Blending critical realist and emancipatory practice development methodologies: making critical realism work in nursing research

PARLOUR R and MCCORMACK B. Nursing Inquiry 2012; 19: 308-321 Blending critical realist and emancipatory practice development methodologies: making critical realism work in nursing research This paper examines the efficacy of facilitation as a practice development intervention in changing practice within an Older Person setting and in implementing evidence into practice. It outlines the influences exerted by the critical realist paradigm in guiding emancipatory practice development activities and, in particular, how the former may be employed within an emancipatory practice development study to elucidate and increase understanding pertinent to causation and outcomes. The methodology is based upon an emancipatory practice development approach set within a realistic evaluation framework. This allows for systematic analysis of the social and contextual elements that influence the explication of outcomes associated with facilitation. The study is concentrated upon five practice development cycles, within which a sequence of iterative processes is integrated. The authors assert that combining critical realist and emancipatory processes offers a robust and practical method for translating evidence and implementing changes in practice, as the former affirms or falsifies the influence that emancipatory processes exert on attaining culture shift, and enabling transformation towards effective clinical practice. A new framework for practice development is proposed that establishes methodological coherency between emancipatory practice development and realistic evaluation. This augments the existing theoretical bases for both these approaches by contributing new theoretical and methodological understandings of causation.     

Bridging the research–practice gap: exploring the research cultures of practitioners and managers

To ensure effective utilization of research in nursing more evidence is needed which illuminates the way nurses think about research, the value which they put on it, and how they envisage that it may help or hinder them in their everyday work. This English study aimed to meet these objectives by describing the research culture of practising nurses, health visitors and midwives, and their managers. It rests on two assumptions. Firstly that the reasons why practitioners do, or do not, base their practice on research are complex, and secondly, that interventions to increase research utilization must be grounded in an appreciation of this complex 'whole'. Thus the study took a qualitative approach to exploring: what participants thought and felt about research; the current status of research based practice; and the opportunities and constraints to increasing research based practice. The results confirm the hypothesis that many factors, both individual and organizational affect research utilization. Furthermore, practitioners and managers hold differing perceptions regarding the nature of research, its role, and the opportunities and constraints which effect its dissemination and utilization. The implications of the results for education, policy and practice are discussed.     

The motivation of health professionals to explore research evidence in their practice: An intervention study

Aim. To assess the impact of multifaceted clinically focused educational strategies that concentrated on introducing dementia care research evidence on health professionals’ awareness and inclination to use research findings in their future practice. Background. The promise of evidence‐based practice is slow to materialize with the limitations of adopting research findings in practice readily identifiable. Method. A pre‐ and post‐test quasi experimental design. The study involved the administration of: a pretest (baseline), an intervention phase, and a post‐test survey, the same research utilization survey. Tool. The Edmonton Research Orientation Survey (EROS), a self‐report tool that asks participants about their attitudes toward research and about their potential to use research findings, was used to determine health professionals' orientation to research. Intervention. The introduction of dementia care research evidence through multifaceted clinically focused educational strategies to improve practice. This was achieved through a resource team comprising a Clinical Nurse Consultant, as a leader and resource of localized evidence‐based knowledge in aged care; an experienced Registered Nurse to support the introduction of strategies and a further experienced educator and clinician to reinforce the importance of evidence in change. Results. Across all the four subscales that are measured in the Edmonton Research Orientation Survey, statistical analysis by independent samples t‐test identified that there was no significant change between the before and after measurements. Relevance to clinical practice. Successful integration of changes based on evidence does not necessarily mean that staff become more aware or are more inclined to use research findings in future to address problems.     

Professional and organizational learning: analysing the relationship with the development of practice

BACKGROUND: Organizational and professional learning are interrelated processes that underpin the contemporary drive for a quality evidence-based delivery of health care in the United Kingdom (UK). DESIGN: A soft systems methodology was used to explore the pervasiveness of practice developments. Three case study sites were identified using matrix sampling and data collected through 29 individual interviews and two focus group interviews, with the interviews augmented with a tool designed to maximize analysis of the processes of developing practice. FINDINGS: The resultant model of developing health care practice includes three processes: using and creating knowledge, understanding and practice of patient care, and effecting development. The whole model was underpinned by professional and organizational learning in which 'expert thinkers' engaged in double loop learning to reconceptualize care rather than just perpetuate existing patterns of care delivery.     

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.     

Admiral nursing competency project: practice development and action research

Aims and background. Admiral Nurses are specialist dementia care nurses working in the community with carers of those who have a dementia. The aim of the competency project (2000–2003) was threefold. Firstly to work collaboratively with these specialist nurses to facilitate the development a competency framework that reflects the needs of the Admiral Nursing Service. Secondly, to provide a way to structure evidence demonstrating evolving competency. Thirdly, to specifically enable the nurses to demonstrate evidence of achieving the UK Nursing and Midwifery Council's Higher Level Practice standard. Design and methods. The two complementary approaches of emancipatory action research and systematic practice development were adopted. Methods were taken from action research and systematic practice development approaches with an emphasis on promoting and enabling enlightenment, critical reflection, ownership and creating the best conditions for long‐term commitment to the competency framework. Results. The main outcome from this project was the development of a specialist nursing competency framework. The Admiral Nurses’ Competency Framework is made up of a set of eight core competencies with three levels of competency statements, loosely structured around the Higher Level Practice standard, and guidance documentation to illustrate how work‐based evidence can be generated to demonstrate competence. There were also process‐derived outcomes associated with combining systematic practice development with emancipatory action research that had an impact on the culture. The main outcomes here were that practitioners engaged in and experienced learning about how to research their own practice and the consequences of doing this. They also learnt about specialist nursing practice more widely than Admiral Nursing. Finally, there was some increase in awareness about the culture within their teams and organizations. The final competency framework reflects the needs of the service, is owned by the majority of practitioners and project commissioners and this has had a positive impact on implementation. Conclusion. In this paper, we report on combining systematic practice development with action research to achieve immediate project aims. In addition we show how a project of this nature can contribute to developing skills in practitioners necessary for cultural changes in practice and contributes to wider issues of modernization within nursing and health care. Relevance to clinical practice. This competency framework will enable Admiral Nurses to demonstrate their level of specialist practice, as individuals and collectively as a service and it also promotes the principles of nurses as life long learners. This may have relevance to other groups of specialist nurses. The project has widespread relevance for two reasons. Firstly, it shows that nurses can be involved in designing and testing a competency framework as collaborators. Secondly, that to achieve this within the spirit of approaches, such as systematic practice development and action research, can be testing for all collaborators even were there is a shared or espoused aim.     

Language, research and nursing practice

AIM OF THE PAPER: This paper highlights the centrality of language in constructing knowledge. It aims at making us sensitive to the political nature of knowledge production and the complex power relationships that may emerge as a result of our efforts to create new knowledge. BACKGROUND: Science, as understood here, is a linguistic construction, rather than a mirror reflection of reality. A number of examples are presented, demonstrating the complex ways in which language is central in shaping all our attempts to know, science included, and nursing practice. CONCLUSION: Based on the analysis presented in this paper an argument is made for a substantial re-thinking of nursing research and its relationship to nursing practice. Research needs to be an integral part of everyday nursing practice, a way of posing questions and reflecting on answers. Further, nurses need to be aware of the potentially coercive nature of knowledge as well as its liberating effect.     

Factors influencing the development of evidence-based practice: a research tool

AIM: The paper reports a study to develop and test a tool for assessing a range of factors influencing the development of evidence-based practice among clinical nurses. BACKGROUND: Achieving evidence-based practice is a goal in nursing frequently cited by the profession and in government health policy directives. Assessing factors influencing the achievement of this goal, however, is complex. Consideration needs to be given to a range of factors, including different types of evidence used to inform practice, barriers to achieving evidence-based practice, and the skills required by nurses to implement evidence-based care. METHODS: Measurement scales currently available to investigate the use of evidence in nursing practice focus on nurses' sources of knowledge and on barriers to the use of research evidence. A new, wider ranging Developing Evidence-Based Practice questionnaire was developed and tested for its measurement properties in two studies. In study 1, a sample of 598 nurses working at two hospitals in one strategic health authority in northern England was surveyed. In study 2, a slightly expanded version of the questionnaire was employed in a survey of 689 community nurses in 12 primary care organizations in two strategic health authorities, one in northern England and the other in southern England. FINDINGS: The measurement characteristics of the new questionnaire were shown to be acceptable. Ten significant, and readily interpretable, factors were seen to underlie nurses' relation to evidence-based practice. CONCLUSION: Strategies to promote evidence-based practice need to take account of the differing needs of nurses and focus on a range of sources of evidence. The Developing Evidence-Based Practice questionnaire can assist in assessing the specific 'evidencing' tendencies of any given group of nurses.     

Barriers to, and facilitators of, research utilization among nurses in Northern Ireland

It is clear from the nursing literature that there are a number of factors which can impede or facilitate the use of research in practice. It is important that these are identified and addressed, both at local and national levels, if evidence-based practice is to become a reality. This study surveyed nurses' perceptions of barriers to, and facilitators of, research utilization. The Barriers Scale was administered to a convenience sample of 2600 nurses in 23 hospitals in Northern Ireland. The number of completed questionnaires was 1368 (52.6%). The results show that the top barrier was 'The nurse does not feel she/he has enough authority to change patient procedures' followed by 'statistical analyses are not understandable'. Seven out of the top 10 barriers were related to 'setting'. The implications of these and other findings are discussed.     

Advanced nursing practice: policy, education and role development

Aims and objectives. This paper aims to explore the critical elements of advanced nursing practice in relation to policy, education and role development in order to highlight an optimal structure for clinical practice. Background. The evolution of advanced nursing practice has been influenced by changes in healthcare delivery, financial constraints and consumer demand. However, there has been wide divergence and variations in the emergence of the advanced nurse practitioner role. For the successful development and implementation of the role, policy, educational and regulatory standards are required. Conclusion. The paper highlights the value of a policy to guide the development of advanced nursing practice. Educational curricula need to be flexible and visionary to prepare the advanced nurse practitioner for practice. The core concepts for the advanced nursing practice role are: autonomy in clinical practice, pioneering professional and clinical leadership, expert practitioner and researcher. To achieve these core concepts the advanced nurse practitioner must develop advanced theoretical and clinical skills, meet the needs of the client, family and the community. Relevance to clinical practice. In a rapidly changing people‐centred healthcare environment the advanced nurse practitioner can make an important contribution to healthcare delivery. The challenges ahead are many, as the advanced nurse practitioner requires policy and appropriate educational preparation to practice at advanced level. This will enable the advanced practitioner articulate the role, to provide expert client care and to quantify their contribution to health care in outcomes research.     

Understanding the challenges of palliative care in everyday clinical practice: an example from a COPD action research project

Palliative care seeks to improve the quality of life for patients suffering from the impact of life‐limiting illnesses. Palliative care encompasses but is more than end‐of‐life care, which is defined as care during the final hours/days/weeks of life. Although palliative care policies increasingly require all healthcare professionals to have at least basic or non‐specialist skills in palliative care, international evidence suggests there are difficulties in realising such policies. This study reports on an action research project aimed at developing respiratory nursing practice to address the palliative care needs of patients with advanced chronic obstructive pulmonary disease (COPD). The findings suggest that interlevel dynamics at individual, team, interdepartmental and organisational levels are an important factor in the capacity of respiratory nurses to embed non‐specialist palliative care in their practice. At best, current efforts to embed palliative care in everyday practice may improve end‐of‐life care in the final hours/days/weeks of life. However, embedding palliative care in everyday practice requires a more fundamental shift in the organisation of care.     

护理信息学专业发展与研究方向分析

本文回顾美国医学信息协会护理信息学工作组（AMIA-NIWG）护理信息学优先发展方向白皮书,2008-2018年的优先研究领域报告,并结合最近2届世界医学信息学大会（MEDINFO）和最近3届国际护理信息学会议（NI）的主题揭示国际上近几年以及未来护理信息学的重要研究议题。结合我国护理实践的需求和时代背景因素,从政策、技术、教育和科研角度提出我国护理信息学的专业发展和研究方向的思考与建议,以推动我国护理信息学学科的发展。     

Developing practice in mental health settings

If practice development (PD) is to be implemented in diverse mental health‐care settings, it is important that managers, researchers, and policy makers are all clear about the nature of the processes involved. The authors draw on the literature to broadly set out local strategies, practicalities, and issues that should be considered and addressed by those planning to undertake PD projects in mental health. Before implementing PD projects, pre‐existing requirements should be recognized and expedited. All aspects of who does what, when, and how should be widely communicated so that continuous evaluation and improvements are generated. Staff need to be adult learners, be aware of their practice values, be able to access supervision, and confront contradictions and tensions between values and practice. PD programmes that are effective are built into mainstream activities, considered core business, utilize existing resources to build sustainable and realistic improvements, take direction from practitioners, and incorporate client needs.     

United Nations’ Sustainable Development Goal 3 Target Indicators: Examples of Advanced Practice Nurses’ Actions

In 2015, the United Nations created 17 Sustainable Development Goals. Sustainable Development Goal 3, “Good Health and Wellbeing,” includes 13 health target metric goals. This short report describes how advanced practice nurses (APNs) have addressed Goal 3 around the world. Given the variation in the APN roles internationally, it is important to capture common aspects of projects conducted during the first 5 years of this initiative. This report serves as a template for further evaluations of the importance of APNs in supporting global health policies. These findings inform how the workforce can effectively pursue these goals.