Integrating evidence-based interventions in clinical settings in Jordan: a policy brief

Background: Evidence-based nursing practice (EBNP) is considered a major and very important global paradigm shift. Unfortunately, most healthcare providers and researchers embrace the concept of evidence-based practice (EBP) without integrating this concept in clinical settings. The current situation of EBP and new practice guidelines utilization in Jordan are scarce. This policy brief aimed to discusses the process of utilizing nursing EBP in clinical settings in Jordan.

Methods: The authors adopted an action plan utilizing a systematic approach to develop and implement specific strategies and policies to integrate EBP in clinical settings in Jordanian hospitals.

We present an experience of one country in terms of introducing a policy brief to establish an EBP policy accompanied by developing an EBP unit in the hospital's country.

Results: A comprehensive description of this policy is provided with reference to the eminent steps of policy analysis and evaluation. In fact, EBP policies and clinical practice guidelines should keep a live document and revise regularly or as needed. Overall, the authors suggest the development of a unit for EBP to deal with issues related to clinical practice guidelines.

Conclusions: Expected outcomes for the introduction of the EBP unit and its policy include increase research utilization and accelerated adoption of new evidence, increase the quality of care provided, increase patient, staff, and managers satisfaction, and decrease staff workload by reducing complications associated with medical errors and outdated interventions.

Beyond awareness of 'difference' and towards social action: 'Solidarity practice' alongside young people

Who I am as a working-class black African woman cannot be disconnected from how I work. It shapes my lens with regard to power, difference and liberation. It is not surprising that I have been drawn to social justice approaches to psychological intervention, such as Narrative Therapy, Coordinated Management of Meaning (CMM), social constructionist systemic therapy and liberation psychology. These practices involve taking up the cause of the oppressed in ways that respect them as agents of their own liberation. In this article, I describe what I term 'solidarity practice' with young people and their families as a counter force resisting the increasingly blaming and individualising discourse of mainstream psychology, psychiatry and social policy.

Knowledge 'Translation' as social learning: negotiating the uptake of research-based knowledge in practice

BACKGROUND

Knowledge translation and evidence-based practice have relied on research derived from clinical trials, which are considered to be methodologically rigorous. The result is practice recommendations based on a narrow view of evidence. We discuss how, within a practice environment, in fact individuals adopt and apply new evidence derived from multiple sources through ongoing, iterative learning cycles.

DISCUSSION

The discussion is presented in four sections. After elaborating on the multiple forms of evidence used in practice, in section 2 we argue that the practitioner derives contextualized knowledge through reflective practice. Then, in section 3, the focus shifts from the individual to the team with consideration of social learning and theories of practice. In section 4 we discuss the implications of integrative and negotiated knowledge exchange and generation within the practice environment. Namely, how can we promote the use of research within a team-based, contextualized knowledge environment? We suggest support for: 1) collaborative learning environments for active learning and reflection, 2) engaged scholarship approaches so that practice can inform research in a collaborative manner and 3) leveraging authoritative opinion leaders for their clinical expertise during the shared negotiation of knowledge and research. Our approach also points to implications for studying evidence-informed practice: the identification of practice change (as an outcome) ought to be supplemented with understandings of how and when social negotiation processes occur to achieve integrated knowledge. This article discusses practice knowledge as dependent on the practice context and on social learning processes, and suggests how research knowledge uptake might be supported from this vantage point.

Letter to the Editor

The editorial in BJN 24(15) written by BJN Editor in Chief, Ian Peate, challenged the Nursing and Midwifery Council's (NMC) Chief Executive and Registrar's assertion that the progress her organisation has achieved over the past 12 months is something to be 'delighted' about. The NMC responded and their letter is below. If you would like to comment on the issue email us: bjn@markallengroup.com.

The application of epic3 guidelines: the complexity of practice

Healthcare-associated infection (HCAI) is a major patient safety concern and is associated with morbidity, mortality and increased healthcare costs. Prevention and control requires a multi-modal approach, but the individual's accountability and rigorous application of standard infection prevention and control behaviours is at its core. The third instalment of the epic3 guidance ( Loveday et al, 2014a ) provided the evidence and advanced the importance of hand-hygiene behaviour, the use of non-sterile gloves and environmental cleanliness. This discussion considers some of the recommendations made in these areas of practice and some of the underlying complexities. Producing guidelines based on the best available evidence and transforming them into policies can be a useful adjunct to communicating the necessary standards. However, policies often erase the complexity of implementation. To strive for the best possible standard is an understandable and laudable objective, but organisations need to be mindful of the difficulties and obstacles that stand in their way, particularly in an era where the philosophy of 'zero tolerance' is gaining popularity.

Epidemiology, quality, and reporting characteristics of systematic reviews and meta-analyses of nursing interventions published in Chinese journals

OBJECTIVES

Systematic reviews (SRs) and meta-analyses (MAs) of nursing interventions have become increasingly popular in China. This review provides the first examination of epidemiological characteristics of these SRs as well as compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses and Assessment of Multiple Systematic Reviews guidelines. The purpose of this study was to examine epidemiologic and reporting characteristics as well as the methodologic quality of SRs and MAs of nursing interventions published in Chinese journals.

METHODS

Four Chinese databases were searched (the Chinese Biomedicine Literature Database, Chinese Scientific Journal Full-text Database, Chinese Journal Full-text Database, and Wanfang Database) for SRs and MAs of nursing intervention from inception through June 2013. Data were extracted into Excel (Microsoft, Redmond, WA). The Assessment of Multiple Systematic Reviews and Preferred Reporting Items for Systematic Reviews and Meta-analyses checklists were used to assess methodologic quality and reporting characteristics, respectively.

RESULTS

A total of 144 SRs were identified, most (97.2%) of which used "systematic review" or "meta-analyses" in the titles. None of the reviews had been updated. Nearly half (41%) were written by nurses, and more than half (61%) were reported in specialist journals. The most common conditions studied were endocrine, nutritional and metabolic diseases, and neoplasms. Most (70.8%) reported information about quality assessment, whereas less than half (25%) reported assessing for publication bias. None of the reviews reported a conflict of interest.

CONCLUSIONS

Although many SRs of nursing interventions have been published in Chinese journals, the quality of these reviews is of concern. As a potential key source of information for nurses and nursing administrators, not only were many of these reviews incomplete in the information they provided, but also some results were misleading. Improving the quality of SRs of nursing interventions conducted and published by nurses in China is urgently needed in order to increase the value of these studies.

Implications of holding ideas of evidence-based practice in nursing

The author of this paper examines emerging implications of holding ideas about evidence and evidence-based practice. Evidence has a very specific role in the delivery of safe clinical care, but it is creating a serious problematic for the practice of nursing. It is proposed that: evidence-based practice be re-situated or reconstructed as a collective and organizational responsibility and not the responsibility of individual nurses in practice; nurses re-focus on articulating a more ethical foundation for praxis, one that emerges from nursing philosophy and one that is co-constituted with persons/families/groups; and nurse leaders and educators establish teaching-learning and practice environments that enable a peer-to-peer process of critical review and curious inquiry of available evidence in the contexts of shared work.

Innovative strategies for teaching nursing research in Taiwan

BACKGROUND

Evidence-based practice is imperative in clinical settings because it bridges the gap between research findings and clinical practice. Promoting nursing student interest and enthusiasm for research is therefore crucial when teaching nursing research.

OBJECTIVE

The aim of thus study was to develop innovative teaching strategies that increase nursing students' interests and engagement in research.

METHODS

This study employed a descriptive, pretest-posttest, quasiexperimental design with 103 participants in the experimental group and 106 in the control group. The Attitudes toward Research Questionnaire, Classroom Engagement Scale, Self-Directed Learning Instrument, Nursing Eight Core Competencies Scale, Value of Teams survey, and a research knowledge test were applied to evaluate the outcomes of the innovative teaching strategies.

RESULTS

Scores for the research knowledge test were significantly higher in the experimental group than in the control group in posttest 1 and posttest 2. After the intervention, participants in the experimental group exhibited higher scores on attitudes toward research, eight core competencies in nursing,value of teams, classroom engagement, and self-directed learning than participants in the control group. Students in the experimental group perceived a lower degree of pressure and higher degrees of interest, enjoyment, and acceptance of the research course than students in the control group.

CONCLUSIONS

This study confirmed that using innovative teaching strategies in nursing research courses enhances student interest and enthusiasm about evidence-based practice.

Queer challenges to evidence-based practice

This paper aims to queer evidence-based practice by troubling the concepts of evidence, knowledge and mental illness. The evidence-based narrative that emerged within biomedicine has dominated health care. The biomedical notion of 'evidence' has been critiqued extensively and is seen as exclusive and limiting, and even though the social constructionist paradigm attempts to challenge the authority of biomedicine to legitimate what constitutes acceptable evidence or knowledge for those experiencing mental illness, biomedical notions of evidence appear to remain relatively intact. Queer theory offers theoretical tools to disrupt biomedical norms and challenges biomedical normativity to indicate how marginalisation occurs when normative truths about mental health classify those who differ from the norm as 'ill' or 'disordered'. Queer theory's emphasis on normativity serves the political aim to subvert marginalisation and bring about radical social and material change. Reference will be made to mental health subjects within each discourse by indicating how the body acts as a vehicle for knowing. Deleuzian notions of the rhizome are used as metaphor to suggest a relational approach to knowledge that does away with either/or positions in either biomedical, or queer knowledge to arrive at a both/and position where the biomedical, constructionist and queer are interrelated and entangled in needing the other for their own evolution. However, queer does not ask for assimilation but celebrates difference by remaining outside to disrupt that which is easily overlooked, assumed to be natural or represented as the norm. The task of queer knowledge is to do justice to the lives lived in the name of evidence-based practice and demands that we consider the relations of power where knowledge is produced. This pursuit creates different knowledge spaces where we identify new intersections that allow for socially just understandings of knowing or evidence to emerge.

Practice guidelines need to address the 'how' and the 'what' of implementation

AIM

The aim of this study was to explore the realities of everyday nursing practice associated with the implementation of a guideline for the assessment and management of cardiovascular risk.

BACKGROUND

The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable and, in spite of much investigation, remains resistant to explanation of what works and why. Exploration of the nature of guideline implementation has the potential to illuminate the complexities of guideline implementation by focussing on the nature of practice. Nurses are well placed at the front line of primary health care to contribute to an understanding of how guideline implementation plays out in their everyday practice.

METHODS

Qualitative description was used, involving focus groups and interviews with 32 participants (20 nurses, four doctors, five managers and three funder/planners), to explore the use of a guideline in everyday primary health-care practice. Thematic analysis of data was managed through an inductive process of familiarisation, coding, categorising and generation of themes.

FINDINGS

Four themes were generated from the data portraying the realities of guideline implementation for primary health-care nurses: self-managing patient, everyday nursing practice, developing new relationships in the health team and impact on health-care delivery. The findings reveal that, even with the best of intentions to implement the guideline, health professionals were frustrated and at a loss as to how to achieve that in practice. Consequently, cardiovascular risk assessment and management was uneven and fragmented. Primary health-care practice environments vary so much that solutions to the difficulties of implementing evidence into practice requires context-specific solution-finding through collaborative teamwork. Furthermore, the attention of guideline developers, health-care policymakers, funders and researchers requires direct focus on the 'how' and the 'what' of evidence implementation.

The impact of nursing innovations in the context of governance and incentives

This discursive paper is a structured analysis of four completed national and regional studies carried out in the UK. It sets out retrospectively to explore the impact of key contextual, professional and personal features and mechanisms on innovation and outcomes in nursing and the extent to which these are common or diverge across the studies (cases).

As successive governments across the world turn their attention to developing nursing as a means of increasing productivity and effectiveness in health care, there is a need for evidence to inform workforce policy and planning about the circumstances that enable positive levers and mechanisms, which influence outcomes to operate. This analysis takes advantage of recent conceptual work on organisational governance and incentives by asking new questions of established data to illuminate our understanding of the pathway to innovation in nursing.

Data from the four evaluations (cases) were aggregated and explored thematically within Davies et al.’s framework (Studying health care organisations — links between governance, incentives and outcomes: a review of the literature. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). http://www.sdo.nihr.ac.uk/files/project/66-final-report.pdf, 2005) of governance, incentives and outcomes. The themes were grouped into three categories: contextual, professional and personal, and interrogated by inter-researcher scrutiny.

Taking account of the limitations of comparing studies carried out for different purposes and in different policy circumstances, there are compelling messages emerging about the organisational support, professional leadership and factors that motivate change and innovation in nursing. The analysis suggests that separating governance from incentives oversimplifies what is a complex interplay between organisational governance and the professional and personal enabling factors supporting innovation. The nature of these relationships deserves further study.

Knowledge constructions in nursing practice: understanding and integrating different forms of knowledge

In this combined ethnographic and hermeneutic study we examined which forms of knowledge nurses make use of and how they construct knowledge. We collected data using participant observations, informal conversations, and interviews. Nurses' knowledge construction took the form of a hermeneutic spiral, a journey in which the nurses moved up and down and horizontally, and in which they created understanding. The nurses constructed knowledge from reading the patient's record, the brief oral handover report, greeting the patient, and reading the patient. By being sensitive, using humor, and emotional involvement, they deepened their understanding. By being suspicious and self-critical, they sought interaction with nurse colleagues, the patient, doctor, and relatives, and obtained additional knowledge. They strove throughout the journey to be one step ahead in their efforts to attain an understanding of the patient's situation. We can relate the knowledge nurses make use of to intertwined forms of episteme, techne, and phronesis.

Checking the checklist: a content analysis of expert- and evidence-based case-specific checklist items

OBJECTIVES

Research on objective structured clinical examinations (OSCEs) is extensive. However, relatively little has been written on the development of case-specific checklists on history taking and physical examination. Background information on the development of these checklists is a key element of the assessment of their content validity. Usually, expert panels are involved in the development of checklists. The objective of this study is to compare expert-based items on OSCE checklists with evidence-based items identified in the literature.

METHODS

Evidence-based items covering both history taking and physical examination for specific clinical problems and diseases were identified in the literature. Items on nine expert-based checklists for OSCE examination stations were evaluated by comparing them with items identified in the literature. The data were grouped into three categories: (i) expert-based items; (ii) evidence-based items, and (iii) evidence-based items with a specific measure of their relevance.

RESULTS

Out of 227 expert-based items, 58 (26%) were not found in the literature. Of 388 evidence-based items found in the literature, 219 (56%) were not included in the expert-based checklists. Of these 219 items, 82 (37%) had a specific measure of importance, such as an odds ratio for a diagnosis, making that diagnosis more or less probable.

CONCLUSIONS

Expert-based, case-specific checklist items developed for OSCE stations do not coincide with evidence-based items identified in the literature. Further research is needed to ascertain what this inconsistency means for test validity.

A potent mix: older people, transitions, practice development and research

The discussion to follow reflects on aspects of findings from research spanning more than a decade focusing on the substantive area of transitions in the care and support needs of older people. Rather than being a report of any of the individual research projects per se, some key issues that have emerged in these studies, and what they might mean for aspects of clinical practice development, are discussed. The aim is to encourage us to take time out to think about what otherwise may be assumed or unexplored understandings of aspects of both clinical practice itself, and how to develop that clinical practice with respect to older people and the transitions they undergo. Three areas of reflection form the focus of the paper. They are around creating a dynamic, contextualised and active research programme able to assist clinical development and practice; capturing and working with the complexity that is a transition; and questioning how independent some of the older people living in the community who participated in the research actually are. Implications for how services and supports are thought about and configured are highlighted throughout. Reflecting on research in this way is an essential part of taking time to care, and can assist in the development of thoughtful and optimal clinical practice.

The research evidence published in high impact nursing journals between 2000 and 2006: a quantitative content analysis

BACKGROUND

Evidence-based practice has become an imperative for efficient, effective and safe practice. Furthermore, evidences emerging from published research are considered as valid knowledge sources to guiding practice.

OBJECTIVES

The aim of this paper is to review all research articles published in the top 10 general nursing journals for the years 2000-2006 to identify the methodologies used, the types of evidence these studies produced and the issues upon which they endeavored.

DESIGN

Quantitative content analysis was implemented to study all published research papers of the top 10 general nursing journals for the years 2000-2006.

METHODS

The top 10 general nursing journals were included in the study. The abstracts of all research articles were analysed with regards the methodologies of enquiry, the types of evidence produced and the issues of study they endeavored upon. Percentages were developed as to enable conclusions to be drawn.

RESULTS

The results for the category methodologies used were 7% experimental, 6% quasi-experimental, 39% non-experimental, 2% ethnographical studies, 7% phenomenological, 4% grounded theory, 1% action research, 1% case study, 15% unspecified, 5.5% other, 0.5% meta-synthesis, 2% meta-analysis, 5% literature reviews and 3% secondary analysis. For the category types of evidence were 4% hypothesis/theory testing, 11% evaluative, 5% comparative, 2% correlational, 46% descriptive, 5% interpretative and 27% exploratory. For the category issues of study were 45% practice/clinical, 8% educational, 11% professional, 3% spiritual/ethical/metaphysical, 26% health promotion and 7% managerial/policy.

CONCLUSIONS

Published studies can provide adequate evidences for practice if nursing journals conceptualise evidence emerging from non-experimental and qualitative studies as relevant types of evidences for practice and develop appropriate mechanisms for assessing their validity. Also, nursing journals need to increase and encourage the publication of studies that implement RCT methodology, systematic reviews, meta-synthesis and meta-analysis methodologies. Finally, nursing journals need to encourage more high quality research evidence that derive from interpretative, theory testing and evaluative types of studies that are practice relevant.

Illuminating the processes of knowledge transfer in nursing

RATIONALE

Over the past 10 years, there has been a propensity to translate research findings and evidence into clinical practice, and concepts such as knowledge transfer, research dissemination, research utilization, and evidence-based practice have been described in the nursing literature.

AIM

This manuscript shows a selective review of the definitions and utilization of these concepts and offers a perspective on their interrelationships by indicating how knowledge transfer processes are the basis of all the concepts under review.

FINDINGS

Definitions and utilization of knowledge transfer in the literature have been influenced by educational and social perspectives and indicate two important processes that are rooted in the mechanisms of research dissemination, research utilization, and evidence-based practice. These processes refer to a cognitive and an interpersonal dimension. Knowledge transfer underlies a process involving cognitive resources as well as an interpersonal process where the knowledge is transferred between individuals or groups of individuals.

CONCLUSION AND IMPLICATIONS

This manuscript can contribute to our understanding of the theoretical foundations linking these concepts and these processes by comparing and contrasting them. It also shows the value and empirical importance of the cognitive and interpersonal processes of knowledge transfer by which research findings and evidence can be successfully translated and implemented into the nursing clinical practice.

Theory and knowledge translation: setting some coordinates

In a healthcare context in which research evidence is not used routinely in practice, there have been increasingly loud calls for the use of theory from investigators working in the field of knowledge translation. Implementation researchers argue that theory should be used to guide the design of testable and practical intervention strategies, and thus, contribute to generalizable knowledge about implementation interventions. The purpose of this commentary is to critique model papers writing by a team of scholars who aimed to disentangle some of the relationships determining research utilization, by scrutinizing an existing conceptual framework that acknowledges, along with other factors, the importance of contextual factors in knowledge translation. These papers are used as a vehicle to explore theory application in knowledge translation research. As theory use and development is in its infancy, some key issues, including different ideological perspectives, factors for and against theory use, ensuring conceptual clarity, selecting coherent overarching frameworks, and choosing appropriately among theories, are considered. Finally, an agenda for theory-informed research is outlined, which highlights the need for scholarly, pluralistic, and collaborative activity if the state of knowledge translation science is to advance.

Factors facilitating and inhibiting evidence-based nursing in Iran

AIM

This paper is a presentation of a study to clarify the concept of evidence-based nursing and to explore the factors that influence evidence-based nursing by Iranian nurses.

BACKGROUND

Evidence-based practice was introduced as an approach to high-quality care intended to improve results for patients. Several nurse researchers have studied factors affecting implementation of evidence-based nursing in western countries. However, there is little or no research on the perceptions of evidence-based nursing and its barriers in eastern countries, especially Iran.

METHODOLOGY

Grounded theory method was used. Interviews with 21 participants and 30 hours of observation were conducted in hospitals in Iran during 2005. Constant comparative analysis was used to analyse the data.

FINDINGS

Two main categories, 'the meaning of evidence-based nursing', and 'factors affecting it', emerged from the data. From participants' perspectives, evidence-based nursing was defined as 'caring for patients based on the nurse's professional knowledge in meeting patients' needs'. The second category, factors affecting evidence-based care, had six subcategories: possessing professional knowledge and experience; having time and opportunity; becoming accustomed; self-confidence; the process of nursing education; and the work environment and its expectations.

CONCLUSION

Managers and educators need to be committed to the principles of EBP, provide resources and create a supportive environment for its implementation. Individual nurses also have a responsibility to carry out evidence-based nursing, and researchers should work with practitioners to generate high quality evidence to support nursing practice.

A review of evidence-based practice, nursing research and reflection: levelling the hierarchy

AIM

This paper examines the evidence-based practice movement, the hierarchy of evidence and the relationship between evidence-based practice and reflective practice.

BACKGROUND

Evidence-based practice is equated with effective decision making, with avoidance of habitual practice and with enhanced clinical performance. The hierarchy of evidence has promoted randomized control trials as the most valid source of evidence. However, this is problematic for practitioners as randomized control trials overlook certain types of knowledge that, through the process of reflection, provide useful information for individualized and effective practice.

METHOD

A literature search was undertaken using CINAHL, medline and Ovid electronic databases in early 2006. The search terms used were: evidence-based practice, research evidence, evidence for practice, qualitative research, reflective practice, reflection and evidence. Other sources included handpicking of books on evidence-based practice, reflection and research. Only material written in English was included.

FINDINGS

The hierarchy of evidence that has promoted randomized control trials as the most valid form of evidence may actually impede the use of most effective treatment because of practical, political/ideological and epistemological contradictions and limitations. Furthermore, evidence-based practice appears to share very similar definitions, aims and procedures with reflective practice. Hence, it appears that the evidence-based practice movement may benefit much more from the use of reflection on practice, rather than the use of the hierarchical structure of evidence.

CONCLUSION

Evidence-based practice is necessary for nursing, but its' effective implementation may be hindered by the hierarchy of evidence. Furthermore, evidence-based practice and reflection are both processes that share very similar aims and procedures. Therefore, to enable the implementation of best evidence in practice, the hierarchy of evidence might need to be abandoned and reflection to become a core component of the evidence-based practice movement.

RELEVANCE TO CLINICAL PRACTICE

Provides an elaborated analysis for clinical nurses on the definition and implementation of evidence in practice.