Advanced clinical roles: investigating dilemmas and changing practice through action research

Research-active nurses' perceptions of the barriers to undertaking research in practice

The aim of the study was to identify how a small group of research-active clinical nurses perceived and overcame the reputed 'barriers' to carrying out research in practice. The nursing literature on research implementation tends to focus on barriers that prevent nurses engaging in research. This study takes a different approach and focuses instead on how some nurses manage to succeed despite the difficulties.

A purposive sample of 12 research-active nurses from one trust was recruited to the study. The small sample was a reflection of the comparatively small number of clinical practitioners involved in research activity. Interviews and rating scales were used to explore the practitioners' attitudes to research in general as well as barriers to research identified through earlier studies. The nurses studied did not consider the commonly perceived barriers to undertaking research to be 'barriers' - some nurses saw them as 'excuses'. The only barriers the nurses acknowledged were staffing, cost and lack of support, but they surmounted these by their determination to carry out their research studies and publish. The study suggests that the main kind of support needed by nurses who want to carry out research is that offered by facilitators, who give them confidence to carry out research and publish their findings.

Developing and testing a strategy to enhance a palliative approach and care continuity for people who have dementia: study overview and protocol

Background

Typically, dementia involves progressive cognitive and functional deterioration, leading to death. A palliative approach recognizes the inevitable health decline, focusing on quality of life. The approach is holistic, proactive, supports the client and the family, and can be provided by the client's usual care team.

In the last months of life, distressing symptoms, support needs, and care transitions may escalate. This project trialed a strategy intended to support a consistent, high quality, palliative approach for people with dementia drawing close to death. The strategy was to implement two communities of practice, drawn primarily from service provider organizations across care sectors, supporting them to address practice change. Communities comprised practitioners and other health professionals with a passionate commitment to dementia palliative care and the capacity to drive practice enhancement within partnering organizations.

Project aims were to document: (i) changes driven by the communities of practice; (ii) changes in staff/practitioner characteristics during the study (knowledge of a palliative approach and dementia; confidence delivering palliative care; views on death and dying, palliative care, and a palliative approach for dementia); (iii) outcomes from perspectives of family carers, care providers, and community of practice members; (iv) the extent to which changes enhanced practice and care continuity; and (v) barriers to and facilitators of successful community of practice implementation.

Methods/design

This action research project was implemented over 14 months in 2010/11 in metropolitan Perth, Western Australia and regional Launceston, Tasmania. Each state based community of practice worked with the researchers to scope existing practice and its outcomes. The research team compiled a report of existing practice recommendations and resources. Findings of these two steps informed community of practice action plans and development of additional resources. Change implementation was recorded and explored in interviews, comparisons being made with practice recommendations. Changes in staff/practitioner characteristics were evaluated using survey data. Findings from semi structured interviews and survey administration established outcomes from perspectives of family carers, care providers, and community of practice members. Consideration of processes and outcomes, across the two state based settings, informed identification of barriers and facilitators. Community of practice reflections also informed study recommendations.

Reducing staff isolation and developing evidence-informed practice in the aged care environment through an action research approach to falls prevention

This study aimed to examine whether an action research approach was effective in reducing the isolation of staff in 2 residential aged care facilities, within the context of an evidence-informed falls prevention program. A Falls Action Research Group comprising 12 nursing/nonnursing staff across 2 residential aged care facilities was established and engaged in critical dialogue and action over 12 months to improve their fall prevention activities. Through the group members' engagement, a research community was established that diminished staff isolation by engaging members in a sustained process of collaboration around falls prevention, which worked to disrupt occupational silos and challenge traditional staff hierarchies.

Realizing a palliative approach in dementia care: strategies to facilitate aged care staff engagement in evidence-based practice

BACKGROUND

There is growing evidence that a palliative approach to care provision for people with dementia in residential aged care facilities improves their quality of life and provides support for family members. Despite the development of Guidelines for a Palliative Approach in Residential Aged Care (hereafter the Guidelines), there is limited evidence that these have been adopted. To date, little research has been undertaken to explore processes which could assist aged care staff to develop their practice consistent with the intent of the Guidelines.

METHODS

This project utilized an action research method, through which staff members from a residential dementia special care unit (SCU) undertook an investigation into their practice to explore how they could develop strategies to support a palliative approach to care provision. A key focus was related to addressing the information needs of family members of residents on the SCU.

RESULTS

Aged care staff involved in this project had little understanding of available evidence that could assist them to better support family members, including the existence of the Guidelines. Through their engagement in successive action research cycles, these staff accessed evidence-based resources and developed strategies to address the information needs of family members.

CONCLUSIONS

When provided with an opportunity to reflect on and critique their practice, aged care staff were better positioned to engage with evidence concerning a palliative approach and to execute change in their practice to improve care provision for family members.

Attracting students to aged care: the impact of a supportive orientation

INTRODUCTION

The 'Building connections in aged care' project sought to investigate quality clinical placements for undergraduate nursing students in residential aged care facilities in Tasmania, Australia.

BACKGROUND

Aged care reportedly holds little attraction to student nurses as an employment option, exacerbating problems with recruiting staff into the sector. This, coupled with knowing the quality of an undergraduate learning experience can influence career choices, provided the impetus for the study.

METHODS

Informed by action research and conducted in three-stages, the project scoped the problem, implemented improvement strategies and assessed sustainability of their effectiveness. Data were collected via structured research meetings and surveys/check lists, and subjected to qualitative and quantitative analysis.

RESULTS

A key finding was the importance of providing students with a comprehensive orientation to the aged care environment.

DISCUSSION

The critical nature of orientation processes in the establishment of a supportive and welcoming environment for students, and to 'setting up' a positive and enjoyable learning experience in aged care settings has not been shown by research to date.

CONCLUSION

Student orientation warrants greater attention. We recommend strategies concerning the structure of student orientation programs, links with university schools of nursing, use of preceptors, and preparing aged care facility staff.

Community-based research: barriers to recruitment of African Americans

The elimination of health disparities for African Americans requires culturally relevant, empirical knowledge, which in turn requires including African Americans in research studies. However, power-difference barriers and conceptual barriers continue to inhibit the recruitment of African Americans. The purpose of this article is to define and discuss certain barriers to the recruitment of African Americans into research studies and to present culturally and contextually sensitive strategies to overcoming these barriers. Power-difference barriers reflect unequal authority and often generate mistrust. Conceptual barriers reflect researchers' need for better understanding about African Americans. Effective strategies include collaboration with the community through a community advisory board and conducting community-based participatory action research. Also, integrating alternative conceptual frameworks with mainstream frameworks may reduce researchers' ideological assumptions about African Americans. To promote optimal recruitment of African Americans, researchers must be aware of power-difference barriers and conceptual barriers and move toward active collaboration with African American communities.

Improving networks between acute care nurses and an aged care assessment team

BACKGROUND

Acute care nurses have an important role in the discharge planning of older people from hospital to home. However, few nurses understand the changing aged care system or the consequences of poor referral on the lives of older people postdischarge.

AIMS AND OBJECTIVES

This paper reports the findings of a research project, which aimed to investigate the possibilities for facilitating the transition of older people from hospital to home through improving the working relationship between nurses and members of a multidisciplinary aged care assessment team (ACAT).

DESIGN AND METHODS

The paper reports one action research cycle from a larger project. Action research was chosen because its focus on knowledge development and action leads to practical solutions to clinical problems. The research approach included interactive forums designed to facilitate effective collaboration between the nurses and ACAT in the discharge planning of older people. Data collection strategies included audiotapes of ACAT research discussions, field notes, policy documents, referral forms and an evaluation tool.

RESULTS AND CONCLUSIONS

The findings illustrate that ward nurses have, at best, a limited knowledge and understanding of the aged care system, its function, or how to access services. They need assistance to develop their knowledge of services available to support older people following discharge. The conduct of interactive forums, which utilize a case study approach, facilitated such knowledge development and empowered the nurses to become more involved in discharge planning. Participation in the forums also facilitated new collaborative partnerships between the nurses and ACAT, which enhanced effective discharge planning.

RELEVANCE TO CLINICAL PRACTICE

The paper outlines practical strategies to support collaboration between ward nurses and community providers and/or multi disciplinary assessment services. It provides a list of key considerations for the development of effective ward/community networks to facilitate the discharge of older people.

Enhancing lives through the development of a community-based participatory action research programme

A community-based participatory action research (PAR) programme that has spanned 5 years is discussed in this article. A primary healthcare philosophy requires research in this practice setting and supports the way healthcare is ideally organized within an integrated team and supported by a community network that includes not only the healthcare workers and service providers but also the community as partners. The principles driving three PAR inquiries are described: the development of a model for prevention of workplace violence; working with clinicians towards improving wound management practice; and management of continence for community-dwelling women living with multiple sclerosis. Participatory action research is a potentially democratic process that is equitable and liberating as participants construct meaning in the process of group discussions. We conclude that the cyclical processes inherent in PAR promote reflection and reconstruction of experiences that can lead to the enhancement of people's lives, either at an individual or community level, or both.

Communication issues for the interdisciplinary community palliative care team

This paper discusses the findings of a critical study that examined the communication patterns between nurses and general practitioners (GPs) providing palliative care in Australia. Interviews and focus groups involved 40 palliative care nurses who worked in the three settings of care: community, hospice and hospital. Issues that impeded effective communication strategies between palliative care nurses and GPs were networking, case management, multiple service providers, lack of standardized documentation and formal tracking of clients, along with difficulties in transmission of relevant practice knowledge. Supporting strategies for effective formal modes of communicating and reporting are described.

Education for advanced nursing practice: an evolving framework

This paper presents and critiques a framework for advanced health care practice. The framework is a set of professional attributes which underpin the delivery of an inter-disciplinary postgraduate course in the United Kingdom (UK). It enables students to review and develop knowledge and skills required to lead and advance nursing and health care practice. The framework is reviewed in relation to UK policy discussion on advanced or higher levels of practice. Brief comparisons are made with international concepts and literature on advanced nursing practice. The potential contribution of this framework to nursing practice and education is discussed. In particular, the framework provides a degree of clarity and coherence in specifying the nature and scope of advanced and higher level practice in the UK.

Identifying strategies for managing urinary incontinence with women who have multiple sclerosis

The aim of this pilot project was to identify strategies for managing incontinence with women who have multiple sclerosis (MS). The project used the formation of a group in which eight women with MS and four Continence Nurse Advisers (CNAs) and the first author were brought together. In the course of the research process, the women found a voice on a topic previously thought of as taboo. When they realized that they had suffered alone and in silence they felt empowered to act. In this way, the methodology evolved from group work into a participatory action research process (PAR), as the group initiated action. Participants formed a self-help group, and continued to meet with each other after the research had run its course.

At the interface of health and community care: developing linkages between aged care services in a rural context

This paper explores issues concerning the development of linkages across the interface between acute and community aged care services in a small regional Australian city. It addresses a participatory action research project that took place over a 2 year period involving an Aged Care Assessment Team (ACAT). Aged Care Assessment Teams are multidisciplinary teams whose members mediate between hospitals and the aged care system in the community and have a key role in developing networks and linkages between various service providers in the field. In an age of economic rationalist-inspired reform agendas in health and community care, rural infrastructures have been compromised to such a degree that the role of rural ACAT in developing linkages between sectors has never been more important. This paper takes up this issue and addresses the project findings, which highlight a field characterised by ineffective linkages within and between the various sectors, a lack of understanding of the operation of the rural aged care system among nurses working in regional hospitals, and the efficacy of ACAT working collaboratively with nurses to create new and more effective linkages in aged care.

Embracing ambiguities and valuing ourselves: issues of validity in action research

Further elucidation is required on the validity of action research. The tendency of nurse action researchers to rely on perspectives of validity from qualitative or ethnographic research only gives a partial picture. Three categories of validity regarding action research are proposed in order to develop understandings and to stimulate debate: dialectical, critical and reflexive. Tensions and processes, moral responsibilities, reflexivity and accounts of action research are discussed to illuminate the validity of action research. The complexity and contradictions inherent even when attempting to demonstrate its validity are highlighted and illustrated with reference to examples of action research.