Evidence-based practice - an incomplete model of the relationship between theory and professional work

RATIONALE, AIMS AND OBJECTIVES: Current day realities of diminishing resources, reductions in spending and organizational change within health care systems have resulted in an increased emphasis on a multidisciplinary team approach to quality patient care. The movement of nursing towards more autonomous practice combined with the current trend towards 'evidence-based practice' in health care demands increased accountability in clinical decision making. This paper focuses on one aspect of nurses' clinical decision making within the demands of evidence-based practice and cardiac surgery. In this field recent advances, combined with increasing demands on health care institutions, have promoted early extubation of post-operative cardiac patients. While this remains a medical role in many institutions, an increasing number of intensive care units now consider it as a nursing role. METHOD: This paper explores the realities of nurses' clinical decision making through a discussion of current practice in the extubation of patients following cardiac surgery. In addition, it considers the implications of current practice for both nurse education and the continued development of clinical nursing practice. CONCLUSION: The findings indicate that evidence-based practice appears to be an incomplete model of the relationship between theory and professional work.     

Professional practice for the extended care environment: learning from one model and its implementation

This article describes a model of professional nursing governance in an 800-bed long-term care facility and discusses the model's implications for nursing education. Seventy registered nurses, 330 ancillary staff, and 50 other health professionals provide care for about 100 residential, 350 intermediate, and 350 skilled nursing care patients in the facility. The governance model includes a registered nurse organization that determines all standards for nursing practice, policies governing practice, and nursing clinical programming. Each registered nurse has 24-hour, seven-days-a-week authority and accountability for a patient caseload. Average annual turnover of registered nurses is 5 per cent, and the average length of employment among the nurses is 7.5 years. Since the model was implemented, measures of patient welfare have increased. Experience with the governance model indicates that nursing education curricula need to increase students' (1) understanding of professional autonomy and accountability, (2) understanding of the role of nursing diagnoses and interventions to structure nursing knowledge, (3) skills of diagnostic and intervention reasoning, (4) consensus decision-making abilities, (5) knowledge of organizational structures and mechanisms for governance, and (6) mastery of technical intervention skills.     

Instrumentalisation of the health system: An examination of the impact on nursing practice and patient autonomy

Most current management systems of healthcare institutions correspond to a model of market ethics with its demands of competitiveness. This approach has been called managerialism and is couched in terms of much‐needed efficiencies and effective management of budgetary constraints. The aim of this study was to analyse the decision‐making of nurses through the impact of health institution management models on clinical practice. Based on Foucault's ethical theory, a qualitative study was conducted through a discourse analysis of the nursing records in a hospital unit. The results revealed that the health institution standardises health care practice, which has an impact on professional and patient autonomy as it pertains to decision‐making. The results of this research indicate that resistance strategies in the internal structures of health organisations can replace the normalisation and instrumentalisation of professional practice aimed at promoting patient self‐determination.     

Generic professional behaviors: implications for the clinical nurse specialist role

The clinical nurse specialist (CNS) as an advanced practitioner contributes significantly to the provision of comprehensive and sophisticated patient care services. If the CNS is to remain a dominant clinical force in these days of cost consciousness in the health care system, however, clinicians and administrators must justify and define this important clinical role. This article offers a framework for describing the role of the CNS from a pragmatic but conceptually based perspective. A professional practice model is examined and discussed in relation to the authority base for practice, the legal definition of nursing. Issues of social relevance and the tradition of sexism are explored as important factors to consider when validating the CNS role. If the CNS is to have the opportunity to make a difference in the practice setting, the position must survive the budgetary process. Clear explanations of the value of basic and advanced nursing practice in our current health care system are critical.     

Caring and professional practice settings: the impact of technology, change, and efficiency

Technology, change, efficiency, and caring are not necessarily concepts that are used in the same sentence when describing motivational and professional practice settings. Caring within health care organizations can take many forms. One of the most significant and meaningful forms is through building networks for shared decision making and shared accountability. While caring can save the life of a patient and convey trust and commitment to patients, families, and staff, it can also save the life of your organization.     

Critical care outreach: the need for effective decision-making in clinical practice (part 2).

As the extension of nursing into roles previously within the domain of medicine and the demand for evidence based practice continue to increase, the quality of decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and for the patient, especially in the provision of critical care outreach (CCOR), to improve outcomes of care. With changes in health care delivery and increased accountability for practitioners' decisions, it is important to understand more about how clinical decisions are made and what factors influence them in order to inform practice. The previous paper outlined the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In this paper, the authors, a Nurse Consultant in CCOR and a research fellow, examine the process of a practitioner's decision making in the practice of CCOR, through a collaborative reflective account of a case study. From this, recommendations are made about the future development of CCOR practitioners and services.     

The role of quality assurance in future midwifery practice

Recent recommendations have been made which would give midwives a more central role in maternity care and a greater degree of independence than they currently enjoy This paper argues that midwives' current attitudes to quality assurance are incompatible with this enhanced role Research conducted in three health districts is described, which explored the perceptions of nurses, midwives and managers towards quality assurance The findings indicate that quality assurance (in whatever form that concept is operationalized) is a demonstration of accountability For managers this accountability is primarily for the service as a whole, whilst nurses and midwives view their accountability as being owed to patients/clients The main methodology which the study identified as being used for monitoring nursing care was the development and auditing of explicit standards This approach has been actively promoted by the Royal College of Nursing, enabling nurses to regain control of the purely professional aspects of the nursing profession Midwives in the study districts showed a marked reluctance to adopt such a strategy, taking the view that as independent practitioners consensus standards would be unacceptable It is argued that this attitude is inconsistent with the basic principle that professionals are accountable for both demonstrating and developing the quality of professional practice It is further suggested that midwives currently have an opportunity to regain professional control of midwifery practice, which will be lost unless they are prepared to take responsibility for evaluating the standards for which they are accountable     

The nursing shortage: dynamics and solutions. A supportive clinical practice model

In a large VA teaching hospital, the primary nursing care delivery model is established with an all-RN staff. Several new initiatives and incentives have been implemented to maintain nurse satisfaction during this period of nurse shortage, but the primary nurse's relationship with her or his patient is the most satisfying and rewarding opportunity in this setting. The professional profile of the nurse staff reflects high academic preparation, certification in clinical area of practice, and involvement in nursing organizations. Primary nursing is successful because of the availability of support services, which enable the nurse to remain with the patient on the nursing unit. The primary nursing care delivery model and staffing were evaluated and revised to include licensed vocational (practical) nurses as associate nurses. Nurses on staff affirm their authority and autonomy to make and carry out clinical decisions about the nursing care of their primary patients. Physicians recognize nurses as the co-primary care provider in a clinical practice atmosphere of mutual respect and collaboration. New opportunities for professional growth and self-actualization enrich the work environment.     

The challenge facing nursing education: to develop clinical performance examination strategies in nursing practice

The clinical performance examinations of qualified health professionals have become a central professional and corporate issue. Nursing experts have to face trends in nursing care delivery toward a clinical competence-based care model that assesses the professional skills and efficacy of nursing professional and students. Objective, structured clinical examination standards and strategies can be effective vehicles for nursing education and practice, promoting the mastery of clinical nursing skills and fostering an evidenced-based practice approach to clinical care.     

The relationship of authority to decision-making behavior: implications for redesign.

Redesigning health care environments has occurred in response to cost and quality pressures. Efforts to redesign the nursing practice environment have focused on the structure and process of nursing care delivery. When redesign efforts address the structure of nursing practice systems to facilitate one important process, nurses' participation in decision making, better patient and organizational outcomes are expected. The purpose of this study was to determine if two dimensions of structure: administrative (decentralization) and professional authority (expertise) influence the process of participation in decision making for two kinds of decisions (caregiving and condition-of-work) that nurses make. The stratified sample consisted of 300 registered nurses working on medical-surgical units. Administrative and professional authority accounted for a small but significant amount of variation in participation in decision making. Because the extent of explained variation was small, the findings may challenge the prevailing assumption that greater authority for decision making results in the exercise of that authority. Redesign of the practice environment therefore must incorporate multiple factors in achieving greater participation in decision making.     

Health teaching in clinical nursing practice

The Nurses' Board of Western Australia identifies health teaching as one of five essential role competencies in its regulation of professional nursing practice. This implies that patient/client education is recognized as a fundamental component of health care, however there is mounting concern within the profession that nurses are not taking full advantage of teaching opportunities that present in clinical practice. This paper reviews literature about health teaching and suggests that patients should be better informed about their health status and future health maintenance.     

Shaping the advanced practice psychiatric-mental health nursing role: a futuristic model

As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the specialty's capacity for innovation and the profession's capacity for new direction and futuristic change.     

The patient's right to know. Implications for interpersonal communication processes.

The right of a patient to have information about his diagnosis, treatment, and prognosis within the framework of communication processes is discussed from the perspectives of the professional, the patient, and the interaction process. The traditional role of the patient is described with attention given to apparent changes in that role. These changes have implications for the health care practitioner who is a product of the authority structure of academic and clinical institutions steeped in traditional autonomous and unilateral decision making in the mystique of the medical arena.     

Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice

In the United Kingdom nurse practitioners are assuming responsibilities traditionally considered to be within the domain of general practitioners. Important amongst these is the referral of patients to medical consultants in secondary care, a responsibility commonly associated with the general practitioner's role as 'gatekeeper' to health care. This paper describes a study designed to identify issues raised by the challenge that a developing nursing role presents to interprofessional working at the interface between primary and secondary care. When invited to comment, study participants (nurse practitioners, nurse educators, medical consultants and general practice registrars) related nursing referrals to issues associated with professional boundary changes, namely: teamwork, regulation of practice, communication, professional conflict and professional relationships. This paper discusses the views of primary and secondary care practitioners about who should take responsibility for the referral of patients in the light of concerns raised about professional competence and accountability. Individual nurse practitioners and their colleagues have found pragmatic ways to manage their work however, although UK government policy supports development of advanced clinical nursing, there remains much work to be done to provide the professional and legal infrastructure to support the role.     

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.     

Reflective practice and clinical supervision: an interprofessional perspective

BACKGROUND: In the United Kingdom, the drive to encourage reflective practice through clinical supervision, as a means of ensuring quality of provision in nursing and other health care professions, is now well-embedded, not only in policy but also in practice. However, debate and critique of these concepts is limited. AIM: The aim of this paper is to draw on research, conducted with undergraduate occupational therapy students and qualified physiotherapists, in order to contribute to the debate about the functions of clinical supervision and reflective practice in nursing and other health care professions. DISCUSSION: Upholding the notion that clinical supervision has the potential to constitute a form of surveillance, we counter the assumption that it is inevitably confessional in nature. A social constructionist perspective is used to illustrate how clinical supervision might involve a complex interplay of factors that dispel notions of predictability, control and rationality. CONCLUSION: Despite acknowledging tensions, we argue that clinical supervision is both necessary and beneficial. It can be advantageous to individual practitioners and professional groups in enhancing practice and accountability, and promoting professional development.     

Accountability: a fundamental component of nursing practice

The nursing care of the patient makes great demands on nurses' knowledge and skills; the care given must be competent, efficient and effective. In order to achieve this, nurses must have the necessary authority to manage and control their practice. This article seeks to examine the concept of accountability and relates its relevance to everyday nursing practice. A theoretical and critical incident approach is employed to demonstrate the principles surrounding accountability within nursing.     

Developing advanced rural nursing practice: a whole new scope of responsibility

Rural registered nurses’ experiences of advanced clinical nursing practice were explored whilst they were enrolled in an advanced primary care course of study. Thirty-two nurses employed in rural health services in Victoria, Australia, studied advanced practice nursing by distance education with a clinical component. At course conclusion, focus groups and a quantitative on-line survey were conducted to explore outcomes. Nurses reported positive self-perceptions of their educational preparation with scores of >7/10 for competence, confidence, preparedness for advanced practice and job satisfaction. Focus group discussions concurred with positive survey results. The course was valuable in developing skills and knowledge, enabling more holistic patient care. The main themes that emerged related to the advancement of the nurse as a professional, and enhancement of patient care. Within their scope of practice, nurses assessed, diagnosed and treated minor patient illness presentations either independently or collaboratively with medical advice. The context of rural health services dictated practice and levels of autonomy. Nurses perceived the new role reduced an overload of medical work, whilst increasing patients’ access to care. As a result of the course 24% of participants reported a change in their work role. Nurses employed in rural health services reported positive potential for advanced collaborative practice in rural health care, in association with medical professionals. Defined role boundaries, role responsibilities and dedicated advanced practice positions will be required to achieve implementation of the role.     

Fostering evidence-based practice in nursing education.

Accountability for outcomes is a fundamental responsibility of professional nurses. Central to such accountability is the ability of critique existing practice patterns, discriminate between alternative and often conflicting information, and demonstrate sound decision making in a manner that can be empirically supported. Although evidence-based nursing practice offers a framework to support these activities, long-standing patterns impede using a more scientifically based approach to patient care. These barriers are reinforced by the sheer volume of information and conflicting worldviews that characterize the postmodern era. Teaching and learning strategies to address the challenge of evidence-based nursing practice in the information age are offered for review and possible adoption by nurse educators.     

Using nurse-sensitive outcomes to improve clinical practice.

With the many uncertainties in the current health care milieu and continuing movement from general guidelines to ensure an optimal practice approach, it is especially vital that critical care nurses facilitate a research culture in their workplace and strive to improve clinical practice through understanding and evaluating research. Outcomes research helps to identify discipline-specific accountability in patient care. Through understanding the basic aspects of outcomes research and the issues that influence nurse-sensitive outcomes, the critical care nurse is informed and can make clearer and appropriate choices in patient care. Outcomes research continues to be instrumental in defining a base for nursing practice. Although it is not necessary or even desirable that all nurses conduct research, nurses are accountable for providing scientific and appropriate care to ensure the optimal outcome for the patient.