The value of participatory action research in clinical nursing practice

This paper demonstrates the value of participatory action research (PAR) and promotes its use by nurses in clinical practice. PAR has gained popularity in nursing and health-care research, offering a way of developing practice-based knowledge that can improve nursing care. PAR is described in detail: what PAR is, how to use PAR in clinical practice, and the steps in the PAR cycle as applied during an exemplar study in which nurses used PAR to address their concerns and develop, implement and evaluate a model of care in an acute medical ward. The authors advocate PAR as a collaborative means to improve the nursing care for patients in varied clinical practice settings.     

Curriculum revision: making the process work

This paper presents the experience of one nursing faculty in revising a baccalaureate programme for registered nurses. Mechanisms used to facilitate the process of curriculum revision and to promote involvement of community agencies as well as faculty members and students are discussed. These mechanisms include use of a core co-ordinating group (curriculum co-ordinator, consultant in instructional development, administrative support person) to guide the process, acceptance of a draft of nursing theory content before proposing specific courses and student and community agency representation on course-development committees. The revision process is then analysed in relation to change theory. Particular attention is given to the concepts of involving all those affected by the change, maintaining open and effective communication and factors which minimize resistance.     

Intuition: a critical review of the research and rhetoric

This paper will explore the concept of intuition in nursing from an acute care and community nursing perspective. It will consider definitions of intuition and examine the research which can inform our understanding of this important component of decision making. In the current health service climate, which demands measurable research-based evidence, the involvement of intuition as an element of judgement is often denigrated. The result is that many nurses are being forced to be covert in their use of this crucial aspect of judgement and focus solely on the conscious elements of decision-making. However, research evidence would suggest that intuition occurs in response to knowledge, is a trigger for action and/or reflection and thus has a direct bearing on analytical processes in patient/client care. The authors therefore argue that the essential nature of intuition cannot be ignored in the practice, management, education and research of nursing.     

Implementation of the i.v. push method of antibiotic administration using the FOCUS/PDCA approach

Home health agencies constantly seek ways to improve patient care as part of their performance improvement program. This includes revising and updating agency policies and procedures. Changing care processes, such as administering intravenous medications, requires input from pharmacy and nursing staff as well as administration. The authors describe how one agency used this process while adopting the i.v. push method of administering certain antibiotics to home care patients.     

Agency nursing in Melbourne,Australia: a telephone survey of hospital and agency managers

BACKGROUND: Agency nursing is a poorly understood and under-researched phenomenon. Despite the considerable costs and possible benefits of using agency nurses, little is known about the nature of agency nursing from different perspectives, including hospital and agency managers. AIM: To describe the professional relationship between hospitals and nursing agencies, utilization trends of agency nurses, and institutional policies relating to the employment of agency nurses. METHODS: A telephone survey was conveyed to managers of 70 acute hospitals (service purchasers) and 26 agencies (service providers) to provide baseline information on the utilization of agency nurses in acute hospitals in Melbourne, Australia. Introductory telephone calls were made to the chief nursing officers of the hospitals and the chief executive officers of nursing agencies in order to explain and seek approval for the proposed project. Approval to conduct telephone interviews was obtained from 30 acute hospitals and six agencies, representing a response rate of 43% and 23%, respectively. Separate questionnaires were used for the two categories of respondent. In some cases the questionnaire could not be completed using the telephone and a copy was then sent by post for completion. RESULTS: Findings revealed the high utilization of agency nurses in hospitals, the limited nature of continuing education for agency nurses, tensions between matching agency nurse qualifications with acute specialty needs and the notion that agencies preferred nurses to be flexible in their work assignments. CONCLUSIONS: The study was limited by the fact that the final sample was small (30 hospitals and six agencies), and therefore may not be representative of the wider population of Melbourne hospitals or agencies. However, it provided evidence on the utilization of agency nurses in public and private hospitals that will help shape policy on the regulation of the agency nursing workforce.     

Agency-nursing work: perceptions and experiences of agency nurses

This paper explores agency-nursing work from the perspective of agency nurses to gain in-depth understanding of their clinical practice, their relationships with the employing agency, hospitals and permanent nurses, and their professional status. For this study, individual interviews were conducted with ten agency nurses who were registered with one of three nursing agencies in Melbourne, Australia. Five major themes emerged from interview data: orientation, allocation of agency nurses, reasons for doing agency-nursing work, experiences with hospital staff, and professionalism. The findings reveal that the primary reason for nurses engaging in agency-nursing work is for the flexibility it offers. While agency nurses described a commitment to professionalism, the findings emphasise the need to establish effective communication networks between agency nurses, nursing agencies and hospital institutions. Such communication between stakeholders is important to facilitate discussion of issues such as appropriate notification of shift availability, appropriate assignment of work and recognition of the agency nurse as a valuable member of the health care team. In particular, the findings highlight the importance of comprehensive orientation and education for agency nurses to shift the focus of their daily work from task completion to more comprehensive patient care.     

Evidence-based nursing: a stereotyped view of quantitative and experimental research could work against professional autonomy and authority

In recent years, there have been calls within the United Kingdom's National Health Service (NHS) for evidence-based health care. These resonate with long-standing calls for nursing to become a research-based profession. Evidence-based practice could enable nurses to demonstrate their unique contribution to health care outcomes, and support their seeking greater professionalization, in terms of enhanced authority and autonomy. Nursing's professionalization project, and, within this, various practices comprising the 'new nursing', whilst sometimes not delivering all that was hoped of them, have been important in developing certain conditions conducive to developing evidence-based practice, notably a critical perspective on practice and a reluctance merely to follow physicians' orders. However, nursing has often been hesitant in its adoption of quantitative and experimental research. This hesitancy, it is argued, has been influenced by the propounding by some authors within the new nursing of a stereotyped view of quantitative/experimental methods which equates them with a number of methodological and philosophical points which are deemed, by at least some of these authors, as inimical to, or problematic within, nursing research. It is argued that, not only is the logic on which the various stereotyped views are based flawed, but further, that the wider influence of these viewpoints on nurses could lead to a greater marginalization of nurses in research and evidence-based practice initiatives, thus perhaps leading to evidence-based nursing being led by other groups. In the longer term, this might result in a form of evidence-based nursing emphasizing routinization, thus--ironically--working against strategies of professional authority and autonomy embedded in the new nursing. Nursing research should instead follow the example of nurse researchers who already embrace multiple methods. While the paper describes United Kingdom experiences and debates, points raised about the importance of questioning stereotyped views of research should have international relevance.     

Clinical Competencies for Community Health Nursing

Cost-containment strategies initiated in the early 1980s caused a major shift in site of care delivery for persons needing nursing care. Where once the majority of clients were cared for in the acute-care setting until they were self-sufficient, now most are discharged to the home environment still requiring acute-care nursing interventions as well as community health nursing skills. This rapid shift in practice sites has placed severe strain on community health nursing agencies. Not only are more nurses required to fill the increased demand for services, but the demand comes at a time when we are experiencing a severe nursing shortage. This has forced many agencies to hire acute care nurses who have little or no community health nursing experience. These nurses come to community health nursing expecting to use the same set of skills and knowledge base used in their acute-care practice; however, the skill levels and concepts required for community health nursing are quite different from the acute care setting. Educational preparation has not kept pace with this shift in practice. Consequently, many nurses are not adequately prepared to enter community health nursing. Preparation must include theoretical and experiential components that focus on assessment skills (of the community and individual), decision making, case management, health systems management, teaching, and leadership. Collaborative efforts between community health organizations and educational institutions would seem to be one solution that would ensure adequately prepared nurses for community health nursing. The establishment and maintenance of strong staff-development programs within community health nursing agencies are also required.     

A Nursing Care Monitoring and Evaluation System: Making it Work in Differentiated Practice

This article describes the evolution of a chart audit tool that became an integral part of a nursing care monitoring and evaluation system at two healthcare agencies in South Dakota. These agencies, an acute care hospital and a federal healthcare agency, continue to use the audit tool for multiple purposes within their institutions. The initial design of the tool had two objectives: to measure objectively the quality and effectiveness of patient care provided by the nursing staff and to educate nurses about expectations of their roles as case managers or case associates. The tool has been revised and continues to be modified to fit needs within hospital, ambulatory care, and community based care settings, to meet program standards for accreditation, and other purposes within each agency.     

Agency nursing work in acute care settings: perceptions of hospital nursing managers and agency nurse providers

There is a paucity of research in investigating agency nursing work from the perspectives of hospital nursing managers and agency nurse providers. This exploratory paper examines the hospital nursing managers' and agency nurse providers' perceptions and experiences of agency nursing work. Individual, in-depth interviews were conducted with three agency nurse providers and eight hospital nursing managers. Because of the lack of previous research in this area, an exploratory, semi-structured interviewing technique was deemed appropriate. Three major themes emerged from interview data: planning for ward allocation, communication and professionalism. In planning for ward allocation, hospital managers were primarily concerned with maintaining adequate numbers of nursing staff in the ward settings. A major concern for agency nurse providers was inappropriate allocation of temporary staff. Communication was valued in different ways. While hospital managers focused on communication between the agency nurse and other permanent members of the health care team, agency providers were concerned with exchanges between agencies and hospital organizations, and between the agencies and agency nurses. For both groups, responsibility for professional development and the status of agency nursing as a career choice for graduate and experienced nurses were the focal aspects for consideration. A limitation of this study is the small number of individual interviews conducted with hospital nursing managers and agency nurse providers. Nevertheless, the findings represent the views of 11 individuals in senior managerial roles. The findings reinforce the need to enhance collaboration between hospitals and nursing agencies, and to examine how divergent views of agency nursing work could be reconciled--with the aim of providing quality patient care.     

Integrative nursing research — an important strategy to further the development of nursing science and nursing practice

In this paper it is argued that integrative nursing research has a great potential for clarifying the theoretical perspective and substance of the nursing discipline as well as making research-based knowledge more accessible to clinical nurses. Two general kinds of integrative research are introduced and illustration provided of how these have been practiced with in nursing. Significant strengths and weaknesses in current practice is highlighted. It is argues that nursing should pay more attention to this kind of research, specifically in terms of developing sound methodological approaches and overcoming the traditional schism between empirical and theoretical research. Sound integrative nursing research promises to improve the development of nursing science as well as making the products of nursing research more easily available for clinical nurses.     

Antimicrobial resistance in critical care

Patients presenting with active infections or at increased risk for infections pose a significant challenge in critical care nursing. It is important for critical care nurses to use effective antimicrobial strategies in patient management to reduce the potential development of antimicrobial resistance. They should be involved actively in promoting patient management through development of research-based nursing guidelines and protocols.     

Listening to nurses' moral voices: building a quality health care environment

In this paper we describe a research project in nursing ethics aimed at exploring the meaning of ethics for nurses providing direct care with clients. This was a practice-based project in which participants who were staff nurses, nurses in advanced practice, and students in nursing were asked to tell us (or describe to us) how they thought about ethics in their practice, and what ethical practice meant to them. We then undertook to analyze, describe and understand the enactment of ethical practice, the opportunities for and barriers to such enactment, as well as the resources nurses need for ethical practice. We drew out implications of these findings for nursing leaders. We identified practice realities that create a climate for ethical or moral distress, and the way in which nurses attempt to maintain their moral agency. Practice realities included nurses' ethical concerns about policies guiding care; the financial, human and temporal resources available for care; and the power and conflicting loyalties nurses encounter inproviding good care. Maintaining moral agency involved use of a variety of ethical resources and the identification of resources needed to provide good care, as well as the processes used to enact moral agency. Nurse leaders are also moral agents. Important implications of these findings for nursing leaders are that they need moral courage to be self-reflective, to name their own moral distress, and to act so that their nursing staff are able to be moral agents. Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent and ethical practice.     

Research utilization in nursing practice — a pilot study

A low research base and inadequate research utilization are seen as obstacles to acquiring credible professional status for nursing. During recent years there has been some debate, both in Europe and in North America, about the extent to which nurses base their practice on research. This paper reviews recent empirical studles about research utilization, then goes on to describe a small pilot study carried out in the UK to attempt to measure research utilization among general nurses at F/G grade. A large-scale, generalizable survey using sirmlar methods is proposed to build on the knowledge gained from the pilot study. Tentative findings are put forward that show a positive attitude towards research among British clinical nurses. Specialist nurse advisors and research-based protocols are helpful to nurses in accessing research literature. The biggest deterrent to research utilization appears to be lack of perceived autonomy — some nurses feel unable to challenge medical colleagues and organizational managers and so fail to make use of research findings available to them. Significant differences are found between the two hospitals studied in the characteristics of their nursing staff, particularly in relation to their research awareness and degree of perceived autonomy.     

Quantifying nursing needs in home health care

A study was conducted to determine what factors were most predictive of the quantity of nursing service and total agency service required by cardiac and cancer patients in home-care agencies. A retrospective record review on 397 patients in 9 randomly selected Connecticut home-care agencies collected demographic data on referral and payment source, support system, discharge status, primary care provider, and health status, as well as total number of professional and nonprofessional visits and length of stay. The Health Status Score, which measured deficits in daily activities and nursing problems, proved to be the best predictor. The ability of the Health Status Score to predict the need for total agency visits was particularly strong for cancer patients. The agency variable was a significant predictor of resource utilization, especially for cardiac patients. A significant limitation of the study was the inconsistency among the agencies regarding closure of records. Future research into resource use in home care depends on consistent and complete recording practices across agencies.     

A model for research implementation

How can critical care nurses develop a research-based practice? These authors describe an emerging research implementation model to conduct and utilize research in the critical care setting.     

Negotiating the role of the practice nurse in general practice

The debate about the role of the practice nurse is not only about practice nursing per se, but raises broader issues about the organization of primary health care Two related issues emerge as significant the role of the practice nurse in providing primary health care, and the effective use of the practice nurse resource in the 'new' National Health Service This paper, by drawing on material from a qualitative study, specifically examines the type of work performed by practice nurses and the factors that influence this The responses of practice nurses, general practitioners, Family Health Service Authority (FHSA) advisers, community nurse purchasers and managers of community nursing provider units suggest that a consensus on the future development of practice nursing is unlikely The different stakeholders emphasized different issues, reflecting their own priorities and backgrounds Practice nurses' accounts of the future, for example, focused on professional issues General practitioners stressed the importance of role development which met then-General Medical Service responsibilities Purchasing agencies, provider units and FHSAs adopted a wider perspective and were more concerned to develop an effective and integrated primary health care service The tensions generated by their different interests and perspectives, and the subsequent organizational and policy initiatives that emerge, will provide the context in which the role of practice nurses will be negotiated