The meaning of practice development: evidence from the field

A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency

Background

Change agency in its various forms is one intervention aimed at improving the effectiveness of the uptake of evidence. Facilitators, knowledge brokers and opinion leaders are examples of change agency strategies used to promote knowledge utilization. This review adopts a realist approach and addresses the following question: What change agency characteristics work, for whom do they work, in what circumstances and why?

Methods

The literature reviewed spanned the period 1997-2007. Change agency was operationalized as roles that are aimed at effecting successful change in individuals and organizations. A theoretical framework, developed through stakeholder consultation formed the basis for a search for relevant literature. Team members, working in sub groups, independently themed the data and developed chains of inference to form a series of hypotheses regarding change agency and the role of change agency in knowledge use.

Results

24, 478 electronic references were initially returned from search strategies. Preliminary screening of the article titles reduced the list of potentially relevant papers to 196. A review of full document versions of potentially relevant papers resulted in a final list of 52 papers. The findings add to the knowledge of change agency as they raise issues pertaining to how change agents’ function, how individual change agent characteristics effect evidence-informed health care, the influence of interaction between the change agent and the setting and the overall effect of change agency on knowledge utilization. Particular issues are raised such as how accessibility of the change agent, their cultural compatibility and their attitude mediate overall effectiveness. Findings also indicate the importance of promoting reflection on practice and role modeling. The findings of this study are limited by the complexity and diversity of the change agency literature, poor indexing of literature and a lack of theory-driven approaches.

Conclusion

This is the first realist review of change agency. Though effectiveness evidence is weak, change agent roles are evolving, as is the literature, which requires more detailed description of interventions, outcomes measures, the context, intensity, and levels at which interventions are implemented in order to understand how change agent interventions effect evidence-informed health care.

Addressing the need for an infection prevention and control framework that incorporates the role of surveillance: a discussion paper

AIM

To present a discussion on theoretical frameworks in infection prevention and control.

BACKGROUND

Infection prevention and control programmes have been in place for several years in response to the incidence of healthcare-associated infections and their associated morbidity and mortality. Theoretical frameworks play an important role in formalizing the understanding of infection prevention activities.

DESIGN

Discussion paper.

DATA SOURCES

A literature search using electronic databases was conducted for published articles in English addressing theoretical frameworks in infection prevention and control between 1980-2012.

RESULTS

Nineteen papers that included a reference to frameworks were identified in the review. A narrative analysis of these papers was completed. Two models were identified and neither included the role of surveillance.

DISCUSSION

To reduce the risk of acquiring a healthcare-associated infection, a multifaceted approach to infection prevention is required. One key component in this approach is surveillance. The review identified two infection prevention and control frameworks, yet these are rarely applied in infection prevention and control programmes. Only one framework considered the multifaceted approach required for infection prevention. It did not, however, incorporate the role of surveillance. We present a framework that incorporates the role of surveillance into a biopsychosocial approach to infection prevention and control.

CONCLUSION

Infection prevention and control programmes and associated research are led primarily by nurses. There is a need for an explicit infection prevention and control framework incorporating the important role that surveillance has in infection prevention activities. This study presents one framework for further critique and discussion.

Developing the clinical mentor role through e-learning

La Trobe University/Austin Health Clinical School of Nursing's final-year undergraduate students undertake an integrated clinical-theoretical experience during which the clinical practicum is facilitated by registered nurses in a mentor model of education. The success of this model is contingent on the educational preparation of the registered nurse for the role of mentor. This article describes the development of a more flexible Web-based preparation program for registered nurses to assist them to fully adopt the role of mentor.

A cooperative inquiry into action learning and praxis development in a community nursing module

As nurse lecturers we investigated practice development and action learning approaches aimed at enabling postregistration bachelor's- and master's-level nursing students (Community Health Studies, Nursing in the Home) to advance practice in the context of policy and professional developments. A patchwork text was used to assess summatively what students achieved (practice change/development) and how this was informed critically, via an extended epistemology. First-person inquiry supplemented by cooperative inquiry postcourse completion (including reflective discussions with 16 students and 16 practice mentors) were used to assist coresearcher constructions of meaning. A relational, tripartite approach to learning and assessment (students', teachers', and practice mentors' collective contributions) depends on continuing reflective attention. Action learning enhances interrelation of experience with dialectic thinking. The patchwork text functions to promote creative writing, evaluative thinking, and praxis development. Role modeling by all, being genuine and not just "talking" genuine, is challenging yet crucial if people are to function as mutual resources for learning.

Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study

BACKGROUND

There is increasing emphasis on person-centred care within the literature and the health care context. It is suggested that a person-centred approach to medication activities has the potential to improve patient experiences and outcomes.

OBJECTIVES

This study set out to examine how nurses and patients interact with each other during medication activities in an acute care environment with an underlying philosophy of person-centred care.

DESIGN

A qualitative approach was used comprising naturalistic observation and semi-structured interviews.

SETTING

The study setting was an acute care ward with a collaboratively developed philosophy of person-centre care, in an Australian metropolitan hospital.

PARTICIPANTS

Eleven nurses of varying levels of experience were recruited to participate in observations and interviews. Nurses were eligible to participate if they were employed on the study ward in a role that incorporated direct patient care, including medication activities. A stratified sampling technique ensured that nurses with a range of years of clinical experience were represented. Patients who were being cared for by participating nurses during the observation period were recruited to participate unless they met the following exclusion criteria: those less than 18 years of age, non-English speaking patients, and those who were unable to give informed consent. Twenty-five patients were observed and 16 of those agreed to be interviewed.

RESULTS

The results of the study generated insights into the nature of interactions between nurses and patients where person-centred care is the underlying philosophy of care. Three major themes emerged from the findings: provision of individualised care, patient participation and contextual barriers to providing person-centred care. While the participating nurses valued a person-centred approach and perceived that they were conducting medication activities in a person-centred way, some nurse-patient interactions during medication activities were centred on routines rather than individualised patient assessment and management. These interactions were based on nurses' perceptions of what was important for the patient and did not provide opportunities for patient participation. Two main contextual barriers in relation to a person-centred approach to medication activities were identified as multidisciplinary communication and time constraints.

CONCLUSIONS

While some nurse-patient interactions during medication activities were consistent with the principles of person-centred care, the study results highlighted factors that influence the nature of these interactions, and identified opportunities to improve nursing practice. To ensure person-centred care is applied to medication activities, nurses should undertake ongoing assessment of patients' needs in relation to their medications and encourage opportunities for increased patient participation.

Reflections on the process of change on acute psychiatric wards during the City Nurse Project

The intention of this paper is to discuss the process of therapeutic change on two acute psychiatric wards during a research project that aimed to reduce conflict and containment. Analysis of fieldwork notes, reflection, team discussion and supervision. The City Nurse Project successfully reduced patient aggression, self-harm and absconding. This paper reports on the reflections made over the course of the year as changes and developments to acute wards took place. Specifically discussed are the beneficial effects of an action research approach, the role of the City Nurse, support for ward managers, education and training, clinical supervision as well as difficulties and barriers to the overall process of change. At an interim stage of the project, the staff have shown a willingness to engage in efforts to change and improve two acute wards. This paper shows the potential to improve acute wards and produce positive outcomes using a working model.

A clinical development unit in cardiology: The way forward

The clinical development unit (CDU) has been recognized as an effective strategy to progress creativity and resourcefulness in nursing practice to improve patient outcomes. Clinical development units, through transformational leadership, promote staff development, the use of research evidence and dissemination of research findings through publication and presentations. The aim of this paper is to clearly articulate the processes (in particular, research and education initiatives) related to the development of staff that address issues in the everyday workplace and, accordingly, have been instrumental in the success of the creation of a CDU in cardiology. These units aim to achieve and promote excellence in an identifiable area of nursing using a systematic, transparent and defensible approach. A review of acute coronary syndrome informed the needs and direction of staff activities in the cardiology unit of a tertiary referral hospital. Through a collaborative staff approach, evidence was carefully examined to plan its appropriate adoption into the clinical area. Nursing practice and education resulting from this review was scheduled into staff career progression. These initiatives have been incorporated into staff development learning, enabling the integration of research into practice, which ultimately has a positive impact on patient outcomes.