The organizational environment and evidence-based nursing

Supporting evidence-based service delivery and organisation: a comparison of an emergent realistic appraisal technique with a standard qualitative critical appraisal tool

A major component of current policies aimed at promoting the delivery of an effective health service is to ensure that practitioners base their practice on research findings. Considerable attention has been focussed on the research community and developing appropriate methods and tools to support these objectives at the national and international level. The appraisal needs of individual practitioners, who might wish to inform local service delivery and organisation and who are often not methodological experts, has been hitherto ignored. This paper reports on the application and testing of a technique for the appraisal of evaluation studies, which is being developed for use by practitioners to inform local service delivery. This technique has previously been applied to a quantitative evaluation. In this paper we report on its application to the appraisal of a qualitative paper. Our aim is to compare it with a standard tool to establish which generates more meaningful information for use by practitioners for the purposes of informing service delivery and organisation. The emergent technique successfully extracted relevant methodological and contextual information, with developmental issues being identified.

A mixed methods pilot study with a cluster randomized control trial to evaluate the impact of a leadership intervention on guideline implementation in home care nursing

Background

Foot ulcers are a significant problem for people with diabetes. Comprehensive assessments of risk factors associated with diabetic foot ulcer are recommended in clinical guidelines to decrease complications such as prolonged healing, gangrene and amputations, and to promote effective management. However, the translation of clinical guidelines into nursing practice remains fragmented and inconsistent, and a recent homecare chart audit showed less than half the recommended risk factors for diabetic foot ulcers were assessed, and peripheral neuropathy (the most significant predictor of complications) was not assessed at all.

Strong leadership is consistently described as significant to successfully transfer guidelines into practice. Limited research exists however regarding which leadership behaviours facilitate and support implementation in nursing.

The purpose of this pilot study is to evaluate the impact of a leadership intervention in community nursing on implementing recommendations from a clinical guideline on the nursing assessment and management of diabetic foot ulcers.

Methods

Two phase mixed methods design is proposed (ISRCTN 12345678). Phase I: Descriptive qualitative to understand barriers to implementing the guideline recommendations, and to inform the intervention. Phase II: Matched pair cluster randomized controlled trial (n = 4 centers) will evaluate differences in outcomes between two implementation strategies. Primary outcome: Nursing assessments of client risk factors, a composite score of 8 items based on Diabetes/Foot Ulcer guideline recommendations.

Intervention: In addition to the organization's 'usual' implementation strategy, a 12 week leadership strategy will be offered to managerial and clinical leaders consisting of: a) printed materials, b) one day interactive workshop to develop a leadership action plan tailored to barriers to support implementation; c) three post-workshop teleconferences.

Discussion

This study will provide vital information on which leadership strategies are well received to facilitate and support guideline implementation. The anticipated outcomes will provide information to assist with effective management of foot ulcers for people with diabetes.

By tracking clinical outcomes associated with guideline implementation, health care administrators will be better informed to influence organizational and policy decision-making to support evidence-based quality care. Findings will be useful to inform the design of future multi-centered trials on various clinical topics to enhance knowledge translation for positive outcomes.

Trial Registration

Current Control Trials ISRCTN06910890

Patterns of research utilization on patient care units

BACKGROUND

Organizational context plays a central role in shaping the use of research by healthcare professionals. The largest group of professionals employed in healthcare organizations is nurses, putting them in a position to influence patient and system outcomes significantly. However, investigators have often limited their study on the determinants of research use to individual factors over organizational or contextual factors.

METHODS

The purpose of this study was to examine the determinants of research use among nurses working in acute care hospitals, with an emphasis on identifying contextual determinants of research use. A comparative ethnographic case study design was used to examine seven patient care units (two adult and five pediatric units) in four hospitals in two Canadian provinces (Ontario and Alberta). Data were collected over a six-month period by means of quantitative and qualitative approaches using an array of instruments and extensive fieldwork. The patient care unit was the unit of analysis. Drawing on the quantitative data and using correspondence analysis, relationships between various factors were mapped using the coefficient of variation.

RESULTS

Units with the highest mean research utilization scores clustered together on factors such as nurse critical thinking dispositions, unit culture (as measured by work creativity, work efficiency, questioning behavior, co-worker support, and the importance nurses place on access to continuing education), environmental complexity (as measured by changing patient acuity and re-sequencing of work), and nurses' attitudes towards research. Units with moderate research utilization clustered on organizational support, belief suspension, and intent to use research. Higher nursing workloads and lack of people support clustered more closely to units with the lowest research utilization scores.

CONCLUSION

Modifiable characteristics of organizational context at the patient care unit level influences research utilization by nurses. These findings have implications for patient care unit structures and offer beginning direction for the development of interventions to enhance research use by nurses.

Strategic collaborative model for evidence-based nursing practice

PURPOSE

To describe a model that has been developed to guide nurses and other health professionals in collaborative efforts toward evidence-based nursing practice.

METHOD

A review of literature was conducted using MEDLINE and CINAHL to search for articles on research utilization for evidence-based practice in health care delivery. Empirical studies; reviews; and theoretical, opinion, and information articles were included in the review in order to provide a more comprehensive view of the state of evidence-based nursing internationally.

FINDINGS

Findings revealed a number of barriers to evidence-based nursing practice, which have persisted over the last two decades, including inadequate knowledge of research among practicing nurses, lack of administrative support for research activities in clinical settings, lack of empowerment of nurses, and lack of needed mentoring from nursing research consultants.

CONCLUSIONS

Barriers in the areas of nursing education and administrative support appear to be major. A need was identified for a pragmatic model that encourages cooperation and collaboration between educators/researchers in academia and the administrative leaders in the clinical facilities if evidence-based nursing practice is to become the norm. FRAMEWORK OF MODEL: The Tyler Collaborative Model is based on an eclectic approach to planned change for creating evidence-based practice. This model identifies a step-by-step process for change, while allowing for the opportunity to integrate any of the previously available methods of critical appraisal to determine the best evidence for practice in each clinical setting.

A comparison of research utilization among nurses working in Canadian civilian and United States Army healthcare settings

Researchers and theorists working in the field of knowledge translation point to the importance of organizational context in influencing research utilization. The study purpose was to compare research utilization in two different healthcare contexts--Canadian civilian and United States (US) Army settings. Contrary to the investigators' expectations, research utilization scores were lower in US Army settings, after controlling for potential predictors. In-service attendance, library access, belief suspension, gender, and years of experience interacted significantly with the setting (military or civilian) for research utilization. Predictors of research utilization common to both settings were attitude and belief suspension. Predictors in the US Army setting were trust and years of experience, and in the Canadian civilian setting were in-service attendance, time (organizational), research champion, and library access. While context is of central importance, individual and organizational predictors interact with context in important although not well-understood ways, and should not be ignored.

Challenges for new nurses in evidence-based practice

AIM

The purpose of this article was to examine issues that new nurses encounter as they enter nursing practice, particularly in an evidence-based practice environment.

BACKGROUND

These issues are not new. In part, these issues arise from our failure to acknowledge the developmental issues that new nurses experience on entry to practice and the lack of role models in evidence-based practice and holistic care.

EVALUATION

This article synthesizes research reported over the last decade to delineate the issues of transition to practice and strategies that have proven effective in addressing them.

KEY ISSUES

The key issues relate to the need to support new nurses in evidence-based and holistic practice, the strategies needed to do so, and the nurse manager's role in this process.

CONCLUSIONS

We must invest resources in assisting new nurses into practice, which may have benefits in terms of both recruitment and retention of new nurses in practice.

The Ottawa Model of Research Use: a guide to clinical innovation in the NICU

PURPOSE/OBJECTIVES

To improve performance of a neonatal transport team by implementing a research-based family assessment instrument. Objectives included providing a structure for evaluating families and fostering the healthcare relationship.

BACKGROUND/RATIONALE

Neonatal transports are associated with family crises. Transport teams require a comprehensive framework to accurately assess family responses to adversity and tools to guide their practice toward parental mastery of the event. Currently, there are no assessment tools that merge family nursing expertise with neonatal transport.

DESCRIPTION OF THE PROJECT

A family assessment tool grounded in contemporary family nursing theory and research was developed by a clinical nurse specialist. The Ottawa Model of Research Use guided the process of piloting the innovation with members of a transport team. Focus groups, interviews, and surveys were conducted to create profiles of barriers and facilitators to research use by team members. Tailored research transfer strategies were enacted based on the profile results.

OUTCOME

Formative evaluations demonstrated improvements in team members' perceptions of their knowledge, family centeredness, and ability to assess and intervene with families. The family assessment tool is currently being incorporated into Clinical Practice Guidelines for Transport and thus will be considered standard care.

CONCLUSION

Use of a family assessment tool is an effective way of appraising families and addressing suffering. The Ottawa Model of Research Use provided a framework for implementing the clinical innovation.

IMPLICATIONS FOR NURSING PRACTICE

A key role of the clinical nurse specialist is to influence nursing practice by fostering research use by practitioners. When developing and implementing a clinical innovation, input from end users and consumers is pivotal. Incorporating the innovation into a practice guideline provides a structure to imbed research evidence into practice.

Using the Ottawa Model of Research Use to implement a skin care program

Addressing skin care issues requires a systematic and comprehensive approach. We used the pragmatic Ottawa Model of Research Use to guide the implementation of clinical practice guidelines in a surgical program of a tertiary care hospital. Assessments were made of existing clinical practice guidelines, the practice environment, and the potential adopters. With this information, we tailored strategies to address the barriers and to implement the guidelines. A formative evaluation demonstrated positive results.

Attitudes and factors affecting research utilization

PROBLEM

The gap between nursing research findings and their application in practice, particularly in rural areas.

METHODS

A descriptive-correlational study design focused on the attitude of nurses (N = 106) in rural practice setting towards nursing research and the relationship between their attitudes and other factors.

FINDINGS

Fewer than a quarter of the nurses in this study had favorable attitudes toward research. Attitudes and interest varied with levels of education and position. Also, the isolation of rural nurses from nurse researchers creates a peculiar barrier to research utilization.

CONCLUSION

The influence of nurse educators/researchers and administrators cannot be overemphasized. Nurse leaders need to perceive nursing research as the base for evidence-based practice, and enhance the utilization of scientific evidence in practice settings.