Obesity: translation and testing of a survey instrument for use in Taiwan

Aim and objectives. The purpose of this paper is to describe a cross‐cultural translation and validation methodology recommended by Vallerand. The translation technique has seven steps and ensures the instrument provides data that are valid and reliable. Background. Translation of data collection instruments is a challenge increasingly being faced by overseas students studying in the West as they choose to research contextual issues of relevance to their home culture. Methods. Six of Vallerand's seven steps are used and modified as the methodical translation of a survey from English to Mandarin. Results. The results revealed there was no significant difference between the original English questionnaire and Mandarin questionnaire. The validation study indicated good internal consistency. The construct validity of the Mandarin version was determined except one item which failed the test. The validation demonstrates only minor effects of language translation. Conclusion. The Mandarin version thus is a valid tool for investigating from the perspective of school nurses, their role and potential contribution to health promotion in relation to the prevention of obesity among school children in Taiwan. Relevance to clinical practice. The results of the study will enable school nurses and their managers to reflect critically on their contribution to the prevention of obesity among Taiwanese school children. The translation technique has enabled the researcher to minimize errors that may have occurred in translation. It adds to the quality of the instrument and offers opportunities in the future to undertake cross‐cultural comparison in an issue of great concern globally.     

Adapting the Individualized Care Scale for cross‐cultural comparison

Scand J Caring Sci; 2010; 24; 392–403
Adapting the Individualized Care Scale for cross‐cultural comparison Rationale: Cross‐cultural comparative studies using reliable and valid instruments can increase awareness of the differences and similarities between health worker’s ability to respond to patients’ individual needs within different health systems. This will enable a better understanding of cultural perspectives in individualized nursing care. Aim: To describe the translation and adaptation process of the Individualized Care Scale (ICS) and examine its reliability and validity in a cross‐cultural study. Design: A cross‐sectional comparative study. Settings: Twenty‐seven orthopaedic and trauma in‐patient units at 14 hospitals in 5 countries. Participants: A total of 1126 patients were included in the study: Finland (n = 425), Greece (n = 315), Sweden (n = 218), UK (n = 135) and USA (n = 33). Methods: A systematic forward‐ and back‐translation procedure using bilingual techniques, a committee approach, pretest techniques and pilot testing were used with a convenience sample to produce a valid ICS for each participating group. Psychometric evaluation of the adapted ICS was based on means, SD, missing data analysis, Cronbach’s alpha coefficients and average inter‐item correlations. Construct validity was examined using sub‐scale correlations to total scales and principal components analysis. Results: The use of the range of options and the sub‐scale mean scores ranging from 2.72 to 4.30 demonstrated the sensitivity of the scale. Cronbach’s alpha coefficients (0.77–0.97) and average inter‐item correlations (0.37–0.77) were acceptable. The sub‐scale correlations to total scales were high (0.83–0.97). The underlying theoretical construct of the ICS was demonstrated by the explained variances ranging from 58% to 79%. Conclusions: The ICS shows promise as a tool for evaluating individualized care in European cultures. The international expansion of an existing instrument developed for one country facilitates comparative studies across countries. There is a need to further test the construct validity and appropriateness of the ICS in different settings in European and nonwestern cultures.     

New measures of diabetes self‐care agency,diabetes self‐efficacy,and diabetes self‐management for insulin‐treated individuals with type 2 diabetes

Aims and objectives. To develop and refine three new scales that measure diabetes self‐care agency, diabetes self‐efficacy and diabetes self‐management to reflect the American Diabetes Association current standards of diabetes care and the American Association of Diabetes Educators self‐care behaviours. And, to establish the clarity, consistency and content validity of the scales. Background. There is a need to have valid and reliable instruments or scales to assess an individual’s diabetes self‐care agency, self‐efficacy and self‐management to plan appropriate interventions that can be effective in improving glycaemic control and delaying or preventing diabetes‐related complications. Design. A methodological design was used to conduct this study. Methods. Ten clinicians and 10 insulin‐treated individuals with type 2 diabetes (T2DM) from a diabetes care center in the southern USA participated in this study. Analysis consisted of inter‐rater agreement to determine clarity and consistency with standards of diabetes care and content validity of individual items on the scales (I‐CVI) and the overall scales (S‐CVI/Ave) to determine relevance for current diabetes care practice. Results. All I‐CVI and S‐CVI/Ave of the DSES exceeded the minimum acceptable criteria. All I‐CVI and the S‐CVI of the DSMS also exceeded the minimum accepted criteria, except for one item that had I‐CVI = 0·70. Evaluation of the items and the directions of the scales by the sample of insulin‐treated individuals with T2DM exceeded the minimum criteria of 80% inter‐rater agreement. Relevance to research and clinical practice. Further psychometric testing of the scales with samples of insulin‐treated individuals with diabetes is warranted and will lay the groundwork for further research and clinical practice to enhance the capability, confidence and actual performance of diabetes self‐management activities among insulin‐treated individuals with T2DM. Conclusions. The scales can be used by diabetes care providers to assess and follow‐up individuals with diabetes who need intense case management. They also can be the measures of choice to conduct future research to test the effects of interventions among insulin‐treated individuals with T2DM.     

Implementation of evidence‐based health care using action research: An emancipatory approach

The aim of the study is to discuss the emancipatory approach to action research as an appropriate methodology for workers' meaningful implementation of evidence‐based health care. Implementation of evidence‐based health care using action research is well supported by the literature. There are various approaches to action research, and they are coherent with the objectives and methods elected to develop the investigation. It is not clear which approach of action research is responsible for meaningful worker engagement in changing praxis. This is a discussion paper based on our experiences and supported by literature on collective health. Health care is defined as a social praxis, dependent upon the capitalist mode of production in which health workers engage themselves in a labour process that has negative (as alienation) as well as positive (as creativity) meanings. Emancipatory changes of social praxis through implementation of evidence‐based health care require that participants understand the positive and negative meanings of their work and engage health workers in a conscious and intentional collaborative educational process. Implementation of evidence‐based health care through emancipatory action research is capable of overcoming alienation and changing social practice through a participatory meaningful process of knowledge translation.     

Quality Assessment of Neonatal Pain Scales Translated and Validated to Brazilian Portuguese: A Systematic Review of Psychometric Properties

ObjectivesThe objective of this systematic review was to identify and describe the psychometric properties of neonatal pain scales that were translated into Brazilian Portuguese and to verify the methodological quality of these translation, transcultural adaptations and validation.DesignThe present study is a systematic review. A systematic search in the literature included studies of development, validation, and transcultural adaptation of neonatal pain scales to Brazilian Portuguese. The instruments must have been developed for health care professionals to evaluate neonatal pain and stress in full-term and preterm newborns.Data SourcesThe search strategy was conducted in PubMed, Web of Science, Scopus, and Scielo databases following The PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).Review /Analysis MethodsA total of 1,479 publications were identified and 5 fulfilled the inclusion criteria, with 4 instruments evaluated. For the methodological quality analysis of the measurement properties of the instruments the Consensus-based Standards for Health Measurement Instruments (COSMIN) Risk of Bias checklist was used. The psychometric properties verified were internal consistency, content validity, reliability, and construct validity.ResultsThree instruments reviewed were inadequate and one was doubtful.ConclusionsThe neonatal pain scales wich were cross culturally adapted to Brazilian Portuguese were shown to be of low methodological quality based on COSMIM checklist. Caution should be considered for clinical decisions about pain management judgment coming from these instruments.     

Cross‐Cultural Adaptation to the Dutch Language of the PainDETECT‐Questionnaire

Background: The PainDETECT‐Questionnaire (PDQ) helps to identify neuropathic components in patients suffering from pain. It can be used by clinicians in daily practice and in clinical trials. Aim: The aim of this study is to perform a translation and cross‐cultural adaptation of the PDQ for use in the Netherlands and Belgium. Methods: The first phase was to translate and cross‐culturally adapt the PDQ to Dutch. The second phase was to assess the face validity in the Netherlands and Belgium using qualitative and quantitative data collection. Results: The length, the readability, and the clarity of the questionnaire were good for all patients. The questionnaire was judged to have a good layout and to be clearly organized. Conclusion: The PDQ Dutch language Version is a well translated and cross‐culturally adapted questionnaire, which might be useful for screening for neuropathic components of pain in the Netherlands and Belgium.?     

Cross‐Cultural Adaptation of the Quality of Diagnoses,Interventions and Outcomes (Q‐DIO) Instrument into Brazilian Portuguese

PURPOSE: To describe the cross‐cultural adaptation of the Quality of Diagnoses, Interventions and Outcomes instrument into Brazilian Portuguese. METHOD: This process entailed translation, synthesis, back‐translation, expert committee review, and pretesting. FINDINGS: Six items were altered in the Brazilian version, and the scoring system was changed from a five‐point to a three‐point Likert‐type scale. Pretesting was conducted on a sample of 40 randomly selected nursing records. Overall reliability as measured by Cronbach's alpha was 0.96. CONCLUSIONS: Adaptation resulted in a preliminary version of the instrument. IMPLICATIONS FOR NURSING PRACTICE: Assessment of the psychometric properties of the instrument in a larger sample of nursing records is required, and such a study is underway.     

Adaptation and validation of the Japanese version of the Health Education Impact Questionnaire (heiQ‐J) for the evaluation of self‐management education interventions

Aim: In many countries, health education interventions are popular; however, few valid measures exist for evaluation of multifactorial interventions. The aim of the present study was to translate and culturally adapt the widely‐used 8 scale Health Education Impact Questionnaire (heiQ) for the evaluation of the Japanese Specific Health Consultation (SHC) in people with metabolic syndrome. Methods: A draft was generated using a standardized forward and back translation protocol with independent translators and consensus meetings. Pilot testing included cognitive interviews (n = 12) resulting in question refinements. To explore psychometric properties, 250 participants aged between 40 and 64 years (retest = 116) completed the Japanese version of the heiQ (heiQ‐J) and comparator scales, mental health and vitality scales of the Medical Outcomes Study 36 item Short‐Form Health Survey, Sense Of Coherence scale, and Social Support Measurement scale. Results: Cognitive interviews revealed that the translation was understood as intended by participants. Internal consistency (α) was good to very good for all scales (0.70–0.88) and test–retest intraclass correlation coefficients were high (≥0.83). Concurrent validity was supported by high correlation with like scales and weak correlation with dissimilar scales. Conclusion: The translated and adapted heiQ‐J has good face and concurrent validity and is reliable. The heiQ‐J is likely to be a useful measure of the quality and impact of the SHC and return valuable data to clinicians and commissioners of health education in Japan.     

The Pain Self‐Efficacy Questionnaire: Cross‐Cultural Adaptation into Italian and Assessment of Its Measurement Properties

The Pain Self‐Efficacy Questionnaire (PSEQ) is a patient self‐reported measurement instrument that evaluates pain self‐efficacy beliefs in patients with chronic pain. The measurement properties of the PSEQ have been tested in its original and translated versions, showing satisfactory results for validity and reliability. The aims of this study were 2 fold as follows: (1) to translate the PSEQ into Italian through a process of cross‐cultural adaptation, (2) to test the measurement properties of the Italian PSEQ (PSEQ‐I). The cross‐cultural adaptation was completed in 5 months without omitting any item of the original PSEQ. Measurement properties were tested in 165 patients with chronic low back pain (CLBP) (65% women, mean age 49.9 years). Factor analysis confirmed the one‐factor structure of the questionnaire. Internal consistency (Cronbach's α = 0.94) and test–retest reliability (ICC_agreement = 0.82) of the PSEQ‐I showed good results. The smallest detectable change was equal to 15.69 scale points. The PSEQ‐I displayed a high construct validity by meeting more than 75% of a priori hypotheses on correlations with measurement instruments assessing pain intensity, disability, anxiety, depression, pain catastrophizing, fear of movement, and coping strategies. Additionally, the PSEQ‐I differentiated patients taking pain medication or not. The results of this study suggest that the PSEQ‐I can be used as a valid and reliable tool in Italian patients with CLBP.     

The German version of the Assessment of Chronic Illness Care: instrument translation and cultural adaptation

Background In Switzerland, there is a dearth of information on the extent to which patients with chronic illnesses receive care congruent with the Chronic Care Model (CCM). To drive quality improvement programmes, it is necessary to have practical assessment tools in the country's own language to evaluate the delivery of CCM activities. Methods German translation and adaptation of the original Assessment of Chronic Illness Care (ACIC). We followed a sequential forward and backward translation approach. In a multidisciplinary committee review the original English version and the translations were compared, instructions and formats modified and cross‐cultural equivalences verified. The second version was pre‐tested and multidisciplinary group discussion led to the final version which aimed to create a comprehensive culturally adapted translation capturing the original idea of the items rather than a direct one to one translation. Results Difficulties encountered during the translation process consisted in the difference of health care settings and health care organization in Switzerland and USA.The adapted German version was delivered to a managed care organization in the city of Zurich to test the initial use for diabetes care. The average ACIC subscale scores were: organization of the health care delivery system: mean (m) = 7.31 (SD = 0.79), community linkages: m = 3.78 (SD = 1.09), self‐management support: m = 4.88 (SD = 1.21), decision support: m = 4.79 (SD = 1.16), delivery system design: m = 5.56 (SD = 1.28) and clinical information systems: m = 4.50 (SD = 2.69). Overall, the ACIC subscale scores were comparable with the scores of the original testing. Conclusion After cultural adaptations the German version of the ACIC is applicable as a tool to guide quality improvement in chronic illness care in German speaking countries in Europe.     

Cross‐cultural validity of the Individualised Care Scale – a Rasch model analysis

Aims and objectives. The aim of this study was to investigate, using Rasch model analysis, the measurement invariance of the item ratings of the Individualised Care Scale. Background. Evidence of reliability is needed in cross‐cultural comparative studies. To be used in different cultures and languages, the items must function the same way. Design. A methodological and comparative design. Methods. Secondary analysis of data, gathered in 2005–2006 from a cross‐cultural survey using the Individualised Care Scale from Finnish, Greek, Swedish and English predischarge hospitalised orthopaedic and trauma patients (n = 1093), was used. The Rasch model, which produces calibrations (item locations and rank) and item fit statistics, was computed using the Winstep program. Results. The rank of average Individualised Care Scale item calibrations (?2·26–1·52) followed a generally similar trend (Infit ≤ 1·3), but slight differences in the item rank by country were found and some item misfit was identified within the same items. There was some variation in the order and location of some Individualised Care Scale items for individual countries, but the overall pattern of item calibration was generally corresponding. Conclusions. The Rasch model provided information about the appropriateness, sensitivity and item function in different cultures providing more in‐depth information about the psychometric properties of the Individualised Care Scale instrument. Comparison of the four versions of the Individualised Care Scale – patient revealed general correspondence in the item calibration patterns although slight differences in the rank order of the items were found. Some items showed also a slight misfit. Based on these results, the phrasing and targeting of some items should be considered. Relevance to clinical practice. The Individualised Care Scale – Patient version can be used in cross‐cultural studies for the measurement of patients’ perceptions of individualised care. Information obtained with the use of the Individualised Care Scale in clinical nursing practice is important, and valid measures are needed in evaluating patients’ assessment of individualised care, one indicator of care quality.     

Reliability,validity and factor structure of the Appraisal of Self‐Care Agency Scale – Revised (ASAS‐R)

Rationale, aims and objectives Self‐care agency is a fundamental concept in nursing and health care research. Having self‐care agency enhances an individual's health‐promoting behaviours and/or specific capabilities for chronic disease self‐management. The purpose of this study was to continue the development and psychometric testing of the Appraisal of Self‐Care Agency – Revised (ASAS‐R). Methods A cross‐sectional methodological design was used to examine the reliability, validity and factor structure of the ASAS‐R among individuals from the general population. The sample consisted of 629 adults who were randomly selected to conduct an exploratory factor analysis (EFA; n = 240) and a confirmatory factor analysis (CFA; n = 389) of the scale. A demographic questionnaire, the ASAS‐R and the Health‐Promoting Lifestyle Profile (HPLP‐II) were the measures used to collect the data. Results The final 15‐item three‐factor ASAS‐R had an overall Cronbach's alpha (α) of 0.89. The three factors extracted, rotated and scored in this study were labelled: having power for self‐care, developing power for self‐care and lacking power for self‐care. All inter‐items and item‐to‐total correlations met recommended criteria of r = 0.30 to r = 0.70, except for one of the items that had an item‐to‐total correlation of 0.71, slightly exceeding the maximum recommended item‐to‐total correlation. The three factors had Cronbach's alphas of 0.86, 0.83 and 0.79, respectively. The three factors together explained 61.7% of the scale items variance. Each item of the scale had a strong factor loading ranging from 0.52 to 0.81. All measures of model fit exceeded the recommended criteria, indicating that the 15‐item ASAS‐R had a very good fit (χ²/d.f. = 1.97, GFI = 0.94, AGFI = 0.92, CFI = 0.96, TLI = 0.95, RMSEA = 0.05, RMR = 0.05 and the PCLOSE = 0.48). Conclusions The 15‐item three‐factor ASAS‐R is a short, reliable and valid instrument to measure self‐care agency among individuals from the general population, but further psychometric evaluation is needed among individuals with chronic diseases, especially those with diabetes mellitus.     

‘One mission accomplished,more important ones remain’: commentary on Every‐Palmer,S., Howick,J. (2014) How evidence‐based medicine is failing due to biased trials and selective publication. Journal of Evaluation in Clinical Practice, 20 (6), 908–914

Every‐Palmer and Howick suggest that evidence‐based medicine (EBM) is failing in its mission because of contamination of research by manufacturer and researcher‐motivated bias and self‐interest. They fail to define that mission and to distinguish between the EBM movement and the research enterprise it was developed to critique. An educational movement, EBM accomplished its mission to simplify and package clinical epidemiological concepts in a form accessible to clinical learners. Its wide adoption within educational circles fostered critical literacy among several generations of practitioners. Illumination of bias, subterfuge and incomplete reporting of research has been a strength of EBM. Increased uptake and use of clinical research within the health care system properly defines the failing mission that eludes Every‐Palmer and Howick. Responsibility for failure to make progress towards its achievement is shared by virtually all relevant streams within the system, including policy, clinical guideline development, educational movements and the development of approaches to evidence synthesis. Discordance between the epistemological premises pervading today's research and health care community and the complex social processes that ultimately determine research use constitutes an important factor that must be addressed as part of a remedy. Enhanced emphasis on and demonstration of alternative approaches to research such as realism and realist synthesis and the momentum towards development of a learning health care system hold promise as guideposts for the rapidly evolving health care environment.     

Testing two self‐care‐related instruments among older home‐dwelling people in Norway

Background. Older persons’ ability and agency for self‐care is an important issue. Therefore, the development of reliable and valid instruments to measure self‐care with regard to both clinical nursing practice and personal health is important for nursing research and practice. Aim and objective. To test reliability and validity of the Norwegian versions of the two self‐care‐related instruments, the Self‐care Ability Scale for the Elderly (SASE) and the Nutritional Form For the Elderly (NUFFE) among older home‐dwelling individuals. Methods. A postal questionnaire that contained these instruments, background variables, health‐related questions and two other self‐care‐related instruments was completed by a randomised sample of 158 older persons in southern Norway. Reliability was assessed as internal consistency and validity as concurrent and construct validity. Results. SASE reached a Cronbach’s alpha coefficient of 0.85 and significant Spearman’s rank correlations for 16 of 17 items. For NUFFE, a Cronbach’s alpha coefficient of 0.64 was obtained and significant correlations for 13 of 15 items. Validity was supported for both instruments. An appropriate cut‐off was found for SASE. For NUFFE, a low cut‐off point was obtained. Conclusions. SASE was shown to have sufficient psychometric properties and can be used in research and clinical practice among older persons. Implications for practice. The psychometric properties of NUFFE can be assessed as sufficient, but further studies are needed regarding the cut‐off point.     

Reliability and validity of the caregiver quality of life index‐cancer (CQOLC) scale in Turkish cancer caregivers

Aims and objectives. The aim of this study was to translate the Caregiver Quality of Life Index‐Cancer into Turkish and test the reliability and validity of the Turkish version of the Caregiver Quality of Life Index‐Cancer in Turkey. Background. Cancer is a chronic illness that affects the entire family and deteriorates the quality of life of cancer caregivers. The Caregiver Quality of Life Index‐Cancer is a widely used instrument to measure quality of life in cancer caregivers. Therefore, identifying and increasing quality of life benefits of cancer caregivers. Design. Methodological research design. Method. This study describes the translation process of The Caregiver Quality of Life Index‐Cancer into Turkish and testing its reliability and validity on quality of life in cancer caregivers. The questionnaire was translated using a back‐translation technique. The statistical analysis was carried out using Cronbach’s alpha to test the internal consistency of the Caregiver Quality of Life Index‐Cancer scale while confirmatory and exploratory factor analyses were carried out using principal component analysis with varimax rotation and Kaiser Normalization to test its construct validity. Results. The Cronbach’s alpha was found to be reliability for the total scale was 0·88 and subscale alpha coefficients ranged from 0·73–0·83. Confirmatory factor analysis resulted in four factor structure: burden, distruptiveness, positive adaptation and financial concerns. Conclusion. The effects of providing care for patients with cancer on caregiver quality of life have not yet been adequately explored in Turkey. The results of this study suggest that the Turkish version of the Caregiver Quality of Life Index‐Cancer is a reliable and valid supplementary measure of the quality of life in cancer caregivers in Turkey. Relevance of clinical practice. In research and practice, valid measurement instruments are needed to assess Quality of Life in Turkish cancer caregivers. The Caregiver Quality of Life Index‐Cancer scale is simple to administer and nurses by using this equipment in routine appointments will be able to better identify caregiver at risk for developing cancer related distress and worse Quality of Life.     

Two new tools for self‐care in ostomy patients and their informal caregivers: Psychosocial,clinical, and operative aspects

Stoma patients and their caregivers need to be autonomous in stoma care, but there are few instruments for measuring the level of self‐care. This study aims to develop and test the psychometric properties of the Ostomy Self‐Care Index (OSCI) and the Caregiver Contribution to Self‐Care in Ostomy Patient Index (CC‐OSCI), from a clinical, operative and psychosocial perspective. A multicentre validation study was conducted on a convenience sample of 468 ostomy patients and 227 caregivers. The signed informed consent forms were obtained before data collection. Tool validation was performed by testing content validity, construct validity, criterion and internal consistency. Two indexes were developed, building on the self‐care theory of chronic illness. For the OSCI, 32 items were developed and grouped into four 5‐point Likert scales: maintenance, monitoring, management and confidence. For the CC‐OSCI, 22 items were developed and grouped into three 5‐point Likert scales: maintenance, monitoring and management. The content validity indexes for the OSCI and CC‐OSCI were 95% and 93%, respectively. Exploratory factor analysis showed appropriate factor loadings (OSCI: min 0.395 to max 0.852; CC‐OSCI: min 0.442 to max 0.841). Criterion validity was established through significant correlation between levels of quality of life, complications, readmissions and self‐care in patients and caregivers. Strong internal consistency was found for the overall index, and within the scales (OSCI: α = 0.975; CC‐OSCI: α = 0.972). The OSCI and CC‐OSCI are valid and reliable indexes. Further studies specifically aimed at predicting the level of self‐care are especially recommended.     

Cultural adaptation and translation of measures: An integrated method

Differences in the conceptualization and operationalization of health‐related concepts may exist across cultures. Such differences underscore the importance of examining conceptual equivalence when adapting and translating instruments. In this article, we describe an integrated method for exploring conceptual equivalence within the process of adapting and translating measures. The integrated method involves five phases including selection of instruments for cultural adaptation and translation; assessment of conceptual equivalence, leading to the generation of a set of items deemed to be culturally and linguistically appropriate to assess the concept of interest in the target community; forward translation; back translation (optional); and pre‐testing of the set of items. Strengths and limitations of the proposed integrated method are discussed. © 2010 Wiley Periodicals, Inc. Res Nurs Health 33:133–143, 2010     

Protocol‐based care: the standardisation of decision‐making?

Aim. To explore how protocol‐based care affects clinical decision‐making. Background. In the context of evidence‐based practice, protocol‐based care is a mechanism for facilitating the standardisation of care and streamlining decision‐making through rationalising the information with which to make judgements and ultimately decisions. However, whether protocol‐based care does, in the reality of practice, standardise decision‐making is unknown. This paper reports on a study that explored the impact of protocol‐based care on nurses’ decision‐making. Design. Theoretically informed by realistic evaluation and the promoting action on research implementation in health services framework, a case study design using ethnographic methods was used. Two sites were purposively sampled; a diabetic and endocrine unit and a cardiac medical unit. Methods. Within each site, data collection included observation, postobservation semi‐structured interviews with staff and patients, field notes, feedback sessions and document review. Data were inductively and thematically analysed. Results. Decisions made by nurses in both sites were varied according to many different and interacting factors. While several standardised care approaches were available for use, in reality, a variety of information sources informed decision‐making. The primary approach to knowledge exchange and acquisition was person‐to‐person; decision‐making was a social activity. Rarely were standardised care approaches obviously referred to; nurses described following a mental flowchart, not necessarily linked to a particular guideline or protocol. When standardised care approaches were used, it was reported that they were used flexibly and particularised. Conclusions. While the logic of protocol‐based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses’ decision‐making process. This has significant implications for the political goal of standardisation. Relevance to clinical practice. The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses’ decision‐making processes in parallel to paying attention to the influence of context.