Sources and models for moving research evidence into clinical practice

High quality research evidence for nursing practice is available from the Cochrane Library and in clinical practice guidelines produced by professional associations. The transfer of research evidence into practice is a complex process, and changing provider behavior is a challenge, even when the relative advantages are strong. An active approach with multifaceted interventions based on the assessment of barriers has been found most effective. An array of interventions for implementing research findings in practice is included, and promising organizational and theoretical perspectives on increasing the use of research evidence for nursing practice are described.

Advanced 'prescribing' of nurses' emergency holding powers under New Zealand mental health legislation

Since the mid-19th century doctors have exercised almost exclusive control in health professionals' decisions concerning compulsory assessment and treatment of the mentally ill. This control has the potential to compromise the legitimate professional practice of other mental health professionals. A new approach to mental health legislation has seen the involvement of a range of health professionals in legislated mental health roles, including the power of registered nurses to detain patients in hospital under Section 111 of the New Zealand Mental Health (Compulsory Assessment and Treatment) Act (1992). Under this Section a nurse who believes that a voluntary patient meets the legal criteria of the Act can independently detain the patient for a period of up to 6 hours, pending further assessment by a medical practitioner. However, anecdotal evidence and a clinical audit undertaken by the authors suggest some doctors 'prescribe' Section 111 at the time of admission. This practice instructs nurses to initiate Section 111 if particular voluntary patients choose to leave hospital. This study outlines practice issues resulting from 'prescribing' Section 111; provides a legal critique of medical practitioners' involvement in this practice; and makes recommendations for guidelines toward a more constructive use of Section 111.

Ethical practice guidelines: an evaluation

Ethical practice guidelines (EPGs) were developed for use in Central Sydney Area Mental Health Service to guide contemporary mental health nursing practice and serve as a resource for clinical mental health nurses in relation to their professional conduct and practice. This survey of mental health nurses aimed to ascertain feedback on the application of the EPGs in the clinical arena. Nurses from the Central Sydney Area Mental Health Service (n = 350) were asked to complete a 15-item survey developed by the authors. A total of 121 nurses completed the survey. Findings from the survey reveal that the information provided in the EPGs is useful (91%) and the EPGs provide sufficient guidance for practice (94%). Most respondents (96%) reported feeling confident dealing with ethical practice situations and 75% indicated interest in further education and training in this domain. Findings from this survey support the need to explore avenues to facilitate education, discussion and reflective practice in relation to ethical mental health nursing practice.

The qualities and skills of practice developers

AIM

To explore and describe the activities and approaches that constitute practice development by providing an insight into the qualities and skills exhibited by staff in practice development roles.

METHOD

This involved examining 177 articles, plus data collected during focus group interviews with 60 staff around the UK and telephone interviews with 25 clinical staff. The focus groups and telephone interviews formed part of an earlier published study Garbett and McCormack (2002).

RESULTS

A range of skills and qualities were highlighted. These include being effective, having vision, being motivated, empathic, experiential, cognitive political, communicative, facilitative and possessing clinical skills.

CONCLUSION

The work of practice developers is of central importance in the light of NHS policy developments, such as the NHS Plan or the response to the Bristol inquiry.

Barriers to research utilisation: the clinical setting and nurses themselves

The advance of the evidence-based practice (EBP) movement has been evident in almost every Western country and health system over the past two or three decades, fuelled by an ever-rising demand on resources. Nurses at all levels are increasingly expected to address the key challenge of EBP, which is to use research evidence in a conscientious, explicit and judicious way when making decisions about patient care. The main aim of the paper is to encourage nurses to embrace the challenge of EBP. First, as background, this paper presents key findings from the limited body of research which has examined barriers to research utilisation in the nursing context. Nurses generally feel there are many barriers, with primary barriers being lack of time, lack of relevant skills, poor team-working and several aspects of nursing 'culture' (ritualistic care, no authority and no incentives). Some conceptual models in implementation of research findings are introduced, and a summary presented of key areas which nurses need to address when considering research utilisation.

Clinical governance: implementing a change in workplace practice

The development of a draft guideline on confirming placement of nasogastric tubes laid the basis for a senior nurse to use the principles of clinical governance to lead an improvement in practice. Key factors included risk management, dissemination of draft guidelines reflecting current evidence and changing practice. Good communication was vital to the project.

Developing and supporting extended nursing roles: the challenges of NHS walk-in centres

BACKGROUND

National Health Service (NHS) walk-in centres offer immediate access to nurse-led primary care. Forty 'pilot' centres are now open, of which nine are in London. In providing clinical assessment, health information and a limited range of treatments to users, they exemplify new nursing roles that are emerging in primary care.

AIM

To describe the emerging roles of walk-in centre nurses, and explore the causes of role stress and review arrangements for training, development and support. METHODS; Semi-structured interviews with 29 managers and nurses from the nine London walk-in centres and with 10 stakeholders providing other primary care services near to three of the walk-in centres. Findings. Walk-in centre nurses are drawn from a wide range of clinical backgrounds. Emerging roles include diagnosing, developing clinical management plans, prescribing and discharging patients. Most find the roles challenging, but at times also stressful. There is no consensus on the most appropriate nursing skill mix for a walk-in centre nor on the core competencies required by the nurses working there. As a result there is no standardization of induction, training or support for walk-in centre nurses - particularly on the balance between taught and apprenticeship-type training.

CONCLUSIONS

Agreement is required on the competencies required for walk-in centre nursing and on appropriate ways to develop and support nurses in their practice. Lessons could be learned from general practitioner training.

Defining resident abuse within the culture of long-term care institutions

Although researchers have identified the presence of resident abuse within long-term carefacilities, it has not come under the same scrutiny as have other aspects of abuse against older adults. This is due, in part, to the difficulty in defining the phenomenon. The purpose of this study was to articulate a definition of resident abuse as perceived by registered nurses working in long-term care institutions. Ethnoscience was the method used to answer this question. The five categories of resident abuse characteristics--perception of hurtfelt by older residents, acts of omission or commission, context of care, intentional or unintentional, and behavioral clusters--that emerged through semistructured interviews and focus groups reflect the descriptions given by participants. Identifying a common definition of resident abuse suggests that assessment and intervention to reduce episodes of it are more likely to be effective.

Survey of continuing professional education within nursing homes

This article reports a survey of qualified nurses employed in nursing homes in a large city in the north of England. The aim of the study was to describe nurses' experiences and perceptions of continuing professional education (CPE), and their views on the development of their knowledge and skills through formal and informal education. Findings revealed that nurses in nursing homes perceived the value of educational programmes but had limited opportunities to attend formal education programmes. They faced a number of barriers and challenges in accessing formal education. Various informal ways of learning were used, including reading professional journals, watching videotapes and television programmes and accessing the Internet. However, respondents appeared not to use fully opportunities for sharing knowledge with colleagues. Although this study is based on a small sample, the findings support those of other studies in this field. Collectively, these studies suggest an urgent need to develop a range of approaches to CPE within care homes, both formal and informal, if the standards outlined within recent policy initiatives are to be achieved.

Application of the development stages of a cluster randomized trial to a framework for valuating complex health interventions

INTRODUCTION

Trials of complex health interventions often pose difficult methodologic challenges. The objective of this paper is to assess the extent to which the various development steps of a cluster randomized trial to optimize antibiotic use in nursing homes are represented in a recently published framework for the design and evaluation of complex health interventions. In so doing, the utility of the framework for health services researchers is evaluated.

METHODS

Using the five phases of the framework (theoretical, identification of components of the intervention, definition of trial and intervention design, methodological issues for main trial, promoting effective implementation), corresponding stages in the development of the cluster randomized trial using diagnostic and treatment algorithms to optimize the use of antibiotics in nursing homes are identified and described.

RESULTS

Synthesis of evidence needed to construct the algorithms, survey and qualitative research used to define components of the algorithms, a pilot study to assess the feasibility of delivering the algorithms, methodological issues in the main trial including choice of design, allocation concealment, outcomes, sample size calculation, and analysis are adequately represented using the stages of the framework.

CONCLUSIONS

The framework is a useful resource for researchers planning a randomized clinical trial of a complex intervention.

Hand decontamination: what interventions improve compliance?

BACKGROUND

Haemodialysis units have traditionally been classified as high-risk areas in relation to infection control. Hand decontamination is the fundamental infection control practice, although this is not always performed optimally Deficiencies in the technique, frequency and appropriateness of this vital practice are frequently reported in health care journals. A literature search was carried out to determine what interventions improve compliance with hand decontamination practice.

METHOD

A literature search was carried out of electronic databases from 1988-2000. Forty articles matched the key search words. When inclusion/exclusion criteria had been applied, seven primary research articles were found to be suitable. Appropriate tools were used to critically analyse the research. The findings were then synthesised into similar themes.

FINDINGS

The interventions used in the seven articles utilised a combination of staff and patient education, feedback and motivational interventions to improve compliance. The evidence showed that these interventions met with different degrees of success. Multiple interventions were generally more successful than individual efforts. The improvement in hand decontamination practice often fell back to base line measurements after the intervention had ceased.

IMPLICATIONS FOR PRACTICE

The findings can cautiously be used to improve practice. A combination of continuous, innovative education and motivation should improve and maintain this important skill.