Implementing a journal club in a palliative care setting: A link in the chain of evidence-based practice

This paper describes the implementation and evaluation of a journal club in a privately funded palliative care unit. Journal club meetings were initiated as part of a quality improvement process to foster the uptake of evidence-based practice. Nurses were presented with research articles each month and discussions were conducted focussing on methodological considerations of the research and implications of the research for patient care. The maximum number of attendees at any one meeting was nine and the minimum number was four. Overall, evaluations were positive about all aspects of the meetings. Attendees found that the selected articles were relevant, providing new information, stimulated discussion and reflection on clinical practice and encouraged further reading. One of the positive aspects of the meetings identified by participants was the facilitation style that enabled discussion in a safe and supportive environment. An important outcome of the meetings is the potential to explore evidence-based practices relevant to palliative care and to implement new practices or revise existing ones. As part of this process practice changes and clinical guidelines have been implemented. A dedicated facilitator with university links and a supportive organisational culture promoted club meetings as a practical way to provide clinical nurses with the opportunity to explore evidence-based research in the area of palliative care.     

Palliative Care in Swaziland

Abstract

Evidence-based practice is the current buzz-word of healthcare practice. It draws on a positivist approach to research centred on the randomised controlled trial. While it is imperative that palliative care embrace evidence-based approaches to patient and family care, at least two key barriers exist. Firstly, palliative care developed as a reaction against positivist science and its approaches to healthcare provision. Consequently, its field of inquiry, and what it counts as evidence, is significantly broader than can be assessed using randomised controlled trials. Secondly, even when appropriate, attempts to conduct randomised controlled trials in palliative care have largely failed. This paper explores the relationship between palliative care and evidence-based practice through a critique of randomised controlled trials as the benchmark for evidence in palliative care.     

Palliative care clinical trials: how nurses are contributing to integrated, evidence-based care

The aim of this paper is to describe the emerging role of the palliative care clinical trials nurse in an era of evidence-based practice and increasing clinical trial activity in palliative care settings across Australia. An overview of the current clinical trials work is provided, with a focus on three aspects of clinical trials nursing practice that have significant implications for patients: managing the consent process, integrating clinical trials into multidisciplinary care, and establishing and building the evidence base to inform practice in palliative care settings. Clinical trials roles provide palliative care nurses with an opportunity to contribute to clinical research, help expand palliative care's evidence base, and develop their own research capabilities.     

Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis

BackgroundDelirium is a serious acute neurocognitive condition frequently occurring for hospitalized patients, including those receiving care in specialist palliative care units. There are many delirium evidence-practice gaps in palliative care, including that the condition is under-recognized and challenging to assess.ObjectivesTo report the meta-synthesis of a research project investigating delirium epidemiology, systems and nursing practice in palliative care units.MethodsThe Delirium in Palliative Care (DePAC) project was a two-phase sequential transformative mixed methods design with knowledge translation as the theoretical framework. The project answered five different research questions about delirium epidemiology, systems of care and nursing practice in palliative care units. Data integration and metasynthesis occurred at project conclusion.ResultsThere was a moderate to high rate of delirium occurrence in palliative care unit populations; and palliative care nurses had unmet delirium knowledge needs and worked within systems and team processes that were inadequate for delirium recognition and assessment. The meta-inference of the DePAC project was that a widely-held but paradoxical view that palliative care and dying patients are different from the wider hospital population has separated them from the overall generation of delirium evidence, and contributed to the extent of practice deficiencies in palliative care units.ConclusionImproving palliative care nurses' capabilities to recognize and assess delirium will require action at the patient and family, nurse, team and system levels. A broader, hospital-wide perspective would accelerate implementation of evidence-based delirium care for people receiving palliative care, both in specialist units, and the wider hospital setting.     

Using evidence-based practice in providing care

Case managers are in prime positions that enable them to implement initiatives, which may lead to evidence-based practice. The possibilities abound regardless of the setting; case managers are charged with the delivery of patient care in the most efficient manner. When the best care is given to patients within the shortest time frame, everyone benefits--the patients and their families, case managers and other staff, and the entire organization. The various tools used to coordinate patient care--protocols and pathways--can be readily used to collect data in a standard way; this is a vital step in initiating evidence-based practice. Initiatives leading to evidence-based practice require several phases: obtaining evidence, monitoring the use of evidence, and evaluating the use of evidence in practice. This article will describe the use of evidence-based practice for case managers and demonstrate the steps to ensuring successful implementation in patient care activities.     

A framework for the introduction and evaluation of advanced practice nursing roles

AIM: This paper describes a participatory, evidence-based, patient-focused process for advanced practice nursing (APN) role development, implementation, and evaluation (PEPPA framework). BACKGROUND: Despite the growing demand for advanced practice nurses, there are limited data to guide the successful implementation and optimal utilization of these roles. The participatory, evidence-based, patient-focused process, for guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA) framework is an adaptation of two existing frameworks and is designed to overcome role implementation barriers through knowledge and understanding of APN roles and environments. The principles of participatory action research directed the construction of the new framework. CONCLUSIONS: The process for implementing and evaluating APN roles is as complex and dynamic as the roles themselves. The PEPPA framework is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems. Engaging environmental stakeholders as participants in the process provides opportunity to identify the need and shared goals for a clearly defined APN role. The process promotes increased understanding of APN roles and optimal use of the broad range of APN knowledge, skills, and expertise in all role domains and scope of practice. The steps for planning and implementation are designed to create environments to support APN role development and long-term integration within health care systems. The goal-directed and outcome-based process also provides the basis for prospective ongoing evaluation and improvement of both the role and delivery of health care services.     

The Liverpool Care Pathway: does it improve quality of dying? [corrected

The Liverpool Care Pathway (LCP) for the dying patient is an integrated care pathway that was developed to assist non-specialist palliative care staff care for dying patients in acute clinical areas. The LCP has generated numerous debates among health professionals regarding its strengths and weaknesses. The complexity of patient needs at the end-of-life cannot be underestimated and the LCP provides the foundations of quality evidence-based care patients require, particularly in the final phase of dying. Nevertheless, not all health professionals are in agreement as to the advantages of using integrated care pathways in clinical practice. Despite the attention that has surrounded the LCP there is limited evidence to suggest that it improves end-of-life care. This article examines the evidence in relation to the LCP as a tool to improve palliative care for dying patients and their families in non-specialized palliative care practice.     

The development and implementation of a clinical skills matrix to plan and monitor palliative care nurses' skills

AimTo develop and implement a region wide skills matrix for palliative care and district nurses in rural Victoria in order to identify and address individual learning needs and appropriate professional development strategies based on the Australian National Palliative Care Standards. This study is the first in a series of papers discussing and evaluating the development and implementation of a skills matrix. Future papers will report on participants’ data reporting.MethodsThe development and implementation of a skills matrix for palliative care nurses was based on using several evidence-based strategies involving four main stages. There were: stakeholder consultation, collaboration, consolidation and implementation. The initial stage of development of the matrix involved consultation with regional stakeholders to establish and refine the project objectives. The second stage involved collection of information from regional stakeholders; brainstorming and discussion of the technical skills required for palliative care and the cross over with district nursing. The third stage involved a facilitated process whereby action plans were devised and the final stage involved a plan for the survey dissemination and evaluation of the training needs.Other evidence-based strategies used were Benner’s theoretical model of clinical competence, the Australian National Palliative Care Standards and the triple C model of project implementation.ResultsThis study reported on the development and implementation of a self-assessment of competencies skills matrix for nurses working in palliative care based on the Australian National Standards of palliative care used by services.The matrix included all the aspects covered by the Australian National Palliative Care Standards and mapped them to various competencies using Benner’s model ranging from novice to expert. The availability of a skills matrix tool to self-assess is important to keep track of the clinical competencies gained by palliative care nurses. Targeted educational interventions identified by the skills matrix have the potential to improve quality of care provided in the palliative care setting.ConclusionThe successful development and implementation of the palliative skills matrix across the Gippsland region relied on using several evidence-based strategies to standardise the competencies across the palliative care setting in rural Victoria, Australia. Examples of these strategies included using Benner’s theoretical competency model, the Australian National Palliative Standards and the triple C model, which included stakeholders’ consultation, collaboration and consolidation.     

Evidence-based care of a patient with a myocardial infarction

Quality nursing care of the patient with a myocardial infarction is realized in accordance with evidence-based practice and by the willingness of nurses to adjust nursing practice as new evidence emerges. The framework for the holistic care of the patient following a myocardial infarction encompasses a comprehensive assessment, planning, intervention and evaluation process. The intention of this case study is to illustrate the rationale and evidence base underpinning the holistic approach to the care of this patient group.     

A framework for generalizability in palliative care

Palliative medicine has only recently joined the ranks of evidence-based medical subspecialties. Palliative medicine is a rapidly evolving field, which is quickly moving to redress its historical paucity of high-quality research evidence. This burgeoning evidence base can help support the application of evidence-based principles in palliative and hospice clinical care and service delivery. New knowledge is generally taken into practice relatively slowly by established practitioners. At present, the translation of evidence into palliative and hospice care clinical practice lags behind emerging research evidence in palliative care at even greater rates for three critical reasons: 1) the application of research results to specific clinical subpopulations is complicated by the heterogeneity of palliative care study subpopulations and by the lack of a recognized schema for describing populations or services; 2) definitional issues in service provision are, at best, confusing; and 3) fundamental research concepts (e.g., external validity, effect size, generalizability, applicability) are difficult to apply meaningfully in palliative care. This article provides a suggested framework for classifying palliative care research subpopulations and the clinical subpopulations to which the research findings are being applied to improve the ability of clinicians, health planners, and funders to interpret and apply palliative care research in real-world settings. The framework has five domains: patients and caregivers; health professionals; service issues; health and social policy; and research.     

What counts as evidence in evidence‐based practice?

BACKGROUND: Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice. AIM: This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care. DISCUSSION: Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive. CONCLUSION: Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.     

Use of the innovation-decision process teaching strategy to promote evidence-based practice.

The purpose of this article is to describe the innovation-decision process teaching strategy (I-DPTS) based on the model of diffusion of innovations [Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: Free Press]. A goal of baccalaureate nursing education is to develop competencies required for evidence-based practice. Such practice merges clinician expertise, patient preferences, and critical evaluation of the literature to improve patient outcomes and reduce health care costs [Melnyk, B. M. (2005). A primer on evidence-based practice. Paper presented at the Purdue School of Nursing Seventh Annual Helen R. Johnson Leadership Conference, West Lafayette, IN]. Several strategies to promote evidence-based practice have appeared in the literature. However, when they are examined in light of the innovation-decision process (Rogers, 2003), they do not address all the essential steps for adoption to occur. The I-DPTS allows students to achieve competencies necessary to overcome barriers associated with implementing best practices. This strategy was successfully implemented in a senior-level introductory nursing research class. Community representatives identified practice issues that could be addressed by student groups. After conducting a search of the literature, students analyzed the evidence, determined best practice based on the evidence, and developed a policy for implementation in clinical settings. At course end, representatives were invited to attend oral and poster presentations. Use of the I-DPTS better prepares students to implement best practice as they embark on their professional careers.     

Dyspnea: applying research to bedside practice

Dyspnea is a common symptom in patients with acute and chronic critical illness as well as in patients receiving palliative care. While dyspnea can be found in a variety of clinical arenas and across many specialties, the mechanisms that cause dyspnea are similar. Although not often the cause for admission to critical care, it may complicate and extend length of stay. This article defines and describes dyspnea and its pathophysiology. Critical care nurses should strive to implement interventions supported by evidence whenever possible. An evidence-based plan of care for the assessment, planning, intervention, and evaluation of the patient with dyspnea is outlined, using levels of recommendation based on the strength of available evidence. Two case studies are presented to illustrate its application to clinical practice.     

An evaluation-based model for palliative care education: making a difference to practice

It has been recognized that education may be one way of improving the provision of palliative care to patients and their families. This article is the culmination of a multi-phase evaluation project that aimed to investigate the effectiveness of palliative care education provided by a hospice education network in the north west of England. Results from a study of 46 students over a three year period indicate that in order for education to be deemed effective, there are certain fundamental requirements. These include responding to the changing and individual needs of participants, competent teaching in theory and practice, and enabling students to make a difference to practice. This paper describes a model for providing palliative care education, which encompasses these fundamental requirements. It also meets the needs of stakeholder and provides evidence of improvements in clinical practice. In particular, it focuses on the challenges of implementing this model in the current climate of clinical effectiveness, evidence-based practice and value for money.     

Pediatric Palliative Care in Sub-Saharan Africa: A Systematic Review of the Evidence for Care Models,Interventions, and Outcomes

ContextThe progressive disease burden among children in sub-Saharan Africa means the provision of palliative care is essential and should be provided alongside treatment where it is available.ObjectivesTo systematically review the evidence for pediatric palliative care models, interventions, and outcomes to appraise the state of the science and inform best practice.MethodsA systematic review search strategy was implemented in eight electronic databases, the search results reported using a PRISMA statement, and findings tabulated.ResultsIn terms of evidence of palliative care provision and outcomes, only five articles were identified. These represent a small range of acute, community, and hospice care and offer some limited guidance on the development and delivery of services.ConclusionPediatric palliative care is a pressing clinical and public health challenge in sub-Saharan Africa. Explicit evidence-based models of service development, patient assessment, and evidence for control of prevalent problems (physical, psychological, social, spiritual, and developmental) are urgently needed. Greater research activity is urgently required to ensure an evidence-based response to the enormous need for pediatric palliative care in sub-Saharan Africa.     

Basics of evidence-based practice. Part 2: Unscrambling the terms and processes

Rapid developments within the enterprise of evidence-based health care have resulted in a state of flux in the related concepts and terminology. Basic processes include original research, evidence summary, translation, implementation, and evaluation. Together with a glossary of basic terms in evidence-based practice (EBP), these provide a basis for nurses to adopt evidence-based practice into clinical decision making.     

Challenges that specialist palliative care nurses encounter when caring for patients with advanced dementia

Specialist palliative care (SPC) has expanded recently in Ireland to incorporate diseases other than cancer, including dementia. Two care areas that pose specific challenges for SPC nurses when caring for people with advanced dementia are pain and nutrition/hydration. Assessment and management of pain for a patient who has advanced dementia differs greatly from that for a typical palliative care patient. Similarly, nutrition and hydration pose extraordinary ethical and practical dilemmas not encountered when caring for a patient without dementia. This paper reports a literature review which revealed that although evidence-based information related to each of these areas is available, it tends to be written from the perspective of health professionals with an interest in dementia rather than from the perspective of the SPC nurse. SPC nurses require evidence-based palliative care research to guide their practice, but such research appears to be limited for patients with advanced dementia. Knowledge from specialists in both dementia care and palliative care needs to be combined if we are to provide these patients with the best possible end-of-life care. Further research is required and evidenced-based guidelines need to be formulated.     

Promoting evidence-based practice: implementing the American Stroke Association's acute stroke program

The use of evidence-based practice for improving patient care outcomes is discussed extensively in the literature. This article describes how a model for change to evidence-based practice developed by Rosswurm and Larrabee was used for the effective implementation of the American Stroke Association's Acute Stroke Program in an acute care hospital. The results demonstrated that patient care and outcomes were improved through the implementation of this exemplar of evidence-based practice.     

Evidence-based laboratory medicine

Evidence-based medicine (EBM) is a method for solving problems concerning the assessment of laboratory testing in patient care. Practising EBM involves the use of the available evidence to make health care decisions. The best way to practice EBM is the development, validation and implementation of guidelines. Guidelines are considered as the process by which healthcare research and experience are translated into improved patient care. In laboratory diagnostics EBM can be best demonstrated in high-prevalence conditions. Because of the number of patients encountered, high-prevalence conditions have a greater impact on patient morbidity and health care expenditure. In evidence-based laboratory medicine the best evidence comes from systematic reviewing studies of diagnostic tests. The reviewing of diagnostic trials and the development of good practice guidelines on the basis of these studies must be an important task of the scientific associations of clinical chemistry and laboratory medicine.