Evidence-based care and the case for intuition and tacit knowledge in clinical assessment and decision making in mental health nursing practice: an empirical contribution to the debate

Standards of proficiency for registered nurses-To what end? A critical analysis of contemporary mental health nursing within the United Kingdom context

Against the backdrop of cultural and political ideals, this article highlights both the significance of mental health nursing in meeting population needs and the regulatory barriers that may be impeding its ability to adequately do so. Specifically, we consider how ambiguous notions of 'proficiency' in nurse education-prescribed by the regulator-impact the development of future mental health nurses and their mental health nursing identity. A key tension in mental health practice is the ethical-legal challenges posed by sanctioned powers to restrict patients' freedom at the same time as the desire (and obligation) to promote patients' self-determined recovery. The genericism of the UK's Future Nurse Standards do little to prepare mental health nurses to navigate the tensions that ensue. This has consequences for nurses and patients alike, as both risk experiencing the distress and dissonance that attends giving or receiving poor care. We argue that more needs to be done to enable mental health nurses to define and articulate the nuances of the profession as part of becoming critical, thoughtful and confident practitioners. Educators can contribute to this mission by aligning curriculum, pedagogy and assessment to create meaningful opportunities for mental health nursing students to engage with the complexities of mental health nursing practice. Without this, the credibility of the profession will continue to be questioned; its future uncertain.

Mental health service users' experiences of telehealth interventions facilitated during the COVID-19 pandemic and their relevance to nursing: An integrative review

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Service users report telehealth interventions to be useful in terms of access and convenience however, a preference for face-to-face interventions remains. Nurses are using telehealth interventions in clinical practice however, further research is necessary in this area as the evidence of their involvement is limited. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper highlights the use of telehealth interventions should augment rather than replace face-to-face care provision.

ABSTRACT

INTRODUCTION: The Covid-19 pandemic saw the swift implementation of physical and social distancing that impacted the way in which mental health services were facilitated. Consequently, telehealth/e-health interventions are increasing in use.

AIM

This integrative review aims to explore existing literature regarding mental health service users' experiences of telehealth interventions facilitated through the COVID-19 pandemic, to determine the visibility of nursing involvement in the facilitation of telehealth interventions and to use these experiences to inform nursing practice.

METHOD

A methodical search of eight (n = 8) academic databases was undertaken using CINAHL, SCOPUS, EMBASE, PsycINFO, Web of Science, Cochrane, MEDLINE and Academic Search Complete between January 2020 and January 2022.

RESULTS

A total of 5133 papers were screened by title and abstract of which (n = 77) progressed for full-text screening. Five (n = 5) papers met the inclusion criteria for this review and results were mapped onto the four meta-paradigms of nursing: person; where the findings discuss the acceptability of telehealth interventions; environment; where the findings highlight barriers and facilitators to the use of telehealth interventions; health; where the findings discuss staff time and logistical issues relating to telehealth interventions and nursing; where the findings centre around the therapeutic relationship.

DISCUSSION

This review highlights there is a paucity of direct evidence relating to nursing involvement in the facilitation of telehealth interventions. However, there are benefits to the use of telehealth interventions that include increased access to services, less perceived stigma and increased engagement which are relevant to nursing practice. A lack of individual contact and concerns relating to infrastructure indicates a fondness for face-to-face interventions remains high.

IMPLICATIONS FOR PRACTICE

There is a need for further research on the role of the nurse in the facilitation of telehealth interventions, specific interventions used and outcomes of such interventions.

Experiences of counselors participating in an innovative project to develop a training program for specialized foster parents of youth (13-18 years)

Background

Children placed in foster care represent a vulnerable and distressed group that requires a high level of care. However, good training programs designed to address specific problems presented in specialized foster care are not easily accessible due to logistical, economic and structural barriers. The lack of easy access and a strong desire to provide high-quality services inspired counselors from a specialized foster care center on the frontline to initiate an innovative, developmentally relevant and locally grounded training program.

Aims

This study focuses on counselors' experiences with the development of the training program and its impact on their work life.

Method

A qualitative research design within a participatory approach framework was used to understand the experiences of the counselors. All the counselors employed in the department and the leaders (n = 14) participated in the study. Data were gathered from participants, including the lead and second authors, using a semi-structured interview, and analyzed using thematic analysis.

Results

The analyses yielded three main categories: (i) Psychological Factors, (ii) Social Dynamics, and (iii) Leadership Style and Support. Each of the first two categories consisted of three subcategories. At the psychological level, the employees' experiences reflected the psychological states and traits required to fuel the tasks required by the project. The social dynamics of working in a team influenced the work process and, in turn, were impacted by it. Lastly, leadership style and support provided the foundation for innovation to germinate and grow.

Conclusion

Engaging in a locally created training program was associated with a strong sense of collaboration and team spirit. Counselors reported high intrinsic motivation and a strong sense of personal pride and drive for their jobs. They were proactive in seeking colleagues with particular expertise and collaborated on project tasks despite differences. The leadership style reflected the presence of transformational leadership behaviors, signaling an organizational culture conducive to innovation. The study provides an example of how aligning employees' personal aspirations with workplace goals and professional development can create a workplace in which employees feel it is enjoyable to go to work.

Public health nurses experience of mental health encounters in the context of primary health care: a constructivist grounded theory study

BACKGROUND

In primary health care people with mental health needs are often overlooked or masked with physical complaints. It has been suggested that public health nurses lack sufficient knowledge when encountering people with mental health problems. Low levels of mental health literacy among professionals are associated with negative patient outcome. There is a need to understand public health nurses process and strategies used when encountering a person with mental health problems in order to promote mental health. This study aimed to construct a theory that explains the process of public health nurses experience when encountering people with mental health problems based on their knowledge, attitudes, and beliefs about mental health.

METHODS

A constructivist grounded theory design was used to meet the aim of the study. Interviews were conducted with 13 public health nurses working in primary health care between October 2019 and June 2021, and the data analysis was performed according to the principles of Charmaz.

RESULTS

The core category, "Public health nurses as a relationship builder - to initiate the dialogue" reflected the process while the main categories "Being on your own", "Being on top of things- knowing your limits", and "Professional comfort zone" reflected conditions that were decisive for initiating a dialogue.

CONCLUSION

Managing mental health encounters in primary health care was a personal and complex decision-making process that depends on the public health nurses' professional comfort zone and acquired mental health literacy. Narratives of the public health nurses helped to construct a theory and understand the conditions for recognizing, managing and promoting mental health in primary health care.

The Problem Management Plus psychosocial intervention for distressed and functionally impaired asylum seekers and refugees: the PROSPER feasibility RCT

Background

The prevalence of psychological morbidity among asylum seekers and refugees is high, but these groups encounter extensive barriers to accessing health and social care. The aim of the PROSPER study was to assess the feasibility of conducting a randomised controlled trial in the UK of Problem Management Plus (PM+), an evidence-based psychosocial intervention delivered by lay therapists for distressed and functionally impaired asylum seekers and refugees.

Design

We undertook a feasibility study of PM+, which included a pilot study of the design features of a future definitive randomised controlled trial and economic evaluation. The feasibility study involved the adaptation of PM+ based on evidence drawn from literature synthesis and local stakeholder engagement, and a two-stage training procedure for lay therapists. These were followed by a pilot trial designed to assess the feasibility of conducting a three-arm randomised controlled trial of five 90-minute sessions of PM+, delivered individually or in groups, with 105 participants randomised 1 : 1 : 1 to individual PM+, group PM+ or a control intervention. Primary health outcomes were anxiety and depressive symptoms at 3 months; other outcomes included post-traumatic stress disorder symptoms, quality of life, progress with identified goals and service use.

Findings

We demonstrated that the form and content of PM+ could be adapted to meet the needs of asylum seekers and refugees. Twelve people with lived experience of the asylum process were successfully trained as lay therapists to deliver this targeted, low-intensity psychosocial intervention in local asylum seeker and refugee communities. The pilot trial was affected by governance issues. It began in December 2019 and was cut short by the COVID-19 pandemic. We were not able to complete recruitment and follow-up as planned; 11 out of 105 (10%) participants were recruited to the pilot trial (individual PM+, n = 4; group PM+, n = 3; control, n = 4); 8 out of 11 participants were followed up at 13 weeks and 7 out of 11 participants were followed up at 26 weeks. (Preliminary data were gathered on recruitment and retention, intervention fidelity and acceptability of study measures, including service use measures.)

Limitations

Protracted delays due to governance issues, followed by the COVID-19 pandemic, meant that we were unable to complete the pilot trial or to provide evidence regarding the feasibility of group PM+. The complexities of working with multiple languages and cultural groups were noted. There were mixed views on how successful PM+ might prove, and we had insufficient evidence to provide clear conclusions.

Future work

Future research could explore how technology can be used to improve the acceptability, feasibility, efficacy and potential cost-effectiveness of scalable mental health interventions and well-being support for distressed asylum seekers and refugees. The use of mobile phone and/or app-based forms of support may help to increase asylum seekers’ and refugees’ willingness to engage in research of this type.

Conclusions

Although it was not possible to specify the parameters for a full randomised controlled trial of PM+ for asylum seekers and refugees in the UK, our findings offer guidance on strategies that may be of value in future studies of this nature.

Trial registration

This trial is registered as ISRCTN15214107.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.

Measuring evidence-based practice in physical therapy: a mix-methods study

BACKGROUND

Evidence-based practice (EBP) is considered the "holy grail" to manage patients by health practitioners (such as physical therapists). However, sometimes, patients are not treated with the best interventions for their condition. Although studies already explored the facilitators and barriers for this issue, they increase in the level of importance if the information gathered are context appropriated. As the profession is relatively new in Portugal, currently little is known about the implementation of EBP in Portuguese physical therapists context. So, the aim of this study is to know if the Portuguese physical therapists use an EBP, and collect and deeper understand the factors, barriers and facilitators associated with EBP.

METHODS

This study incorporated a mixed-methods design (quantitative and qualitative). In an attempt to ensure the correct population sample, a national professional association e-mail database and the e-mails of past students from national schools were requested. For the quantitative data it was choose an e-survey, adapted from the EBP: Beliefs, Attitudes, Knowledge, and Behaviors of Physical Therapists Portuguese version questionnaire, consisted of 55 close-ended questions. It was analyzed response frequencies and associations between variables with logistic regression analyses. For the qualitative data, it was choose to perform semi-structured interviews in purposefully selected physical therapists to include different sociodemographic factors (especially those found to be statistically significant in the logistic regression) and survey responses regarding the physical therapists' beliefs, attitudes, knowledge, and behaviors. The interviews were performed in an online software, where only audio contact was performed. The audios were anonymized and verbatim transcribed, and the texts explored by the thematic approach.

RESULTS

From the 277 physical therapists that shown interest in participating in the study, 193 fully completed the questionnaire and, from those, 10 participated in the interviews. The Portuguese physical therapists reported positive beliefs, attitudes, knowledge, and behaviors regarding EBP. Among the physical therapists characteristics it seems that age (younger therapists), education (participating in continuing education courses; belonging to practice-orientated organizations; having a doctorate degree; pursuing a higher academic degree; and being a clinical instructor), and workplace (working for someone else account; and academic sector) are the main factors in the Portuguese EBP implementation. The Portuguese physical therapists, beyond the physical therapists individual characteristics and workplace, also stated that evidence, patients, clinical experience, schools, country and physical therapy characteristics, may behave as facilitators or barriers when performing an EBP.

Engagement, Responsibility, Collaboration, and Abandonment: Nurses' Experiences of Assessing Suicide Risk in Psychiatric Inpatient Care

Suicide risk assessment is a complex task for nurses working in psychiatric inpatient care. This study explored psychiatric inpatient nurses' experiences of assessing suicide risk. A qualitative design was used, and 10 interviews were subjected to qualitative content analysis. Nurses described suicide risk assessments as requiring them to create caring alliances and to take responsibility. Collaborating with colleagues was another part of nurses' experiences, as was feeling abandoned. To make the assessment safely, nurses need a combination of caring alliances, support from colleagues, clear guidelines, training and time for collegial reflection to create a supportive working climate.

Navigating complexity of child abuse through intuition and evidence-based guidelines: a mix-methods study among child and youth healthcare practitioners

BACKGROUND

Dutch child and youth health care (CYHC) practitioners monitor and assess the well-being of children. One of their main concerns is identifying cases of child abuse, which is an arduous and sensitive task. In these contexts, CYHC-practitioners use both evidence-based guidelines aimed at increasing the quality of care through rationalised decision-making, and intuition. These two practices are seen as being at odds with each other, yet empirical research has shown that both are necessary in healthcare. This study aims to unravel how intuition is perceived and used by Dutch CYHC-practitioners when identifying and working with cases of child abuse, and how this relates to their evidence-based guidelines.

METHODS

A sequential exploratory mixed-methods design: in-depth semi-structured interviews with CYHC-physicians focused on perceptions on intuition, which were followed by a survey amongst CYHC-practitioners on the recognition and use of the concept.

RESULTS

The majority of CYHC-practitioners recognise and use intuition in their daily work, stating that it is necessary in their profession. CYHC-practitioners use intuition to 1) sense that something is 'off', 2) differentiate between 'normal' and 'abnormal', 3) assess risks, 4) weigh secondary information and 5) communicate with parents. At the same time, they warn of its dangers, as it may lead to 'tunnel vision' and false accusations.

CONCLUSION

Intuition is experienced as an integral part of the work of CYHC-practitioners. It is understood as particularly useful in cases of child abuse, which are inherently complex, as signs and evidence of abuse are often hidden, subtle and unique in each case. CYHC-practitioners use intuition to manage and navigate this complexity. There is an opportunity for guidelines to support reflection and intuition as a 'good care' practice.

Blockchain-driven customer order management

Purpose

The purpose of this paper is to investigate the effects of Blockchain on the customer order management process and operations. There is limited understanding of the use and benefits of Blockchain on supply chains, and less so at processes level. To date, there is no research on the effects of Blockchain in the customer order management process.

Design/methodology/approach

A twofold method is followed. First, a Blockchain is programmed and implemented in a large international firm. Second, a series of simulations are built based on three scenarios: current with no-Blockchain, 1-year and 5-year Blockchain use.

Findings

Blockchain improves the efficiency of the process: it reduces the number of operations, reduces the average time of orders in the system, reduces workload, shows traceability of orders and improves visibility to various supply chain participants.

Research limitations/implications

The research is based on a single in-depth case that has the scope to be tested in other contexts in future.

Practical implications

This is the first study that demonstrates with real data from an industrial firm the effects of Blockchain on the efficiency gains, reduction on the number of operations and human-processing savings. A detailed description of the Blockchain implementation is provided. Furthermore, this research shows a list of the resources and capabilities needed for building and maintaining a Blockchain in the context of supply chains.

Originality/value

This is the first study that demonstrates with real data from an industrial firm the effects of Blockchain on the efficiency gains, the reduction in the number of operations and human-processing savings. A detailed description of the Blockchain implementation is provided. This paper contributes to the resource-based view of the firm, by demonstrating two new competitive valuable capabilities and a new dynamic capability that organisations develop when implementing and using Blockchain in a supply–demand process. It also contributes to the information processing theory by highlighting the analytics capabilities required to sustain Blockchain-related operations.

Self-Management Education for Bipolar Disorders: A Hermeneutic-Phenomenological Study on the Tacit Knowledge of Mental Health Nurses

Background: Self-management of bipolar disorder (BD) education is a complex nursing intervention in which patients and informal caregivers are taught to be actively involved in self-monitoring and self-regulating activities. Some studies question if nurses are sufficiently equipped to deliver these educational tasks. Other studies suggest that nurses have gathered their knowledge implicitly by experience, but to date, this tacit knowledge is not described from the experiences of mental health nurses (MHNs) in ambulant BD care. Objective: To detect the tacit knowledge used by MHNs by interpreting their experiences in delivering self-management education to people with BD and their informal caregivers. Methods: A phenomenological-hermeneutical study amongst MHNs (N = 9) from three ambulant BD care clinics in the Netherlands. Face-to-face, open, in-depth interviews guided by a topic list, were conducted and transcribed verbatim prior to the hermeneutical analysis. Findings: We found five categories resembling the complex character of self-management interventions provided by MHNs: Building a trustful collaboration, Starting a dialogue about needs and responsibilities, Explaining BD, Utilizing mood monitoring instruments, and Conceptualizing self-management of BD. Conclusion: Eventually MHNs use tacit knowledge to cope with situations that demand an outside-the-box approach. Self-management education is partially trained and partially mastered through experience. Practice implications: In order to facilitate long-term self-management of BD, the collaboration of a supporting network is essential.

Empathy as an Ethical Imperative

Empathy is an often-discussed topic among nurse scientists, educators, and professional practitioners. There is a small, but growing, body of research with a focus on empathy and its direct impact on clinical patient outcomes. However, nurses continue to place value on behavioral aspects of empathy, such as understanding the thoughts and feelings of others, caring, and perspective taking (Hojat, 2016; Kunyk & Olson, 2001). These empathic behaviors are foundational to establishing the nurse-patient relationship. The nurse-patient relationship is also central to the delivery of ethical patient care (American Nurses Association [ANA], 2015). Ethical care directly reflects elements of professional empathy, such as providing compassionate care, understanding the patient's perspective, and thoughtful consideration of the needs and values of each person (ANA, 2015). Empathy and ethics are connected, and both play a vital role in the decision-making process of nurses, particularly for decisions involving some level of uncertainty that require moral reasoning or values-based judgment (Barlow, Hargreaves, & Gillibrand, 2018).

V. Application of Lean Six Sigma in IT support services – a case study

Purpose

Lean Six Sigma (LSS) has been accepted globally across the service sector as a management strategy for achieving process excellence. In the past one decade, the application and success of LSS in services is remarkable across Information Technology (IT) organisations. However academic research has seldom derived implications from this practitioner’s science of improving processes. The purpose of this paper is to feature the application of LSS in the system maintenance department of a manufacturing firm.

Design/methodology/approach

The research reported in this paper is based on a case study carried out in system maintenance department using the Six Sigma Define-Measure-Analyse-Improve-Control (DMAIC) approach and its application in reducing complaint resolution time.

Findings

The LSS article presented here highlights a real-world case study of how LSS DMAIC methodology help reduce the complaint resolution time from 12.5 to 8.5 h (~30 per cent improvement) and the corresponding standard deviation from 28 to 17.4 days. This study also has resulted in reducing the turn-around-time of all the core processes in the organisation. The indirect financial savings estimated as a result of this overall impact was around INR2.5m.

Research limitations/implications

The research was restricted to studying the impact of LSS in one organisation. The validity of the results can be improved by including more organisations and more case studies from the IT support services.

Originality/value

This could serve as a resource for both practitioners to derive useful implications and to academicians as it contributes to the LSS body of knowledge towards theory testing.

Factors influencing clinical decision making used by mental health nurses to provide provisional diagnosis: A scoping review

Medical diagnosis has traditionally been the role of medical officers. However, mental health nurses working in crisis/emergency settings within Australia are expected to provide a provisional diagnosis postassessment of a consumer. There is limited literature and understanding how mental health nurses develop a provisional diagnosis. In this scoping review, we aimed to first identify and describe the clinical decision-making processes used by mental health nurses across a variety of clinical settings. Second, we sought to explore the factors influencing mental health nurse's diagnostic practice in a variety of settings. Literature was searched using CINAHL (EBSCOhost), PubMed, and ProQuest. Peer-reviewed literature published between 2007 and 2017 was used for this scoping review. Two major themes were identified: clinical decision making (CDM) in mental health nursing and diagnostic practice in nursing. A combination of clinician, environmental, and patient factors were found to have influenced CDM. Furthermore, mental health nurses rely heavily on tacit knowledge when making clinical decisions. Little is known about the use of diagnostic practice in mental health nursing in Australia; however, the limited literature revealed an overlap between the factors which influence CDM and diagnostic practice, respectively. Further research is needed into the use of diagnostic practice in mental health nursing to develop frameworks to assist with CDM pertaining to application of provisional diagnosis by mental health nurses working in assessment environments.

Leadership in the ‘Wicked’ Problem of Bosnia’s civil war: A case study examining ethical decision making under duress

The author, as a UN Commander in Bosnia in the early 1990s, faced what he believed to be an ethically insoluble dilemma entangled in the Wicked Problem of Bosnia’s civil war. Bosnia’s civil war was a Wicked Problem constructed by history, the warring factions and the UN’s policy of neutrality. The moral uncertainty of leading in Bosnia’s Wicked Problem generated a tendency to construct Tame Problems enabling forthright action guided by deontological principles of moral certainty. The reality of the Wicked Problem required leaders to adopt Utilitarian judgements based on projected consequences, as in Bosnia’s grey zone the Deontological certainties did not appear valid. When a Wicked Problem morphed into a crisis or Critical Problem requiring direct action, the morally correct course had to be instinctive aligning with Virtue ethics, the ethical character of the actors. This article is an attempt at reflective learning through post hoc sense making of events portrayed in a case study, the events fractured relationships, changed lives and provided stark lessons.

[Concept Analysis of Tacit Nursing Knowledge]

PURPOSE

The purpose of this qualitative study is to investigate the nature of tacit nursing knowledge practiced in the clinical field in Korea using hybrid models, and to clarify the definitions and attributes of the concept.

METHODS

The definition and nature of tacit nursing knowledge, obtained through a review of the extensive literature at the theoretical stage of the research, and the analysis of the in-depth interview data conducted by the career nurses in the fieldwork stage, are compared and analyzed.

RESULTS

The tacit nursing knowledge was found in three dimensions as knowledge related to the person, the clinical situation work context, the self, the others, and the task. The tacit nursing knowledge was defined as personal nursing knowledge and artistic skills that show up as unconscious behavior patterns, learned informally, and internalizedthrough repeated clinical practice experience based on professional nursing knowledge.

CONCLUSION

Tacit nursing knowledge has been widely used in clinical practice and has been shown to have a great impact, directly or indirectly, on clinical nursing. Therefore, individual and organizational efforts are needed for validation and clarification using the generation, sharing, collection, and peer review of sound implicit nursing knowledge to ensure that it is properly applied.

Factors influencing health practitioners' cognitive processing and decision-making style

Successful interventions, healthcare planning, and patient-centered care require explanation, justification, and collaboration through interprofessional clinical decision-making (CDM). Understanding health practitioners' decision-making styles and influencing factors can enhance CDM capabilities. Health professionals and students (N = 229) completed an online survey on their decision-making styles, interprofessional education, interprofessional practice, discipline education, clinical experience, processing styles, personality, interpersonal motivational factors, and age. To assess the influence of task structure, participants answered CDM questions on a high- and a low-structured case study. Age demonstrated an effect on the level of clinical experience, while clinical experience also mediated the effect of age on rational processing styles. While personality results were mixed, consistent with previous findings, conscientiousness predicted rational processing style. Effects of interpersonal motivation on personality were also mixed, insofar as results indicated an association between conscientiousness and both experiential and rational processing styles. Interpersonal motivation also predicted rational processing styles. The complexity of CDM and factors influencing healthcare practitioners' processing and decision-making styles was highlighted. To optimize CDM processes by addressing errors and biases, CDM, and practice complexity, healthcare practitioner education should include theory-driven CDM orientation frameworks.

Understanding each other in the medical encounter: Exploring therapists' and patients' understanding of each other's experiential knowledge through the Imitation Game

The ability of health-care professionals to understand the lived experiences of their patients has become increasingly important but has been a difficult topic to investigate empirically because it involves two distinctive research strands: interpretative phenomenological analysis and patient-provider communication. While interpretative phenomenological analysis focuses on experiences and illness narratives of patients, but not on therapist's understanding of those, patient-provider communication surveys focus primarily on effective forms of communication without addressing the actual illness experiences of patients. There is a need for empirical research that combines both strands to investigate not only the experiences of patients but also whether professionals are able to understand these. This study combined both strands by means of a novel research method called the Imitation Game (combined with other qualitative methods). This sociological method was developed to investigate what different social groups know of each other's lifeworld. It focused on the important domain of eating disorder treatment to investigate whether therapists were able to understand the experiences of their patients and vice versa. This study provides insights into the domains in which therapists and patients were able to develop insights into each other's experiential knowledge (and where they had difficulties in doing so). The findings also implicate the high potential of the Imitation Game as an interdisciplinary research method. We propose that the Imitation Game may be particularly valuable as a 'can opener' that enables the development of in-depth, qualitative insights into the substantive themes that matter in the lifeworlds of patients and therapists.

Viewing dressing evaluation through a pragmatic lens: The application of Dewey's experimentalism in the development of evidence for dressing selection

RATIONALE, AIMS, AND OBJECTIVES

The aim of this paper is to (1) summarize the challenges with developing evidence for dressing selection in wound care, (2) discuss the limiting influence that the Evidence-Based Practice movement has had in this field, and (3) discuss the opportunities offered by Dewey's theory of experimentalism as a pragmatic solution to develop a structured body of evidence.

FINDINGS

Whilst the number of dressings available on the market continue to proliferate, limited progress has taken place to develop a methodology for dressing evaluation that is relevant to clinical practice. It is proposed that experimentalism can be operationalized with a mixed-methods approach that may include the following: (1) medical histories and patient's stories; (2) participant observation and informal interviews; (3) a comparative study between a new dressing and standard care; (4) a patient's satisfaction survey; (5) a staff survey; (6) a cost examination; (7) an evaluation of the packaging and procurement route; and finally (8) a clinical meeting to triangulate the data and reach a consensus.

CONCLUSION

Experimentalism offers a framework for the construction of evidence used for dressing selection. Central to this concept is the integration of experience to the data collected. The context of the evaluation has equal weight to the data thus collected.

Nurses' Experiences in using Physical Activity as Complementary Treatment in Patients with Schizophrenia

INTRODUCTION

Schizophrenia is a common disease with a high risk of comorbidity in both psychiatric and somatic diseases. Physical activity is proven effective in reducing symptoms of schizophrenia and increasing overall health. Still it is not used systematically in the care of persons with schizophrenia.

AIM

The aim of this study is to describe nurses' experience, including personal motivation, in using physical activity as complementary treatment in patients with schizophrenia.

METHOD

Interviews in three focus groups with 12 participating nurses were conducted. Qualitative content analysis was used to analyze data.

RESULTS

Physical activity was commonly used. Although several nurses signaled positive patient response, i.e. less anxiety and better quality of sleep, the overall consensus was an uncertainty regarding the benefits. It was perceived as non-evidence based form of intervention.

CONCLUSION

The uncertainty of the benefits of physical activity is evident in nursing staff and poses a resistance to implement systematic physical activity as a complementary treatment in schizophrenia. A new awareness of evidence based nursing is suggested to promote a wider and more receptive attitude to reduce patient vulnerability in persons with schizophrenia.

Cognitive continuum theory in interprofessional healthcare: A critical analysis

Effective clinical decision making is among the most important skills required by healthcare practitioners. Making sound decisions while working collaboratively in interprofessional healthcare teams is essential for modern healthcare planning, successful interventions, and patient care. The cognitive continuum theory (CCT) is a model of human judgement and decision making aimed at orienting decision-making processes. CCT has the potential to improve both individual health practitioner, and interprofessional team understanding about, and communication of, clinical decision-making processes. Examination of the current application of CCT indicates that this theory could strengthen interprofessional team clinical decision making (CDM). However, further research is needed before extending the use of this theoretical framework to a wider range of interprofessional healthcare team processes. Implications for research, education, practice, and policy are addressed.

Mental Health Nurses' Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor

The purpose of the study is to investigate mental health nurses' experiences of recognizing and responding to suicidal behavior/self-harm and dealing with the emotional challenges in the care of potentially suicidal inpatients. Interview data of eight mental health nurses were analyzed by systematic text condensation. The participants reported alertness to patients' suicidal cues, relieving psychological pain and inspiring hope. Various emotions are evoked by suicidal behavior. Mental health nurses seem to regulate their emotions and emotional expressions, and balance involvement and distance to provide good care of patients and themselves. Mental health nurses have an important role and should receive sufficient formal support.

The perception of intuition in clinical practice by Iranian critical care nurses: a phenomenological study

Background

Intuition as a way of learning in nursing is applied to decision making and judgment in complicated clinical situations. Several studies have been conducted on intuition in clinical settings, but comprehension of this concept is unclear. Moreover, there is a lack of information about intuition in critical care nurses caring for more seriously ill patients. This study aimed to explore Iranian critical care nurses’ understanding of intuition in clinical practice.

Methods

In a descriptive–phenomenological study, 12 nurses employed in critical care units of the hospitals affiliated to Kermanshah University of Medical Sciences were purposively recruited to the study. A semistructured interview was administered, and then written verbatim. The data were managed by MAXQDA 10 software, and qualitative analysis was undertaken using the seven-stage approach of Colaizzi.

Results

Of the 12 nurses who participated in the study, 7 (58.3%) were female and married, and 10 (88.3%) held a bachelor’s degree in nursing. The mean and standard deviations of participants’ age, job experience, and critical care experience were 36.66±7.01, 13.75±6.82, and 7.66±3.36 years, respectively. Four main themes and eleven sub-themes were elicited from the qualitative analysis; the main themes including “Understanding intuition as a feeling”, “Understanding intuition as a thought”, “Understanding intuition as receiving signs”, and “Understanding intuition as an alarm”. Because they have trust in their own intuition, the nurses made further assessments and paid more attention to patients. They were also better prepared after receiving intuition alarms to perform the appropriate responses, and acting upon the alarms reduced the nurses’ physical and psychological signs.

Conclusion

The findings showed how intuition was understood by the critical care nurses; therefore, these results can be considered to form a theoretical basis for designing other studies. Because of the significant role of intuition in enhancing the nursing care of critically ill patients, it is suggested that more qualitative, quantitative, and trials studies be performed to reinforce intuition in nursing; moreover, to incorporate intuition into nursing curriculums, it should be debated in academic settings.

State of Science, "Intuition in Nursing Practice": A Systematic Review Study

INTRODUCTION

There were many attempts for introducing "intuition" to nursing practice, But despite the efficacy, it has been ignored as a valid way of knowing. Therefore the current study was conducted for evaluating the state of sciences to intuition in nursing practice.

MATERIALS AND METHODS

In a systematic review study, all researches, published from 1995 to 2014, were searched in the databases of "PubMed", using "intuition" and "nursing" keywords. The abstract of articles were read in scrutiny, then the related researches selected, thereafter the full text of them was assessed carefully.

RESULTS

From searching the databases, 144 articles with "intuition and nursing" were found, 53 as original research, and 15 with inclusion criteria were selected. Most of the studies had qualitative approaches design as phenomenology (N=4), content analyses (N=2) and grounded theory (N=1), six was done for developing the instrument, and two studies have been conducted as descriptive method.

CONCLUSION

The results revealed the researches about intuition in nursing mostly were conducted with qualitative and instrument developing methodology and there is a lack of quantitative and trial studies.

The implications of Kristeva's notion of the abject in understanding the significance of therapeutic knowledge and practice in mental health nursing

Mental health nursing knowledge is largely excluded in certain key clinical guideline groups despite nursing practice being so important to service users. This exclusion may be because mental health nurses work close to what cannot be spoken of easily, or at all--the abject. Good mental health nursing practice depends on the individual person of the mental health nurse rather than any knowledge frameworks. Education should focus on relational aspects of practice to develop this and to define the core identity of mental health nursing as a therapy. This paper discusses therapeutic knowledge and practice in mental health nursing through Kristeva's notion of the abject as that which is the other side of language, closely linked to the feminine space of the chora. The chora is a provisional, stable space, associated with the mother's body, where the first possibility of signification can take place. Mental health nursing is a therapeutic practice that draws on knowledge that is practical, tacit, empirical, embodied and intuitive, as well as knowledge that is regarded here as beyond the tacit; the latter indicating an encounter with the abject. Mental health nursing as a practice potentially places an extraordinary ethical onus on the individual nurse in his/her relations with patients and indicates that it is the person of the nurse who is therapeutic rather than any knowledge framework, with major implications for education and professional identity. The presence of mental health nursing practice at the heart of the mental health care system, while effectively being ignored as a treatment by the National Institute for Health and Care Excellence, embodies a critique of the currently dominant evidence-based paradigm.

Integrating an evidence-based intervention into clinical practice: 'transitional relationship model'

The transitional relationship model (TRM) facilitates the discharge process by providing peer support and hospital staff involvement until a therapeutic relationship has been established with a community care provider. A quasi-experimental, action-oriented research design was employed in which psychiatric wards at six hospital sites implemented the model in three waves. Helpful strategies were identified by each wave of wards for consideration by subsequent wards. Using an ethnographic approach, qualitative data were examined to uncover experiences and perceptions of TRM implementation and to help identify key issues that were supporting or hampering implementation. Specific strategies that facilitate the implementation of TRM include: (1) the use of educational modules for on-ward hospital staff training and peer training; (2) presence of on-site champions; and (3) supportive documentation systems. Issues identified as barriers to implementation included: (1) feeling drowned, swamped and overwhelmed; (2) death by process; (3) team dynamics; and (4) changes in champions. Staged large-scale implementation of the TRM allowed for iterative improvements to the model leading to positive outcomes. This study highlights the need to address work environment issues, particularly interprofessional teams.

New theory from an old technique: the Rolma matrices

BACKGROUND

Understanding the reasons behind non-adherence to clinical practice guidelines is a complex process. Many explanatory models have been proposed that are grounded in qualitative theory. The 2 × 2 matrix has often been used to condense this potentially complex information into a format understandable to clinicians without educational or qualitative backgrounds.

METHODS

The concept of tacit knowledge and its interplay with evidence-based practice is explored and the role of matrices in demonstrating various interactions is defined.

RESULTS

Two new matrices are proposed to describe how experience and tacit knowledge may determine the outcome of patients, regardless of the evidence base.

CONCLUSIONS

The Rolma 1 and 2 matrices can be used to demonstrate to all clinicians, regardless of their background, how their experiences effect judgements and why junior (and senior) staff may not appear to engage with best practice.

Irish psychiatric nurses' self-reported barriers, facilitators and skills for developing evidence-based practice

Evidence-based practice places an emphasis on integration of clinical expertise with available best evidence, patient's clinical information and preferences, and with local health resources. This paper reports the findings of a study that investigated the barriers, facilitators and skills in developing evidence-based practice among psychiatric nurses in Ireland. A postal survey was conducted among a random sample of Irish psychiatric nurses and survey data were collected using the Development of Evidence-Based Practice Questionnaire. Respondents reported that insufficient time to find and read research reports and insufficient resources to change practice were the greatest barriers to the development of evidence-based practice. Practice development coordinators were perceived as the most supportive resource for changing practice. Using the Internet to search for information was the highest-rated skill and using research evidence to change practice was the lowest-rated skill for developing evidence-based practice. Nurses' precursor skills for developing evidence-based practice, such as database searching and information retrieval, may be insufficient in themselves for promoting evidence-based practice if they cannot find evidence relating to their particular field of practice or if they do not have the time, resources and supports to develop their practice in response to evidence.

Creation of an evidence-based practice reference model in falls prevention: findings from occupational therapy

PURPOSE

This study attempted to capture the evidence-based practice (EBP) behaviours of expert occupational therapy (OT) clinicians in order to develop a reference model of EBP in falls prevention.

METHODS

Expert clinicians participated in the creation of a clinical vignette through focus group discussions. Using the vignette as the stimulus case, the same clinicians answered questions that reflected the EBP process. Validation of original responses and data synthesis occurred through a second focus group. This validation process resulted in the elaboration of a tree structure EBP decision model.

RESULTS

Findings show that clinicians are not expert evidence-based practitioners. Although some of the experts' clinical decisions were based on a combination of professional experience and research evidence, clinicians relied primarily on clinical experience for more complex aspects of decision-making. When explicitly instructed to answer questions corresponding to the five EBP steps, experts were compelled to think about the use of evidence and could proceed through the EBP process.

CONCLUSIONS

The model represents the expert clinical decisions in each of the EBP steps and illustrates what aspects of the decision-making process are in line with EBP versus aspects that are driven primarily by experience. This research has the potential to assist clinicians working in prevention of falls in geriatric rehabilitation who can use the model as a practice framework to guide them through the EBP process.

Evidence-based practice: a review of theoretical assumptions and effectiveness of teaching and assessment interventions in health professions

Health care professionals are expected to use a systematic approach based on evidence, professional reasoning and client preferences in order to improve client outcomes. In other words, they are expected to work within an evidence-based practice (EBP) context. This expectation has had an impact on occupational therapy academic programs' mandates to prepare entry-level clinicians who demonstrate competence in the knowledge, skills and behaviors for the practice of evidence-based occupational therapy. If the EBP approach is to be entrenched in the day to day practice of future clinicians, a pedagogically sound approach would be to incorporate EBP in every aspect of the curriculum. This, however, would require a comprehensive understanding of EBP: its basis, the principles that underpin it and its effectiveness in promoting core professional competencies. The existing literature does not elucidate these details nor does it shed light on how requisite competencies for EBP are acquired in professional education in general and in occupational therapy education in particular. Drawing from educational psychology and EBP in the health professions, this paper provides a critical review of the evidence that supports EBP and the effectiveness of EBP teaching and assessment interventions in professional heath sciences programs and offers suggestions for the design of EBP instruction, grounding recommendations in educational theory for the health professions.

Approaches to clinical decision-making: a qualitative study of naturopaths

The type of information used and its application in clinical practice has generated interest due to its relationship to evidence-based medicine (EBM). However, it is also acknowledged that the principles of EBM place less value on practitioners' experience and intuitive insights when making clinical decisions. Research in this area has been conducted with conventional health professionals, meanwhile complementary and alternative medicine practitioners such as naturopaths have received little attention. In response interviews were undertaken with naturopaths to explore their approach to information-seeking and application in clinical settings. Thematic analysis identified how naturopaths incorporate deductive reasoning alongside intuition and clinical experience to overcome difficulties in applying information to relevant clinical situations. This research provides an understanding of the approach taken by naturopaths to improve the relevance of available data when making clinical decisions and is of significance for health policy and health service delivery in this area.

A Grounded Theory of Intuition among Occupational Therapists in Mental Health Practice

Objectives:

This study aimed to explore occupational therapists' understanding and use of intuition in mental health practice.

Method:

Using a grounded theory approach, a theoretical sample of nine occupational therapists practising in mental health settings participated in semi-structured interviews. Data were analysed using the constant comparative method.

Findings:

Intuition was found to be embedded within clinical reasoning. From the data, intuition was defined as knowledge without conscious awareness of reasoning. The participants viewed intuition as elusive and underground, and suggested that professional experience led to a more comfortable use of intuition. Using intuition relied on therapists' understanding of their own and others' emotions, and intuition partnered analysis within their clinical reasoning. A grounded theory of the use of intuition in mental health settings is proposed.

Conclusion:

Occupational therapists practising in mental health settings understand intuition to be an instinctive understanding of situations, resulting from their professional experience and the understanding of emotions.

Judging nursing information on the WWW: a theoretical understanding

AIM

This paper is a report of a study of the judgement processes nurses use when evaluating World Wide Web information related to nursing practice.

BACKGROUND

The World Wide Web has increased the global accessibility of online health information. However, the variable nature of the quality of World Wide Web information and its perceived level of reliability may lead to misinformation. This makes demands on healthcare professionals, and on nurses in particular, to ensure that health information of reliable quality is selected for use in practice.

METHOD

A grounded theory approach was adopted. Semi-structured interviews and focus groups were used to collect data, between 2004 and 2005, from 20 nurses undertaking a postqualification graduate course at a university and 13 nurses from a local hospital in the United Kingdom.

FINDINGS

A theoretical framework emerged that gave insight into the judgement process nurses use when evaluating World Wide Web information. Participants broke the judgement process down into specific tasks. In addition, they used tacit, process and propositional knowledge and intuition, quasi-rational cognition and analysis to undertake these tasks. World Wide Web information cues, time available and nurses' critical skills were influencing factors in their judgement process.

CONCLUSION

Addressing the issue of quality and reliability associated with World Wide Web information is a global challenge. This theoretical framework could contribute towards meeting this challenge.

Tacit knowledge of caring and embodied selfhood

The tacit knowledge paradigm is gaining recognition as an important source of knowledge that informs clinical decision-making. It is, however, limited by an exclusive focus on knowledge acquired through clinical practice, and a consequent neglect of the primordial and socio-cultural significance of embodied selfhood, precisely what provides the foundational structure of tacit knowledge of caring and facilitates its manifestation. Drawing on findings from a qualitative study of 43 dementia care practitioners in Ontario, Canada that utilised research-based drama and focus group methodology, we argue that embodied selfhood is fundamental to tacit knowledge of caring. Results are analysed drawing upon the theoretical precepts of embodied selfhood that are rooted in Merleau-Ponty's (1962) reconceptualisation of perception and Bourdieu's (1977, 1990) notion of habitus. We conclude with a call for further exploration of the body as a site of the production of tacit knowledge.

Patient initiation of information: exploring its role during the mental health intake visit

OBJECTIVE

Describe the role of patients' initiation of information in patient-provider communication during mental health intake visits.

METHODS

One hundred and twenty-nine mental health intake visits of diverse racial/ethnic patients were videotaped. Semi-structured interviews were conducted with patients and providers following each intake visit. We qualitatively analyzed the interviews to identify themes related to patients' initiation of information. We quantitatively analyzed the videos of the intake visits utilizing a checklist that identified whether the patient or the provider initiated the information exchanged.

RESULTS

Patient initiation of information affected providers' evaluation of the credence of the information, assessment of rapport and appraisal of the success of the intake visit. Patients' initiation of information varied with patients' race, age and prior treatment experience; and provider's age, discipline and experience. Patients expressed a personal preference either to not be interrupted or to be asked questions by their providers.

CONCLUSION

Our findings illuminate the role of patient initiation of information in provider decision-making and highlight the importance of tailoring the communication style to patients' preferences.

PRACTICE IMPLICATIONS

Encouraging explicit communication with patients about expectations related to information exchange styles is recommended. Improving provider awareness of assumptions regarding their decision-making is also suggested.

Clinical utility of predictors of return-to-work outcome following work-related musculoskeletal injury

INTRODUCTION

Clinical expertise is one source of evidence that is generally under-utilised in the development of an evidence-base in rehabilitation. The current study aimed to incorporate this valuable clinical expertise in determining the utility of multiple predictors of return-to-work outcome following injury.

METHODS

Following systematic review of the rehabilitation literature and review, a total of 85 predictors were evaluated for clinical relevance by an expert panel of rehabilitation practitioners (n = 12). Each predictor was rated according the importance of the predictor in rehabilitation, its potential for modification and its classification into one of seven broad areas. In addition, practitioners were asked to provide a rationale as to why the predictor was important to rehabilitation. Analyses were conducted using inter-rater agreement statistics and text analysis.

RESULTS

Predictors that were most commonly reviewed in the literature were not considered to be of greatest clinical utility, according to the current sample. From the total predictor set, only nine predictors were identified as clinically useful (i.e., both highly important and highly modifiable). Text analysis of the qualitative data revealed that these nine predictors highlighted the significance of time, context and engagement in rehabilitation practice.

CONCLUSION

In the current study, predictors that were considered most clinically relevant were those that generally described workplace related processes. The findings confirmed the underlying supportive and collaborative processes that integrate predictors and account for their influence on outcome. Future rehabilitation efforts and indeed, individual outcomes, could benefit by incorporating these key predictors in targeted programs.

Testing nonlocal observation as a source of intuitive knowledge

This study explored the hypothesis that in some cases intuitive knowledge arises from perceptions that are not mediated through the ordinary senses. The possibility of detecting such nonlocal observation was investigated in a pilot test based on the effects of observation on a quantum system. Participants were asked to imagine that they could intuitively perceive a low-intensity laser beam in a distant Michelson interferometer. If such observation were possible, it would theoretically perturb the photons' quantum wave functions and change the pattern of light produced by the interferometer. The optical apparatus was located inside a light-tight, double-steel walled, shielded chamber. Participants sat quietly outside the chamber with eyes closed. The light patterns were recorded by a cooled digital camera once per second, and average illumination levels of these images were compared in counterbalanced mental blocking versus nonblocking conditions. By design, perturbation would produce a lower overall level of illumination, which was predicted to occur during the blocking condition. Based on a series of planned experimental sessions, the outcome was in accordance with the prediction (z = -2.82; P = .002). This result was primarily due to nine sessions involving experienced meditators (combined z = -4.28; P = 9.4 x 10(-6)); the other nine sessions with nonmeditators were not significant (combined z = 0.29; P = .61). The same experimental protocol run immediately after 15 of these test sessions, but with no one present, revealed no hardware or protocol artifacts that might have accounted for these results (combined control z = 1.50; P = .93). Conventional explanations for these results were considered and judged to be implausible. This pilot study suggests the presence of a nonlocal perturbation effect that is consistent with traditional concepts of intuition as a direct means of gaining knowledge about the world, and with the predicted effects of observation on a quantum system.

Clinical judgement in the interpretation of evidence: A Bayesian approach

AIM

This paper presents an argument for the use of Bayesian reasoning in considering the value of evidence in making nursing judgements.

BACKGROUND

Nursing has taken on board the drive towards evidence-based practice. There has been little discussion, however, of how evidence should be interpreted. There is a growing interest in health care in the use of Bayesian reasoning for evidence interpretation, both in research and in clinical practice; as yet, there is a limited discussion in the literature of relevance to nursing.

OBJECTIVES

To provide a short tutorial in the application of Bayes rule to a clinical judgement. To discuss the implications for practice of adopting a Bayesian perspective.

DISCUSSION

The relationship between evidence and clinical judgement is outlined. The need to accept uncertainty, and be equipped to deal adequately with this, is discussed: some basic ideas of probability are rehearsed. An outline of Bayesian reasoning is offered and a demonstration of the application of Bayes rule to a nursing judgement is presented.

RELEVANCE TO PRACTICE

A rationale for adopting a Bayesian perspective on evidence interpretation is offered: namely the changing context of practice, with the blurring of professional boundaries and the need to articulate judgements, the avoidance of error and the opportunity to identify the appropriate areas for investigation in nursing.

A model to describe the relationship between knowledge, skill, and judgment in nursing practice

This paper explores the relationship between knowledge, skill, and judgment and proposes a model to describe that relationship. Through illustration of the components and interrelationships within this model one can more clearly understand the nature of nursing work. Drawing on Benner's work on novice to expert, the model shows the interrelationship and the evolution of knowledge, skill, and judgment in a nurse's practice.