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.     

Factors impacting on shared care working relationships between practice nurses and general practitioners: a literature review

Practice nurses have worked in general practice for many years yet little is known or published in Australia about their work. Recent health care reforms in Australia, particularly the establishment of the Divisions of General Practice and various best-practice innovations linked to the National GP Strategy have seen an increase in the role of practice nurses. Despite this GPs in Australia are cautious about the role of practice nurses. Much of this caution arises from reform in general practice in Britain particularly the establishment of fund-holding for general practice. This article reviews the literature on practice nurses in Britain and Australia within the framework of the health reforms in general practice in both countries.     

Caught in the middle: experiences of tobacco-dependent nurse practitioners

PURPOSE: To explore how tobacco-dependent nurse practitioners (NPs) describe their experiences with health promotion and disease prevention practices with patients who smoke. DATA SOURCES: Twelve NPs who completed a graduate level NP program of study participated in face-to-face interviews and/or online chat room interviews. CONCLUSIONS: Participants' responses revealed three themes relevant to their experience as tobacco-dependent clinicians with health promotion responsibilities. These themes centered around (a) living as an insider in the world of tobacco addiction, (b) having the outside-in view of living with a tobacco addiction, and (c) being caught in the middle of a tobacco addiction. IMPLICATIONS FOR PRACTICE: All of the tobacco-dependent participants described limited smoking-cessation interventions with their patients. A barrier to implementation of more aggressive interventions, perhaps, is the provider's own tobacco addiction. With increasing evidence that tobacco-dependent health care professionals are not adequately intervening with tobacco-dependent patients, effective strategies are needed to assist and/or support not only tobacco-dependent patients but providers as well.     

From competence to capability: a study of nurse practitioners in clinical practice

Aims and objectives. This research aimed to understand the level and scope of practice of the nurse practitioner in Australia and New Zealand further using a capability framework. Background. The original study, from which the present paper was developed, sought to identify competency standards for the extended role of the nurse practitioner in Australia and New Zealand. In doing so the researchers became aware that while competencies described many of the characteristics of the nurse practitioner they did not manage to tell the whole story. In a search of the literature, the concept of capability appeared to provide a potentially useful construct to describe the attributes of the nurse practitioner that went beyond competence. Design. A secondary analysis of data obtained from interviews with nurse practitioners working in Australia and New Zealand was undertaken. These data had previously been obtained in a study to identify nurse practitioner competencies. The analysis described in this paper investigated whether or not the components of capability would adequately explain the characteristics of the nurse practitioner. Methods. Fifteen nurse practitioners were interviewed from Australia and New Zealand. A secondary (deductive) analysis of interview data using capability as a theoretical framework was conducted. Results. The analysis showed that capability and its dimensions is a useful model for describing the advanced level attributes of nurse practitioners. Thus, nurse practitioners described elements of their practice that involved: using their competences in novel and complex situations as well as the familiar; being creative and innovative; knowing how to learn; having a high level of self‐efficacy; and working well in teams. Conclusions. This study suggests that both competence and capability need to be considered in understanding the complex role of the nurse practitioner. Relevance to clinical practice. The dimensions of capability need to be considered in the education and evaluation of nurse practitioners.     

Patterns of practice: Master's prepared nurse practitioners

Graduates of the Primary Care-Family Nurse Clinician Program at the University of Pennsylvania School of Nursing were surveyed as part of an overall, ongoing evaluation of graduate level primary care education in the school. The main focus of the survey was to discover the scope of practice characteristic of the program graduates. The survey revealed that the majority of graduates were providing direct patient care, while some were teaching primary care or embarking on related forms of practice. The graduates were found to be involved in assessment, education and counseling, and were working with physicians and others to provide comprehensive patient care.     

Clinical practice characteristics of gerontological nurse practitioners: a national study

PURPOSE: To determine the clinical practice characteristics of gerontological nurse practitioners (GNPs) in the United States and ascertain whether length of employment, geographic region of practice, work setting, and educational preparation influence GNPs' delivery of advanced clinical services and clinical procedures. DATA SOURCES: The Gerontological Nurse Practitioner Practice Profile was mailed to a stratified random sample of 1000 GNPs certified by the American Nurses Credentialing Center. CONCLUSIONS: Despite the growing demands for GNPs, of the 472 GNPs who responded to the survey, only half were working full-time as a GNP. Although the role was established over 30 years ago, 56% of the respondents indicated that they were the first GNP in the position. There was a statistically significant positive relationship between being the first GNP in his or her practice and the percent of primarily medical advanced clinical services performed. GNPs who worked in multiple clinical setting performed more advanced clinical services and medical procedures than GNPs who only worked in one setting. IMPLICATIONS FOR PRACTICE: This study provides insight into the complex practice characteristics of GNPs. GNPs are combining the nursing skills so necessary to care for older adults with advanced clinical services and clinical procedures deemed medical acts. Various factors influence how GNPs practice, including geographic location, type of practice, and whether the GNP was the first person to be employed as a nurse practitioner at the practice.     

Adherence to a guideline on cardiovascular prevention: a comparison between general practitioners and practice nurses

Background

Patient non-compliance with prescribed treatment is an important factor in the lack of success in cardiovascular prevention. Another important cause is non-adherence of caregivers to the guidelines. It is not known how doctors and nurses differ in the application of guidelines. Patient compliance to treatment may vary according to the type of caregiver.

Objective

To compare adherence to cardiovascular prevention delivered by practice nurses and by general practitioners.

Setting

Six primary health care centres in the Netherlands (25 general practitioners, six practice nurses).

Methods

701 high risk patients were included in a randomised trial. Half of the patients received nurse-delivered care and half received care by general practitioners. For 91% of the patients treatment concerned secondary prevention. The Dutch guideline on cardiovascular prevention was used as protocol. A structured self-administered questionnaire was sent by post to patients. Data were extracted from the practice database and the questionnaire.

Results

Intervention was received by 77% of respondents who visited the practice nurse compared to 57% from the general practitioner group (OR = 2.56, p < 0.01). More lifestyle intervention was given by the practice nurse; 46% of patients received at least one lifestyle intervention (weight, diet, exercise, and smoking) compared to 13% in general practitioner group (OR = 3.24, p < 0.001). In addition, after one year more patients from the practice nurse group used cardiovascular drugs (OR = 1.9, p = 0.03). Nurses inquired more frequently about patient compliance to medical treatment (OR = 2.1, p < 0.01). Regarding patient compliance, no statistical difference between study groups in this trial was found.

Conclusion

Practice nurses adhered better to the Dutch guideline on cardiovascular prevention than general practitioners did. Lifestyle intervention advice was more frequently given by practice nurses. Improvement of cardiovascular prevention is still necessary. Both caregivers should inquire about patient adherence on a regular basis.     

Shifting patterns of practice: nurse practitioners in a managed care environment

The purpose of this qualitative study was to uncover patterns across nurse practitioner (NP) experiences that contribute to understanding their perceptions of managed care, how it affects daily practice, and how NPs respond to a changing managed care workplace. In-depth interviews were conducted with 14 NPs representing primary care, specialty, and independent practices. Over an 18-month period, data collection and analysis occurred simultaneously using standard methods of purposive sampling, constant comparison, memoing, and member checks. This study illuminates the tension NPs experience between a business and a professional ethic and the strategies they use to reconcile this difference with core nursing values. Type of setting, workplace dynamics, and length of time in practice contributed to variation in NP perspectives.     

Complementary therapy practice: defining the role of advanced nurse practitioners

The purpose of the study was to identify the current and perceived clinical role functions of advanced nurse practitioners (ANPs) within the complementary health paradigm and their learning needs. Participants were asked to identify their referral practices to complementary practitioners, current and perceived clinical activities with respect to six most popular complementary therapies, learning needs and concerns regarding their use. A random sample of 389 ANPs registered with the College of Nurses of Ontario participated in a mailed survey using a modified Dillman approach, an established method for improving response rate through repeated mailings. An overall response rate of 55.3% (215 out of 389 eligible participants) was achieved. The results show that ANPs are currently engaged in clinical activities involving these therapies, with a trend towards more participation in assessing the need for them and counselling on the risks and benefits. ANPs are interested in validating the use of these therapies and acquiring more knowledge on the scientific principles, evidence of efficacy, pharmacology and potential interactions with conventional medicine.