Pre‐registration education: making a difference to critical care?

This paper aims to discuss the development of a pre-registration high-dependency nursing programme and evaluate its effects on student's perceived learning and confidence in managing critically ill patients. The programme consists of two modules that compliment one another, 'Care of the Acutely III Adult' focuses on a variety of disease processes and subsequent nursing care. Whilst the second module titled 'Caring for the Highly Dependant/Critically III Adult' focuses on assessment skills related to critically ill patients. The paper explores the content and delivery of the modules including the advantages and disadvantages of implementing them. Student evaluation from 59 nursing students found that student's knowledge, assessment skills and management of the critically ill patient had improved since completing the modules. Nurse Consultants, intensive therapy unit matrons and Critical Care Outreach nurses have acknowledged an increase in the number of nursing students identifying and referring critically ill patients to outreach teams. They also stated improvements in nurse recruitment in critical care since commencement of the modules.     

Drugs and blood transfusions: dogma‐ or evidence‐based practice?

summary .  There is a lack of consensus on the safety of the coadministration of drugs and red blood cells (RBCs). A systematic review was undertaken to establish the evidence base for this question and assess how the evidence may be translated into present clinical day practice. Comprehensive searches of MEDLINE, EMBASE, CINAHL, the Cochrane Library and hand searching of transfusion journals, guidelines and websites identified 12 relevant papers: 11 in-vitro experiments and 1 case report. Data on incidences of haemolysis and agglutination following coadministration were extracted and analysed. Overall findings suggest that iron chelators (two papers), antimicrobials (three papers) and lower doses of opioids (three papers) are safe to coadminister with RBCs. Haemolysis was observed with higher doses of opioids (three papers). Transposition of these findings to clinical practice is limited because of the lack of clinical applicability of in-vitro experiments and diversity in how, and what, clinical outcome measures were used. Further evidence from true clinical settings would be required to inform clinical practice on the efficacy and safety of the coadministration of drugs and RBCs.     

Shared decision making: Does a physician's decision‐making style affect patient participation in treatment choices for primary immunodeficiency?

Overall health care spending in the United States is equivalent to more than 15% of GDP, yet outcomes rank below the top 25 in most quality categories when compared with other Organization for Economic Cooperation and Development (OECD) countries. The majority of spending is consumed by small patient populations with chronic diseases. Experts believe increased patient‐physician shared decision making (SDM) should result in better overall longitudinal care but understanding the physician's role in facilitating SDM is limited. Structural equation modelling was applied to results of a 2016 questionnaire‐based survey of 330 US physicians who treat approximately 55% of primary immune deficiency requiring immune globulin therapy; it tested the relationship between slow/rational vs fast/intuitive decision‐making styles and SDM as mediated by patient‐centric care and moderated by physician's trust in the patient. The results showed a statistically significant relationship between slow/rational decision making and SDM. The results also suggest differences related to age, gender, education, and race but no differences related to trust.     

Why evidence‐based practice now?: a polemic1

Evidence-based practice (EBP) first appeared on the healthcare horizon just over a decade ago. In 2003 its presence has intensified and extended beyond its initial relation to medicine embracing as it does now, nursing and the allied health disciplines. In this paper, I contend that its appearance and subsequent growth and development are the effects of potent "regimes of truth", four of which bear the names: positivism, empiricism, pragmatism and economic rationalism. My aim is to show how EBP generates the controversy it does because its nature and methods are inextricably interwoven with the way it has become politicised and professionalised. This exegesis is an attempt to outline how the combined effects of the four forms of rationality mentioned above allow for both the methods and objectives of EBP to be constructed as they are, while at the same moment producing the particular effects of knowledge and power in terms of who sells and who buys the idea of EBP in the culture of contemporary healthcare.     

Patient preferences for medical decision making: who really wants to participate?

OBJECTIVES: To identify the determinants of patient preferences for participation in medical decision making. METHODS: Data were analyzed for 2,197 patients from the Medical Outcomes Study, a 4-year observational study of patients with chronic disease (hypertension, diabetes, myocardial infarction, congestive heart failure, and depression). Multivariate logistic regression models estimated the effects of patients' sociodemographic, clinical, psychosocial, and lifestyle characteristics on their decision-making preferences. RESULTS: A majority of the patients (69%) preferred to leave their medical decisions to their physicians. The odds for preferring an active role significantly decreased with age and increased with education. Women were more likely to be active than men (odds ratio [OR] = 1.44, P < 0.001). Compared with patients who only suffered with unsevere hypertension, those with severe diabetes (OR = 0.62, P = 0.04) and unsevere heart disease (OR = 0.45, P = 0.02) were less likely to prefer an active role. Patients with clinical depression were more likely to be active (OR = 1.64, P = 0.01). Patients pursuing active coping strategies had higher odds for an active role than "passive" copers, while those who placed higher value on their health were less likely to be active than those with low health value (OR = 0.59, P < 0.001). CONCLUSIONS: Although a majority of patients prefer to delegate decision making to physicians, preferences vary significantly by patient characteristics. Approaches to enhancing patient involvement will need to be flexible and accommodating to individual preferences in order to maximize the benefits of patient participation on health outcomes.     

Nursing migration: global treasure hunt or disaster‐in‐the‐making?

International nurse migration--moving from one country to another in the search of employment--is the focus of this article. The majority of member states of the World Health Organization report a shortage, maldistribution and misutilisation of nurses. International recruitment has been seen as a solution. The negative effects of international migration on the 'supplier' countries may be recognised today but are not effectively addressed. Nurse migration is motivated by the search for professional development, better quality of life and personal safety. Pay and learning opportunities continue to be the most frequently reported incentives for nurse migration, especially by nurses from less-developed countries. Career opportunities were considered key incentives for nurses emigrating from high-income countries. Language was reported to be a significant barrier. The positive global economic/social/professional development resulting from international migration needs to be weighed against a substantial 'brain and skills drain' experienced by supplier countries. The vulnerable status of migrant nurses is also of concern in certain cases. The focus on short-term solutions as opposed to resolving the problem of a worldwide shortage of nurses causes great concern. Recent initiatives attempt to curb or channel international recruitment. The delicate balance between recognising the right of individual nurses to migrate and a collective concern for the health of a nation's population must be achieved.     

Medical hegemony in decision‐making – a barrier to interdisciplinary working in intensive care?

BACKGROUND: Health care policy in the United Kingdom identifies the need for health professionals to find new ways of working to deliver patient-focussed and economic care. Much debate has followed on the nature of working relationships within the health care team. AIM: This paper reports on an ethnographic study that examined the nursing role in clinical decision-making in intensive care units. This was chosen as a case for analysis due to the close doctor-nurse relationships that are essential in this acute and complex care setting. METHODS: Data were collected during two-stages of fieldwork using participant observation, in-depth ethnographic interviews and documentation across three clinical sites. FINDINGS: The findings revealed the different types of knowledge used for, divergence of roles involved in and degree of authority in clinical decision-making. Furthermore, conflict arose between doctors and nurses due to these differences and in particular because medicine dominated the decision-making process. CONCLUSIONS: The nursing role, whilst pivotal to implementing clinical decisions, remained unacknowledged and devalued. Medical hegemony continues to render nurses unable to influence substantially the decision-making process. This has fundamental ramifications for the quality of team decision-making and the effectiveness of new ways of inter-professional working in intensive care.     

Managing a good death in critical care: can health policy help?

Aim: This paper discusses end‐of‐life care (EoLC) in critical care through exploration of what is known from the international literature and what is currently presented within UK policy. Background and context: EoLC is an important international critical care issue, and currently provides a key focus for health care policy in the UK. While society holds that critical care is delivered in a highly technical area with a strong focus on cure and recovery, mortality rates in this speciality remain at approximately 20%. When patient recovery is not an outcome, discussions with patient, family and extended care teams turn towards futility of treatment and end‐of‐life management. However, there are specific barriers to overcome in EoLC for the critically ill. Conclusion: A key issue for EoLC in critical care is a lack of robust systems to prospectively identify individuals who are most at risk of dying. A further challenge is divergent perspectives within and across clinical teams on treatment withdrawal and limitation practices. To streamline patient management and underpin a hospice approach to care, EoLC policies are currently being used within the UK. While this provides a national framework to address some key critical care clinical issues in the UK, there is a need for further refinement of the tool to reflect the reality of EoLC for the critically ill. It is important that international best practice exemplars are examined and clinicians actively engage and contribute to ensure that any local EoLC frameworks are fit for purpose.     

How do we know if a clinical practice guideline is good? A response to Djulbegovic and colleagues' use of fast‐and‐frugal decision trees to improve clinical care strategies

Clinical practice guidelines (CPGs) and clinical pathways have become important tools for improving the uptake of evidence‐based care. Where CPGs are good, adherence to the recommendations within is thought to result in improved patient outcomes. However, the usefulness of such tools for improving patient important outcomes depends both on adherence to the guideline and whether or not the CPG in question is good. This begs the question of what it is that makes a CPG good? In this issue of the Journal, Djulbegovic and colleagues offer a theory to help guide the development of CPGs. The “fast‐and‐frugal tree” (FFT) heuristic theory is purported to provide the theoretical structure needed to quantitatively assess clinical guidelines in practice, something that the lack of theory to guide CPG development has precluded. In this paper, I examine the role of FFTs in providing an adequate theoretical framework for developing CPGs. In my view, positioning guideline development within the FFT framework may help with problems related to adherence. However, I believe that FTTs fall short in providing panel members with the theoretical basis needed to justify which factors should be considered when developing a CPG, how information on those factors derived from research studies should be interpreted, and how those factors should be integrated into the recommendation.     

Acute stroke thrombolysis: time to dispense with the clock and move to tissue-based decision making?

Currently, imaging is predominantly used to exclude patients for thrombolysis, rather than identify patients most likely to benefit. This means that patients are being selected for treatment without reference to tissue pathophysiology. Imaging of specific stroke pathophysiology may be the key to selecting patients most likely to benefit from thrombolysis, and could revolutionize acute stroke assessment and treatment. The technology is available to identify the acute infarct core and possibly the penumbra, via magnetic resonance diffusion-weighted imaging, and both magnetic resonance- and computed tomography-perfusion imaging techniques. However, these modalities require fine tuning before they can be reliably implemented in a routine clinical setting.     

Education in palliative care: making a difference to practice?

This article presents part of a multiphase evaluation project, which aims to investigate the effectiveness of a number of palliative care educational programmes provided by a hospice education network in the north of England. Information is reported from four cohorts of students (n = 46) who undertook courses between October 1998 and April 2000. Particular emphasis was placed on the views of students and whether education made a difference to their clinical practice. An action research approach was used which asked the question 'Does education develop competent confident practitioners, who are able to initiate changes in their practice?' Early indications suggest that education does make a difference to practice. Students reporting feeling more confident, having a greater knowledge of palliative care and being more skilled in caring for patients and their families. Furthermore, students have made recognizable changes to their practice, some of which are detailed here.     

Meta‐analysis: the glass eye of evidence‐based practice?

Meta-analysis was developed as a technique for combining the results of many different quantitative studies: it is often used to produce quantitative estimates of causal relations and/or association between variables. Meta-analysis is sometimes regarded as a central component of evidence-based practice. We draw attention to an incompatibility in the epistemology and methods of reasoning in quantitative meta-analysis and the epistemology and reasoning implicit in expert practice. We argue that this may be because the common perception of meta-analysis appeals to truth as correspondence; we suggest that rejecting the naive realism that underpins truth as correspondence allows meta-analysis to be understood in terms of truth as coherence. We can then develop an account of meta-analysis that does not depend upon reduction to a mathematical procedure but is an attempt to maximise coherence in beliefs about what works that is consistent with clinical reasoning in expert practice.