How to define ‘best practice’ for use in Knowledge Translation research: a practical,stepped and interactive process

Objectives Defining ‘best practice’ is one of the first and crucial steps in any Knowledge Translation (KT) research project. Without a sound understanding of what exactly should happen in practice, it is impossible to measure the extent of existing gaps between ‘desired’ and ‘actual’ care, set implementation goals, and monitor performance. The aim of this paper is to present a practical, stepped and interactive process to develop best practice recommendations that are actionable, locally applicable and in line with the best available research‐based evidence, with a view to adapt these into process measures (quality indicators) for KT research purposes. Methods Our process encompasses the following steps: (1) identify current, high‐quality clinical practice guidelines (CPGs) and extract recommendations; (2) select strong recommendations in key clinical management areas; (3) update evidence and create evidence overviews; (4) discuss evidence and produce agreed ‘evidence statements’; (5) discuss the relevance of the evidence with local stakeholders; and (6) develop locally applicable actionable best practice recommendations, suitable for use as the basis of quality indicators. Conclusions Actionable definitions of local best practice are a prerequisite for doing KT research. As substantial resources go into rigorously synthesizing evidence and developing CPGs, it is important to make best use of such available resources. We developed a process for efficiently developing locally applicable actionable best practice recommendations from existing high‐quality CPGs that are in line with current research evidence.     

Increasing research evidence in practice: a possible role for the consultant nurse

AIMS: To determine the extent to which clinical nursing practice has adopted research evidence. To identify barriers to the application of research findings in practice and to propose ways of overcoming these barriers. BACKGROUND: Way back in 1976, nursing and midwifery practice started adopting research evidence. By 1990s, there was some transparency of research evidence in practice, but more could have been done to widen its adoption. Many barriers were identified which could hinder implementation of the evidence in practice, and the effort to remove these remains weak. EVALUATION: 25 research articles from across Europe and America were selected, and scrutinized, and recommendations analysed. FINDINGS: Many clinical practitioners report a lack of time, ability and motivation to appraise research reports and adopt findings in practice. The clinical environment was not seen as research friendly as there were a general lack of research activities and facilities locally. There was a clear lack of research leadership in practice. IMPLICATION FOR NURSING MANAGEMENT: This paper reviewed the research evidence from several published research papers and provides consultant nurses with practical suggestions on how to enhance research evidence application in their practice. It recommends how consultant nurses can make their practice more research transparent by providing the required leadership, creating a research-friendly organization, developing a clear research agenda and facilitating staff develop a local research framework for reading research and implementing research evidence in their practice.     

Evidence-based surgery at ASERNIP-S. Can this improve quality in surgical practice? Australian Safety and Efficacy Register of New Interventional Procedures-Surgical

The Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S) project has been established to form a register of new surgical procedures which have been assessed for their safety and efficacy. The ASERNIP-S project systematically reviews the evidence and produces recommendations on the future use of surgical procedures in clinical practice. Further data may be collected to provide information on the outcomes of procedures in use in Australia. Horizon Scanning of new and emerging techniques and technologies complements the ASERNIP-S process. This research identifies procedures that will impact on clinical practice in the near future. Dissemination of information from ASERNIP-S assessments, both locally and internationally, is important for quality improvement. The ultimate aim is for appropriate changes in practice to ensure the highest quality of Australian healthcare.     

Optimal Bladder Management Following Spinal Cord Injury: Evidence,Practice and a Cooperative Approach Driving Future Directions in Australia

We examined spinal cord injury (SCI) catheterization practices in Australia to understand practice patterns and consistency with research evidence. A national facilitated discussion forum was held during the annual Australian and New Zealand Spinal Cord Society conference attended by 66 conference delegates. Initially, presentations were given on the latest laboratory research examining bladder changes following SCI; an overview of evidence-based recommendations indicating that intermittent catheterization is best practice; and results of a single-center practice audit that demonstrated substantial delay in transition between acute SCI and intermittent catheterization. The ensuing discussion covered current catheterization practices in both inpatient SCI units and the community and highlighted gaps between evidence and practice, with considerable variation in practice between centers and settings. Reported challenges to implementing best practice included social, economic, and resource factors. A disconnect between hospital and community practice was also identified as an important barrier to long-term uptake of intermittent catheterization following acute SCI. The discussion identified 3 proposed activities: (1) explore current practice and bladder health following SCI in greater depth across SCI units and in local communities through audits and standardized biochemical analysis; (2) determine the behavioral drivers of current practice; and (3) develop a knowledge translation strategy to better align practice with current clinical practice guidelines.     

The development of a national guideline on the management of leg ulcers

This paper describes the development of an evidence-linked clinical guideline for the management of uncomplicated venous leg ulcers. Guidelines are developed to provide recommendations for clinical practice which are based on summaries of good quality research evidence. The aim of the guideline discussed in this article is to direct primary health care practitioners to the most effective method of assessment and treatment of venous leg ulcers and to discourage practices that do not have convincing or sufficient evidence of effectiveness. The three most important steps to the development of a valid clinical guideline are: basing recommendations on the best available evidence; explicit linkage between guideline recommendations and quality of evidence; and the involvement of a multidisciplinary group. The steps are discussed in relation to the development of the guideline alongside an introductory presentation on the role guidelines can play in improving practice. Issues arising from guideline development such as valid ways of obtaining patient input and lack of evidence are also discussed.     

Disseminating research: how joint NHS and university posts can support this process

This article outlines the key challenges inherent in sharing and disseminating research findings within NHS organisations. Staff working in joint posts between universities and clinical settings are in a unique position to address these challenges. They should encourage article publication, presentations, and the implementation of recommendations that are locally relevant. An action research approach is key to boosting the likelihood of findings being implemented. Such steps would also enable clinical staff to become more research aware.     

Using consensus methods to develop clinical practice guidelines for intensive care: The Intensive Care Collaborative project

BACKGROUND: Clinical practices or procedures based on the best available evidence are an essential resource within an intensive care unit (ICU). Maintaining the currency of a local clinical practice manual is challenging however, particularly in relation to the time required, other workload pressures and the availability of staff with relevant skills to interrogate the literature. The aim of the Intensive Care Collaborative (ICC) project was to use the synergism of group processes to develop state-based clinical guidelines for six common intensive care practices - eye care, oral care, endotracheal tube management, suctioning, arterial line management, and central venous catheter (CVC) management. METHODS: Participants were 55 senior nurse clinicians from all nine area health services in NSW, seven academic facilitators, and staff from the Intensive Care Coordination and Monitoring Unit (ICCMU). A range of approaches were used to develop the six clinical practice guidelines (CPG) and related systematic literature reviews, including a preparatory educational seminar for participants, formation of working groups of clinicians, with subsequent teleconferences, e-mail and online forums to identify the scope of each guideline and review the literature. A consensus development conference (CDC) was conducted to finalise the reviews with a nominal group technique (NGT) used to develop recommendations for practice. External Validation Panels (EVP) verified the recommendations in each clinical practice guideline. Group voting was undertaken using a Likert scale (1-3 disagree, 4-6 neutral, 7-9 agree) with consensus agreement set as a median of at least seven. RESULTS: Eighty-three recommendations for practice were developed for the six Clinical Practice Guidelines; 50% were based on research literature evidence (23% with high levels of evidence). The balance were based on consensus opinion of the panel members. Only five recommendations were not validated by external validation. CONCLUSION: This project has demonstrated a method for guideline development that is robust, incorporating evidence from research and clinical expertise utilising an objective egalitarian framework.     

Using consensus methods in developing clinical guidelines for exercise in managing persistent low back pain

Objectives

To generate expert consensus evidence for the purpose of developing more complete guidelines for people with persistent low back pain than is possible using current research evidence alone. Gaps in research evidence lead to incomplete practice recommendations unless a scientific process can provide supplementary consensus evidence that is a basis for additional recommendations.

Design

A modified Nominal Group Technique (NGT). This followed a systematic review indicating incomplete research evidence.

Setting

UK-wide coordinated by the Chartered Society of Physiotherapy.

Participants

Twenty-three individuals selected for their expertise as clinicians, researchers, managers and patients.

Methods

Three stages: a first-round questionnaire of clinical questions unanswered by the systematic review; an electronic conference for outstanding questions unanswered by the first questionnaire; and a second-round questionnaire for these outstanding questions. All three stages were carried out electronically.

Results

Of 17 clinical questions unanswered by the systematic review, consensus evidence was generated for 14 questions by the modified NGT and this led to 14 recommendations for practice. Consensus was not reached for the remaining three questions.

Conclusions

The modified NGT was a practical and cost-effective way of generating consensus evidence from a UK-wide group. The consensus evidence was the basis of appropriately graded recommendations for effective care of people with persistent low back pain. Consensus methods have been little used in physiotherapy to date but are likely to be valuable in developing clinically useful, evidence-based tools for future practice.     

A clinical development unit in cardiology: the way forward

The clinical development unit (CDU) has been recognized as an effective strategy to progress creativity and resourcefulness in nursing practice to improve patient outcomes. Clinical development units, through transformational leadership, promote staff development, the use of research evidence and dissemination of research findings through publication and presentations. The aim of this paper is to clearly articulate the processes (in particular, research and education initiatives) related to the development of staff that address issues in the everyday workplace and, accordingly, have been instrumental in the success of the creation of a CDU in cardiology. These units aim to achieve and promote excellence in an identifiable area of nursing using a systematic, transparent and defensible approach. A review of acute coronary syndrome informed the needs and direction of staff activities in the cardiology unit of a tertiary referral hospital. Through a collaborative staff approach, evidence was carefully examined to plan its appropriate adoption into the clinical area. Nursing practice and education resulting from this review was scheduled into staff career progression. These initiatives have been incorporated into staff development learning, enabling the integration of research into practice, which ultimately has a positive impact on patient outcomes.     

Improving public health nursing education: recommendations of local public health nurses

OBJECTIVES: This paper reports recommendations for improving public health nursing (PHN) undergraduate, graduate, and continuing education (CE) made by staff-level public health nurses working in local health departments (LHDs). Implications for academia and practice are discussed. DESIGN: A cross-sectional written survey was used to collect data from 424 public health nurses in 76 LHDs in Wisconsin (68% response rate) in 2003. Recommendations for improving undergraduate, graduate, and CE were made through responses to open-ended survey questions. Content analysis was conducted to identify major themes among responses. RESULTS: Major themes emerging from the recommendations for undergraduate education included the need for more clinical public health experiences and population-focused practice content. Graduate education improvement recommendations included addressing access barriers and increasing organizational incentives. Improved access and more public health content were the major recommendations for improving CE. CONCLUSIONS: Implications for academia focus on increasing opportunities for students to experience population-focused PHN and to learn organizational and collaborative practice skills, supporting PHN preceptors and building evidence for PHN intervention through research. Implications for practice include the need to expand opportunities for students with LHDs and to collaborate with academic partners for education and research.     

Evaluating acute musculoskeletal complaints

Clinical practice guidelines (CPG) are now widely available summarizing large amounts of scientific evidence and providing specific recommendations for the evaluation, diagnosis, and management of varied health problems. In order to take advantage of the available CPGs in clinical practice, providers must be aware of their existence and be able to critique them for scientific merit and relevance to specific clinical settings. This ongoing series is designed to provide a brief review of a different CPG each month. This month, the CPG reviewed addresses the evaluation of an extremely common set of complaints: musculoskeletal symptoms. The document emphasizes the importance of a thorough history and physical for these presentations and indicates when specific diagnostic studies and/or consultations are warranted.     

Occupational therapy and physiotherapy for the patient with burns: principles and management guidelines

Clinical practice guidelines are a tool to assist with clinical decision making. They provide information about the care for a condition and make recommendations based on research evidence, which can be adapted locally. A focus group within the Allied Health Interest Group of the Australian and New Zealand Burn Association has compiled the "Occupational Therapy and Physiotherapy for the Patient with Burns--Principles and Management Guidelines." These guidelines are designed as a practical guide to the relevant clinical knowledge and therapy intervention techniques required for effective patient management. Content areas include respiratory management, edema management, splinting and positioning, physical function (mobility, function, exercise), scar management, and psychosocial and mutual elements. The document has undergone extensive review by members of the Australian and New Zealand Burn Association to ensure clarity, internal consistency, and acceptability. The guidelines have been endorsed by the Australian and New Zealand Burn Association. An abridged version of the guidelines is included in this article, with the full document available from www.anzba.org.au.     

Pain management in Australian emergency departments: Current practice,enablers, barriers and future directions

Objective: To explore current pain management practice in Australian EDs and identify enablers and barriers for best‐practice pain management. Methods: Five focus groups and two in‐depth interviews were held with ED clinical staff (n= 47) from six hospitals in three states. Participants were asked open‐ended questions to determine current pain management practices, enablers and barriers to implementing best‐practice pain management, and understand change in practice within the ED setting. Results: Emergency department staff identified a gap between evidence‐based pain management recommendations and everyday practice. Perceived barriers to improving pain management included a lack of time and resources, a greater number of urgent and serious presentations that place pain management as a lower priority, organizational protocols and legislative issues. All groups noted difficulty in applying pain management guidelines in the context of competing priorities in the challenging ED environment. A culture of learning clinical practice from respected senior staff and peers was perceived to be a key enabler. Participants consistently expressed the view that evidence‐based practice improvement should be championed by senior clinical staff, and that evidence to demonstrate the benefits of change must be presented to support the need for change. Conclusions: Effective and sustainable system change requires a strategy that is initiated within the ED, targets opinion leaders, is supported by evidence, and engages all levels of ED staff.     

Consensus guidelines on sedation and analgesia in critically ill children

Objective The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multi-disciplinary expert panel created to produce consensus guidelines on sedation and analgesia in critically ill children and forward knowledge in these areas. Sedation and analgesia are recognised as important areas of critical care practice and adult clinical practice guidelines in these fields remain amongst the most popular of those produced by the Society of Critical Care Medicine. However, similar clinical practice guidelines have not previously been produced for the critically ill paediatric patient.Design A modified Delphi technique was used to allow the Working Group to anonymously consider draft recommendations in three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences. Once consensus had been reached, a systematic review of the available literature was carried out.Outcome A set of consensus guidelines was produced including 20 key recommendations, 10 relating to the provision of analgesia and 10 relating to the sedation of critically ill children. An evaluation of the existing literature supporting these recommendations is provided.Conclusions Multi-disciplinary consensus guidelines for maintenance sedation and analgesia in critically ill children have been successfully produced and are supported by levels of evidence (excluding sedation and analgesia for procedures and excluding neonates). The working group has highlighted the paucity of high-quality evidence in these important clinical areas and this emphasises the need for further randomised clinical trials in this area.This article is discussed in the editorial available at: Financial support received: none.Conflict of interest: none.     

Evidence-based practice habits: putting more sacred cows out to pasture

For excellence in practice to be the standard for care, critical care nurses must embrace evidence-based practice as the norm. Nurses cannot knowingly continue a clinical practice despite research showing that the practice is not helpful and may even be harmful to patients. This article is based on 2 presentations on evidence-based practice from the American Association for Critical-Care Nurses' 2009 and 2010 National Teaching Institute and addresses 7 practice issues that were selected for 2 reasons. First, they are within the realm of nursing, and a change in practice could improve patient care immediately. Second, these are areas in which the tradition and the evidence do not agree and practice continues to follow tradition. The topics to be addressed are (1) Trendelenburg positioning for hypotension, (2) use of rectal tubes to manage fecal incontinence, (3) gastric residual volume and aspiration risk, (4) restricted visiting policies, (5) nursing interventions to reduce urinary catheter-associated infections, (6) use of cell phones in critical care areas, and (7) accuracy of assessment of body temperature. The related beliefs, current evidence, and recommendations for practice related to each topic are outlined.     

Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain

ObjectiveThe purpose of this study was to develop best-practice recommendations for chiropractic management of adults with neck pain.MethodsA steering committee of experts in chiropractic practice, education, and research drafted a set of recommendations based on the most current relevant clinical practice guidelines. Additional supportive literature was identified through targeted searches conducted by a health sciences librarian. A national panel of chiropractors representing expertise in practice, research, and teaching rated the recommendations using a modified Delphi process. The consensus process was conducted from August to November 2018. Fifty-six panelists rated the 50 statements and concepts and reached consensus on all statements within 3 rounds.ResultsThe statements and concepts covered aspects of the clinical encounter, ranging from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral for patients presenting with neck pain.ConclusionsThese best-practice recommendations for chiropractic management of adults with neck pain are based on the best available scientific evidence. For uncomplicated neck pain, including neck pain with headache or radicular symptoms, chiropractic manipulation and multimodal care are recommended.     

Ethical decision making in clinical research: application of CELIBATE.

The need for high-quality evidence to support practice is an ongoing issue in occupational therapy. As a consequence, growing numbers of occupational therapists are engaged in both clinical practice and research activities. Therapists who find themselves in these dual roles are sometimes faced with ethical conflicts when the responsibilities of being a researcher appear, on the surface, to diverge with the responsibilities of being an occupational therapist. This article applies one clinical tool, CELIBATE, to problem solve through an ethical dilemma experienced by a clinician involved in research. Based on the experience of using the tool, recommendations are presented to make CELIBATE more useful in research situations.     

Psychosocial health care needs assessment of adult cancer patients: a consensus-based guideline

Purpose

Although recommended as an essential part of cancer care, there is limited evidence regarding the optimum approach to psychosocial health care needs assessment in this setting. To address this gap, the Cancer Journey Action Group of the Canadian Partnership Against Cancer (CPAC) and the Canadian Association of Psychosocial Oncology (CAPO) partnered to develop consensus-based recommendations regarding the routine assessment of psychosocial and supportive care needs. The purpose of this paper is to summarize the evidence that informed the guideline and disseminate the recommendations developed by the expert panel.

Methods

Clinical practice recommendations were developed by a panel comprised of psychosocial and interdisciplinary experts. Recommendations were informed by a review of oncology clinical practice guidelines, systematic reviews, and primary research, through to May 2008. Following expert consensus on the recommendations, the clinical practice guideline was externally reviewed by a purposively selected sample of national and international interdisciplinary experts.

Results

A total of nine clinical practice guidelines, three systematic reviews, and 14 primary studies were included in the review. Overall, this body of literature suggested that routine collection of psychosocial health care data has an influence on communication with oncologists and other study specific outcomes, but the evidence was limited by heterogeneity and methodological limitations. Based on the interpretation of this body of evidence by clinical experts, research methodologists, and external reviewers, 12 substantive recommendations were developed regarding the process and parameters of psychosocial needs assessment in adult cancer patients.

Conclusion

Given the limitations in the current body of evidence, there remains a need for rigorous empirical research regarding the optimal approach to psychosocial needs assessment, including the specific characteristics that influence effectiveness on patient outcomes. This guideline fills an important gap in psychosocial care, regarding the routine assessment of psychosocial health care needs.     

Factors influencing involvement in research and career choice: a survey of graduating physical medicine and rehabilitation residents

OBJECTIVE: To assess the extent to which physical medicine and rehabilitation (PM&R) residents' involvement in research and selection of postgraduate practice may be related to residency program research requirements and support for presentations. DESIGN: Internet-based survey. SETTING: Anonymous access to Web form. PARTICIPANTS: PM&R residents graduating in June 2004 and 2005. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Involvement in research, postgraduate practice setting and planned research effort, residency research requirement, and support for scientific presentations. RESULTS: One hundred sixty (24%) of the 657 graduating residents, representing 25 states, the District of Columbia, and Puerto Rico, responded. Eighty-five percent indicated research involvement, with 74% reporting a research requirement and 85% residency program financial support for presentations. On average, respondents planned to devote 7% (95% confidence interval, 5%-9%) of their time to research once in practice. There was a statistically significant association between the existence of a research requirement and involvement in research (P < .001). However, there was no evidence of a statistically significant association between either the existence of a research requirement or presentation support and the selection of an academic career. There were no significant regional disparities for the existence of a research requirement, travel support, or number of presentations. However, there was a statistically significant regional difference in the proportion of postgraduate practice time that the respondents planned to devote to research. CONCLUSIONS: A requirement for PM&R residents to be involved in research may influence research activity during residency but may not be associated with selection of an academic or research-oriented practice.     

A national Position Statement on adult end-of-life care in critical care

Patient death in critical care is not uncommon. Rather, the provision of end-of-life care is a core feature of critical care nursing, yet not all nurses feel adequately prepared for their role in the provision of end-of-life care. For this reason, the Australian College of Critical Care Nurses (ACCCN) supported the development of a Position Statement to provide nurses with clear practice recommendations to guide the provision of end-of-life care, which reflect the most relevant evidence and information associated with end-of-life care for adult patients in Australian critical care settings. A systematic literature search was conducted between June and July, 2020 in CINAHL Complete, Medline, and EMBASE databases to locate research evidence related to key elements of end-of-life care in critical care. Preference was given to the most recent Australian or Australasian research evidence, where available. Once the practice recommendations were drafted in accordance with the research evidence, a clinical expert review panel was established. The panel comprised clinically active ACCCN members with at least 12 months of clinical experience. The clinical expert review panel participated in an eDelphi process to provide face validity for practice recommendations and a subsequent online meeting to suggest additional refinements and ensure the final practice recommendations were meaningful and practical for critical care nursing practice in Australia. ACCCN Board members also provided independent review of the Position Statement. This Position Statement is intended to provide practical guidance to critical care nurses in the provision of adult end-of-life care in Australian critical care settings.