Barriers to evidence-based nursing: a focus group study

Title. Barriers to evidence‐based nursing: a focus group study Aim. This paper reports a study to explore the barriers to evidence‐based nursing among Flemish (Belgian) nurses. Background. Barriers obstructing the call for an increase in evidence‐based nursing have been explored in many countries, mostly through quantitative study designs. Authors report on lack of time, resources, evidence, authority, support, motivation and resistance to change. Relationships between barriers are seldom presented. Methods. We used a grounded theory approach, and five focus groups were organized between September 2004 and April 2005 in Belgium. We used purposeful sampling to recruit 53 nurses working in different settings. A problem tree was developed to establish links between codes that emerged from the data. Findings. The majority of the barriers were consistent with previous findings. Flemish (Belgian) nurses added a potential lack of responsibility in the uptake of evidence‐based nursing, their ‘guest’ position in a patient’s environment leading to a culture of adaptation, and a future ‘two tier’ nursing practice, which refers to the different education levels of nurses. The problem tree developed serves as (1) a basic model for other researchers who want to explore barriers within their own healthcare system and (2) a useful tool for orienting change management processes. Conclusion. Despite the fact that the problem tree presented is context‐specific for Flanders (Belgium), it gives an opportunity to develop clear objectives and targeted strategies for tackling obstacles to evidence‐based nursing.     

A primer for clinical researchers in the emergency department: Part IV: Multicentre research

In this series we address key topics for clinicians who conduct research as part of their work in the ED. Multicentre research is conducted to enrol larger numbers of participants and improve the validity and generalisability of the findings. Little has been published outlining the practical mechanics of multicentre research in the ED. This article presents strategies for setting up, conducting and participating in multicentre studies in the Australian and international settings. We address the two major categories of multicentre research, collaborative group research based on a group of researchers from a moderate‐sized number of EDs and large‐scale investigator‐led research where a central group of investigators leads a large pool of research sites. Although we focus on clinical trials, the basic principles also apply to multicentre observational studies.     

Identification of perceived barriers of pain management in Iranian children: a qualitative study

Hospitalized children are often inadequately treated for their pain. Paediatric nurses experience these inadequacies more than other health-care team members. This research was an attempt in the form of a phenomenological study to reveal some major barriers in children pain management as the nurses had perceived. Sixteen nurses were interviewed in the medical, surgical and infectious paediatric wards of a hospital in Iran. Data analysis were based on Colaizzi method that surfaced three main themes in different areas namely: organizational barriers, limitations relating to child's characteristics and barriers relating to the nature of disease and its treatments. The study results have shown organizational limitations added to the lack of authority for administering some medical intervention, inadequate equipment and utilities and unavailability of opioids as the main pain controlling and restricting factors. Additional factors that relate to the child specifications like age, temperament, behaviour, expression and gender affect the assessment and treatment of pain. The results revealed identified barriers in real context. It seems that some guidelines are needed to achieve optimal pain management.     

Visceral pain in humans: Lessons from animals

Acute and persistent neuropathic and inflammatory injuries of healthy animals have contributed importantly to our current understanding of nociception and pain. Studies have differentiated somatic from visceral nociceptive input, and elucidated the pathways of transduction, transmission, perception, and modulation of the input. Other animal studies have identified important genetic and environmental influences on responses to nociception. Studies of naturally occurring visceral pain syndromes in animals also have added to our understanding of comparable syndromes in humans. Because of the aversive nature of pain, use of healthy animals to study pain in the service of other animals and humans is a decision to be taken carefully, and carries with it the responsibility of treating the animals as humanely as possible.     

Learning to navigate the healthcare system in a new country: a qualitative study

Objective: Learning to navigate a healthcare system in a new country is a barrier to health care. Understanding more about the specific navigation challenges immigrants experience may be the first step towards improving health information and thus access to care. This study considers the challenges that Thai and Filipino immigrant women encounter when learning to navigate the Norwegian primary healthcare system and the strategies they use.

Design: A qualitative interview study using thematic analysis.

Setting: Norway.

Participants: Fifteen Thai and 15 Filipino immigrant women over the age of 18 who had been living in Norway at least one year.

Results: The women took time to understand the role of the general practitioner and some were unaware of their right to an interpreter during consultations. In addition to reliance on family members and friends in their social networks, voluntary and cultural organisations provided valuable tips and advice on how to navigate the Norwegian health system. While some women actively engaged in learning more about the system, they noted a lack of information available in multiple languages.

Conclusions: Informal sources play an important role in learning about the health care system. Formal information should be available in different languages in order to better empower immigrant women.     

Work-based learning: a leadership development example from an action research study of shared governance implementation

AIM: An empowering action research study was undertaken to evaluate and strengthen the implementation of shared governance. One aim was to identify factors that acted as aids or barriers to effective decision-making by clinical leaders. As a work-based learning approach, action research was expected to lead to integration of learning into practice by researcher and participants alike. BACKGROUND: Shared governance replaces traditional hierarchies and requires and develops clinical leaders. Strategies are needed to maximize learning from introduction of such initiatives at the individual, group and organizational level. METHODS: Participant-observations and interviews were undertaken with shared governance council members from one model in north-west England. RESULTS: Leadership skills and knowledge and shared governance practices were significantly enhanced. Preparation for council roles was considered inadequate. Increased structured time for reflection and action planning was indicated. CONCLUSIONS: Implementation of shared governance has succeeded in developing leadership capacity. Evaluation findings have led to improvements in the overall shared governance model. Action research has been found to have great utility at optimizing work-based learning. Nurse Managers need to develop their coaching and facilitating skills and recognize there is no "quick fix" for developing clinical leaders. Implications include the need to support learners in identifying and implementing changes arising from work-based learning activities, the significant resource implications and the need to optimize the organizational climate if work-based learning approaches to leadership and management development are to succeed.     

Depression in painful chronic disorders: The role of pain and conflict about pain

Chronic pain severity, the responses of the significant other to the patient's pain, and social network relationships were investigated for their contributions to depression among patients with myofascial pain disorders (N= 67) and arthritis (N= 83). Interview data were gathered using the Beck Depression Inventory, McGill Pain Inventory, Multidimensional Pain Inventory, and Interpersonal Relationships Inventory. Patients with myofascial pain disorders reported significantly more severe depression and pain, more conflict about their pain, and more network conflict than those with arthritis. They also reported less network social support. After controlling for the type of painful chronic disorder, multiple linear regression analyses indicated that more severe depression was significantly associated with more severe pain, conflict about pain, and less network social support. Conflict about pain may increase the risk of depression for patients with chronic painful disorders. Patients with myofascial pain disorders, however, may experience more conflict about their pain because of the absence of objective physical findings that corroborate the report of pain.     

The use of audit in acute pain services: a UK perspective

Clinical audit aims to improve the quality of patient care. It identifies, from research evidence, the best treatment for patients, measures current practice and then attempts to improve any deficiencies in order to improve the quality of clinical care. This review will outline the successive steps required to implement the clinical audit, identify the barriers to change, highlight examples of well-conducted acute pain audit and introduce the concept of measuring quality within acute pain services. In addition, the role of clinical audit in national clinical effectiveness strategies will be explored. Recent changes in the law restricting access to patients’ confidential data may have a profound bearing on audit, epidemiological research and ultimately clinical governance and the future implications for large-scale investigative audit will be discussed.     

A failed fall prevention study in an acute care setting: Lessons from the swamp

Designing and implementing fall intervention studies in acute care settings presents researchers with a number of challenges. To date, there are no fall prevention interventions that have unequivocal empirical support in these settings. Based on the best available evidence a multistrategy fall prevention program was implemented using a pretest-post-test design over a 12-month period. The results indicated no reduction in the fall rate. Contrary to the expected result, the fall rate increased post the implementation of the multistrategy fall prevention program. To assist other researchers understand the contextual and methodological barriers to conducting fall prevention research in acute care settings, this paper discusses the difficulties experienced in this study.     

Perspectives on research evidence and clinical practice: a survey of Australian physiotherapists

Background and Purpose . Physiotherapists' use of research evidence with clinical decision‐making has interested researchers world‐wide since 1980; however, little is known about such practices in Australia. The present survey sought information on Australian physiotherapists' perceptions of the importance of research, and barriers to uptake of evidence in clinical practice, when compared with an international cohort from 2001. Method . An Australian‐relevant version of an English (UK) National Health Service (NHS) survey instrument was used to canvass 453 physiotherapists, randomly selected from the South Australian Physiotherapy Registration Board 2004–2005 records. The first survey was mailed in August 2005, a reminder was sent two weeks later to non‐responders and a follow‐up survey was sent in April 2006 to non‐responders whose addresses had changed since 2005. Results . There was a 51% response rate. Of the non‐responders, 12% were not contactable at their listed address, highlighting the mobility of Australian physiotherapists. Most respondents had undertaken research as students (59.5%) or as students and clinicians (11.5%). Of these, 37.1% were encouraged to embark on more research, and 20.5% were discouraged. The significant predictors of positive perceived importance of research were: previous research experience; being positive about undertaking further research; working in hospitals and holding a postgraduate degree. Clinicians working privately were significantly less likely than managers to be positive about research importance. The only significant predictor for not perceiving barriers to uptake of evidence was being positive about undertaking future research. Conclusions . The study identified constraints on uptake of evidence into practice that were related to accessing, reading and interpreting published research, and implementing findings. Found consistently across employment categories were barriers relating to lack of time, uncertainty about what the research reported, scepticism about the value of research and being isolated from peer support and literature sources. The responses indicated a positive shift towards evidence uptake since the 2001 NHS survey, suggesting an influence of increased exposure to information on evidence‐based practice. A greater focus on research whilst training, the application of educational strategies for empowerment, better knowledge transfer and upskilling within the workplace, and ensuring dedicated time and organizational support for research activities are indicated. Copyright © 2007 John Wiley & Sons, Ltd.     

Neuropathic pain phenotyping as a predictor of treatment response in painful diabetic neuropathy: Data from the randomized,double-blind,COMBO-DN study

Sensory profiles are heterogeneous in neuropathic pain disorders, and subgroups of patients respond differently to treatment. To further explore this, patients in the COMBO-DN study were prospectively assessed by the Neuropathic Pain Symptom Inventory (NPSI) at baseline, after initial 8-week therapy with either duloxetine or pregabalin, and after subsequent 8-week combination/high-dose therapy. Exploratory post hoc cluster analyses were performed to identify and characterize potential subgroups through their scores in the NPSI items. In patients not responding to initial 60 mg/d duloxetine, adding 300 mg/d pregabalin for combination treatment was particularly effective regarding the dimensions pressing pain and evoked pain, whereas maximizing the duloxetine dose to 120 mg/d appeared more beneficial regarding paresthesia/dysesthesia. In contrast, adding 60 mg/d duloxetine to 300 mg/d pregabalin in case of nonresponse to initial pregabalin led to numerically higher decreases in all NPSI dimensions/items compared to maximizing the pregabalin dose to 600 mg/d. Cluster analysis revealed 3 patient clusters (defined by baseline scores for the 10 NPSI sensory items) with different pain profiles, not only in terms of overall pain severity, but also across NPSI items. Mean Brief Pain Inventory average pain improved in all clusters during combination/high-dose therapy. However, in patients with severe pain, the treatment effect showed a trend in favor of high-dose monotherapy, whereas combination therapy appeared to be more beneficial in patients with moderate and mild pain (not significant). These complementary exploratory analyses further endorse the idea that sensory phenotyping might lead to a more stratified treatment and potentially to personalized pain therapy.     

Femoral neck stress fracture presenting as gluteal pain in a marathon runner: case report

A case is described of a 50-year-old man with a femoral neck stress fracture presenting as gluteal pain. An operative pinning procedure of the femoral neck was performed for stabilization. Femoral neck stress fractures are often misdiagnosed early in their presentation. The signs and symptoms can mimic those of more commonly seen disorders. Appropriate physiatric history and physical examination, along with indicated studies, will help prevent misdiagnosis and potentially serious complications associated with musculoskeletal pathology.     

Lessons learned and advice from Vietnam war nurses: a qualitative study

AIM: The aim of this paper is to describe guidance for nurses today from the lessons learned by nurses who served in the Vietnam War. BACKGROUND: There is little research focusing on nurses' experiences in the Vietnam War. Lessons learned and subsequent advice from nurses who served in Vietnam may be helpful to those serving in current and future wars. METHODS: A Husserlian phenomenological approach was taken, using interviews with a purposive sample of Registered Nurses who were female, and had served in the United States of America armed forces in Vietnam during the war. FINDINGS: Seven theme clusters described the lesson learned and guidance offered by the Vietnam War nurses: advice about journaling, training, caring for yourself, use of support systems, talking about your experiences, understanding the mission, and lack of preparation for war. CONCLUSIONS: Much can be learned from the lessons learned and advice given by Vietnam War nurses. These lessons stress that nurses need to take a pro-active role in preparing themselves for deployment to a war zone, and that institutional training for war needs to be intensive and realistic. The environmental, cultural, technological, clinical and psychosocial demands of war nursing need to be comprehensively addressed before nurses deploy to a war.