure of nurses and physicians to collaborate, and the underlying meaning behind this failure. Using a phenomenological and participatory approach, 18 family nurse practitioners and physicians in joint practice were interviewed separately and together about their practice relationships. Transcribed interviews and data summaries were returned to the participants for review and validation. Emergent themes were analyzed using the critical theory of Jürgen Habermas. Results demonstrated that distorted communication and nonmeaningful interactions were promoted by both nurses and physicians. Elements identified as contributing to more successful collaborative practices included a willingness to move beyond basic information exchange in nurse/physician interactions, the willingness and ability to challenge distortions and assumptions in the relationship, and a belief system based on critical self-reflection.     

Competencies in the context of entry-level registered nurse practice: a collaborative project in Canada

Aim: To present the process used by professional staff from 10 Canadian jurisdictional regulatory bodies to develop entry‐level competencies for registered nurse practice. Background: Canada is composed of provinces and territories, commonly referred to as jurisdictions with the governmental legal authority to administer the affairs of the area. Each jurisdiction establishes regulatory bodies with the mandate to protect the public. The Executive Directors of the jurisdictional regulatory bodies initiated this collaborative project to develop entry‐level competencies for registered nurses. The purpose of the project was to enhance the consistency of entry‐level registered nurse competencies, thereby supporting reciprocity of registration and workforce mobility, within Canada. This was the first time that Canadian nursing regulatory bodies have collaborated in a jurisdictional‐driven project of this magnitude for registered nurses exclusively. This initiative has demonstrated how nursing regulatory bodies, working together, can achieve a common goal. Process: The project participants worked from 2004 to 2006, developing and refining the competencies. Multiple methods were used to accomplish the task, including monthly teleconferences, frequent E‐mail communications, small group work and face‐to‐face meetings. At various stages in the project, consultation with registered nurses within several participating jurisdictions occurred, depending on where each jurisdiction was in their jurisdictional competency review. This project spanned a 2‐year period and resulted in a comprehensive document that captured the views of the participants and enhanced the resulting document. Conclusion: The result is a document stating the core competencies for entry‐level registered nurses in the 10 participating jurisdictions and includes several components that establish the context in which entry‐level competencies are developed and applied. The 119 competency statements are organized in a standard‐based framework of five categories: professional responsibility and accountability; knowledge‐based practice; ethical practice; service to the public; and self‐regulation. The project team plans to follow up on implementation as each jurisdiction decides how to use the competencies within their particular jurisdiction.