Emergency department management of hip fractures: Development of an evidence‐based clinical guideline by literature review and consensus

The Emergency Department at Dandenong Hospital has recently developed an evidence‐based clinical guideline for the emergency department management of hip fractures. This paper will comment on the role of clinical guidelines in the emergency department, discuss the process of the development of evidence‐based guidelines for the care of hip fractures and present the evidence found during the development process. Evidence‐based recommendations for practice are made regarding pulse oximetry and supplemental oxygen, preoperative use of skin traction, thromboembolism prophylaxis, pain management including the use of nerve blocks, pressure area care, the use of indwelling urinary catheters and time to surgical repair.     

Successful implementation of clinical practice guidelines for pressure risk management in a home nursing setting

Rationale This paper reports an initiative which promoted evidence‐based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia. Aim and objectives The aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers. Method In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client profile (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted. Results Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. The pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk. Conclusion Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well‐adopted practice. Success continued following organizational wide implementation. Pilot study findings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group.     

Nurses’ clinical reasoning concerning management of peripheral venous cannulae

Aim. The aim was to describe nurses’ clinical reasoning regarding peripheral venous cannulae management by focusing on the clinical information and circumstances considered during the decision‐making process. Background. On every shift nurses make several decisions, among others concerning the management of peripheral venous cannulae. Thrombophlebitis is a common complication associated with its use, although more severe complications can arise. There are clinical practice guidelines within the area, but they are not always adhered to. Previous studies have examined decisions related to the management of peripheral venous cannulae, but did not include observations in a naturalistic setting. Design. A qualitative study combining observations and interviews. Methods. Participant observation facilitated open interviews about the clinical reasoning behind decision‐making in observed situations, as well as semi‐structured interviews regarding clinical reasoning about the general management of peripheral venous cannulae. Transcribed interview texts were analysed with content analysis. Results. Three main categories describe clinical information and circumstances: the individual patient situation, the nurse’s work situation and experience of peripheral venous cannulae management. The overall theme of the interview texts was that the clinical reasoning was a balancing act between minimising patient discomfort and preventing complications from the peripheral venous cannulae. Conclusions. At all times the patients’ well‐being was considered, but the ways the nurses approached this differed depending on how they considered clinical information in the individual patient situation, circumstances in their own work situation and their experience of peripheral venous cannulae management. Relevance to clinical practice. Knowledge of the clinical information and circumstances considered in naturalistic settings, is valuable when implementing and adjusting clinical practice guidelines to local settings. This knowledge is also useful in nursing education as student nurses’ and nurses’ ability to balance between preventing complications and avoiding discomfort is important for enhancing patient care.     

What is the relationship between nurses’ attitude to evidence based practice and the selection of wound care procedures?

Aim. To investigate qualified nurses’ attitudes to evidence‐based practice and whether this influenced their selection of wound care products. Background. The literature shows that previous studies on attitudes to evidence‐based practice tended to be part of a wider study. The general consensus was that there was a positive attitude to evidence‐based practice. However, there appeared to be no published studies specifically addressing nurses’ attitudes to evidence‐based wound care. Design. Survey design using a questionnaire completed by 156 qualified nurses working in three UK National Health Trusts. Results. A statistically significant difference was seen between those nurses with a tissue viability link nurse role (p = 0·002) and those without a link nurse role; those educated to first degree (p < 0·001) and those without a first degree; and those who had received formal tissue viability training (p < 0·001) and those with informal tissue viability training. There was also a highly statistically significant relationship between the clinical grade of staff and the overall attitude to evidence‐based practice (p < 0·001). Conclusions. Nurses who had attained a higher level academic qualification, had a tissue viability link nurse role and those who had received formal tissue viability training scored generally higher in the wound care knowledge tests and in attitude to evidence‐based practice. Relevance to clinical practice. The care received by patients in relation to wound care could be dependent upon factors that are related to the individual characteristics of the nurse providing the care and these factors, in turn, are related to education and training with respect to wound care. Better general education and better specific training in wound care could lead to better wound care.     

Constrained nursing: Nurses’ and assistant nurses’ experiences working in a child and adolescent psychiatric ward

The role of nurses and nursing in CAP inpatient care is unclear, and nurses are at risk of moral distress due to having to deal with complex demands while lacking organizational support. This study aimed to describe nurses’ and assistant nurses’ experiences working in child and adolescent psychiatric inpatient care. Eight nurses and seven assistant nurses working in a child and adolescent ward in Sweden participated in the study. Data were collected in 2019 using semi-structured qualitative interviews and subject to qualitative content analysis. Results describe nurses’ and assistant nurses’ experiences of child and adolescent psychiatric inpatient care in one theme, Constrained nursing, and four categories: Striving to be there for children and parents; Finding a way to manage work; Depending on others; Lacking nursing leadership. Findings suggest that good, person-centred and recovery-oriented nursing practice can exist in CAP inpatient care but remain unrecognized and lacking support due to unclear roles and responsibilities and lack of nursing leadership. This study is reported in accordance with the COREQ guidelines.     

Evidence‐based nursing: clarifying the concepts for nurses in practice

Aim. To provide a critical analysis of key concepts associated with evidence‐based nursing (EBN) to substantiate an operational definition for nurses to use in practice. Background. Despite the plethora of literature surrounding what evidence‐based nursing is and is not and how it differs from its cousins, evidence‐based medicine and evidence‐based practice, nurses still struggle to get evidence into practice. Several reasons for this have been reported, for example, a lack of understanding about what evidence‐based nursing means or time to engage with and apply the evidence into practice. Design. An in‐depth critical review and synthesis of literature was undertaken. Method. Using the key words; evidence‐based nursing, evidence‐based medicine and evidence‐based practice 496 articles were yielded. These articles were limited to 83. Using Burns and Grove’s (2001) phased approach to reviewing the literature the articles were critically reviewed and categorised into key concepts and themes. Results. The in‐depth critical review and synthesis of the literature demonstrated that evidence‐based nursing could be defined as a distinct concept. The review clearly shows that for evidence‐based nursing to occur, nurses need to be aware of what evidence‐based nursing means, what constitutes evidence, how evidence‐based nursing differs from evidence‐based medicine and evidence‐based practice and what the process is to engage with and apply the evidence. Conclusion. The in‐depth critical review and synthesis of the evidence‐based nursing literature reinforces the need to consolidate a position for nursing in the evidence‐based field. The review confirms that evidence‐based nursing can be defined and conceptualised; however, for nurses to engage and apply with the evidence‐based processes they need to be informed of what these are and how to engage with them in practice. Relevance to clinical practice. This paper examines the concept of evidence‐based nursing and its application to clinical practice.     

Using the NHS sustainability framework to understand the activities and resource implications of Canadian nursing guideline early adopters

Aims and objectives. To examine the activities and resource implications for the initial cohort of healthcare organisations involved in the introduction of multiple nursing guidelines. Background. The Best Practice Spotlight Organization initiative was launched in 2003 as part of the Registered Nurses’ Association of Ontario’s Best Practice Guidelines programme. While previous research has evaluated improvements in patient care and outcomes, there has been limited research from an organisational perspective on the activities conducted to introduce nursing guidelines. Design. Secondary analysis of retrospective narrative data. Methods. We conducted a content analysis of the 2004–2006 annual reports from the seven participating sites. We used both deductive and inductive approaches to categorise the guideline implementation activities and their resource implications. Results. All sites reported implementing multiple guidelines (four to nine guidelines per site) and used a wide range of implementation activities that clearly addressed nine of the 10 NHS Sustainability dimensions. The dimension not reported was benefits beyond helping patients. All sites established steering committees that involved staff and senior leaders, reviewed selected guidelines and recommendations, reviewed existing policies and procedures and developed new policies and procedures, recruited champions or peer mentors, applied for additional external funding to support activities, developed relationships with external clinical partners, included guideline implementation in orientation, developed intra‐agency web‐based and print communications for the project, and evaluated practice changes. For each of these activities, the sites reported expenditures and resource usage. Conclusions. The organisational processes used for the introduction of new nursing guidelines in Canada are remarkably consistent with factors identified by leaders and change agents in the UK who developed the NHS Sustainability Model. Relevance to clinical practice. A multidimensional framework for sustainability is useful for planning successful guideline implementation across an organisation. Examples of specific activities and resource implications for organisational change are provided.