Clinical guidelines: promoting clinical effectiveness or a professional minefield?

Guidelines as governance: Critical reflections from a documentary analysis of guidelines to support user involvement in research

Although guidelines to regulate user involvement in research have been advocated and implemented for several years, literature still describes the process as challenging. In this qualitative study, we take a critical view on guidelines that are developed to regulate and govern the collaboration process of user involvement in research. We adapt a social constructivist view of guidelines and our aim is to explore how guidelines construct the perception of users and researchers and thus the process of involvement. Twenty-two guidelines published between 2006 and 2019 were analyzed iteratively. The analysis focuses on values which are emphasized in the guidelines on the distribution of entities, knowledge, and tasks between users and researchers. The analysis indicates that users and researchers are constructed differently; researchers are mainly constructed as responsible initiators and caretakers, while users are constructed as powerless and vulnerable. The guidelines portray the collaboration process as harmonious and assume a normative perspective. In doing so, challenges described in the literature related to power imbalances are not addressed. Based on these findings, we ask if these guidelines might function to maintain existing power imbalances between users and researchers.

Assessing the quality of guidelines for primary aldosteronism: which guidelines are worth applying in diverse settings?

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Objective:

To review the validity and applicability of clinical guidelines on the management of primary aldosteronism and to list their discrepancies to allow health-care providers and guideline developers to make informed decisions.

Design and methods:

Primary aldosteronism management guidelines, including specialist, subgroup, general guidelines written in English, were obtained from electronic databases. Appraisers independently extracted the data, and used the Appraisal Guidelines Research and Evaluation II (AGREE-II) tool and the Institute of Medicine (IOM) criteria to independently evaluate the methodological quality of the guidelines. Then, the appraisers used the Guideline Implementability Appraisal (GLIA) tool to assess the implementation of the guidelines that complied with AGREE-II and IOM. In addition, we further compared the discrepancies in the primary aldosteronism management recommendations.

Results:

We have identified 12 guidelines published between 2006 and 2016. Only the Endocrine Society and the Canadian Hypertension Education Program guidelines of them were of good methodological quality according the AGREE-II and IOM instrument, but with still much room for improvement. Neither of these two was rated as easily implementable according to the GLIA tool. Discrepant recommendations were identified at all management steps (screening, confirmation, classification, treatment and follow-up).

Conclusion:

The guidelines quality was mostly poor, and the higher quality guidelines also needed improvement prior to their implementation. Meanwhile, significant differences existed in the recommendation for the same clinical problem. Therefore, future guideline development should be performed in strict accordance with the AGREE-II, IOM and GLIA criteria to improve the diagnosis and treatment of primary aldosteronism.

Improving delirium care for hospitalized older patients. A qualitative study identifying barriers to guideline adherence

RATIONALE, AIMS AND OBJECTIVES

Guidelines are intended as a means of getting research evidence into practice and ensuring provided care is of sufficient quality. However, the effect of guidelines is hindered by limited guideline adherence. The aim of this study is to identify and classify barriers to adherence by nurses to a guideline on delirium care.

METHODS

Open-ended interviews were conducted with a purposive sample of 63 research participants. The sample included 28 nurses, 18 doctors and 17 policy advisors working in 19 hospitals in the Netherlands. The interviews were conducted between June and September 2011. The data were analysed using thematic analysis.

RESULTS

Barriers to guideline adherence that were identified could be grouped into four themes: motivation and goals, knowledge and skills, professional role and identity, and context and resources. While the interviews with nurses, doctors and policy advisors produced similar views of the current situation, doctors and policy advisors placed a higher importance on education as a means of stimulating adherence.

CONCLUSIONS

This study illustrates that individual, social and organizational factors play a role in nurse's adherence to a delirium guideline. The potential benefits of following a guideline, both for patients and for nursing staff, need to be highlighted in order to motivate nurses. When formulating new guidelines, nurses' perceptions of their professional role and patient care need to be taken into account to ensure that policy makers and managers are realistic about guideline adherence and engage with nurses from a position of mutual respect and trust.

The nursing work of hospital-based clinical practice guideline implementation: an explanatory systematic review using Normalisation Process Theory

OBJECTIVE

To investigate the dynamics of nurses' work in implementing Clinical Practice Guidelines.

DESIGN

Hybrid: systematic review techniques used to identify qualitative studies of clinical guideline implementation; theory-led and structured analysis of textual data.

DATA SOURCES

CINAHL, CSA Illumina, EMBASE, MEDLINE, PsycINFO, and Sociological Abstracts.

METHODS

Systematic review of qualitative studies of the implementation of Clinical Practice Guidelines, analysed using Directed Content Analysis, and interpreted in the light of Normalisation Process Theory.

RESULTS

Seven studies met the inclusion criteria of the review. These revealed that clinical practice guidelines are disposed to normalisation when: (a) They are associated with activities that practitioners can make workable in practice, and practitioners are able to integrate it into their collective workflow. (b) When they are differentiated from existing clinical practice by its proponents, and when claims of differentiation are regarded as legitimate by their potential users. (c) When they are associated with an emergent community of practice, and when members of that community of practice enrol each other into group processes that specify their engagement with it. (d) When they are associated with improvements in the collective knowledge of its users, and when users are able to integrate the application of that knowledge into their individual workflow. And, (e) when nurses can minimise disruption to behaviour norms and agreed professional roles, and mobilise structural and cognitive resources in ways that build shared commitments across professional boundaries.

CONCLUSIONS

This review demonstrates the feasibility and benefits of theory-led review of studies of nursing practice, and proposes a dynamic model of implementation. Normalisation Process Theory supports the analysis of nursing work. It characterises mechanisms by which work is made coherent and meaningful, is formed around sets of relational commitments, is enacted and contextualised, and is appraised and reconfigured. It facilitates such analysis from within the frame of nursing knowledge and practice itself.

Evidence-based practice: SLTs under siege or opportunity for growth? The use and nature of research evidence in the profession

BACKGROUND

Speech and language therapists are encouraged to be evidence-based practitioners in contemporary clinical practice. This apparently signifies their commitment to 'good' practice. An examination of evidence-based practice (EBP) and its adoption in clinical practice is therefore warranted.

AIMS

This paper aims to explore EBP, specifically research evidence, as related to the field of speech and language therapy (SLT), using profession specific and cross-disciplinary examples. It asks the reader to consider whether research evidence contributes positively to SLT practice, or adds to the demands placed on clinicians?

METHODS & PROCEDURES

A review of the literature on the nature and use of research evidence in the field of speech and language therapy and related health professions was undertaken using multiple databases (Cochrane, Medline, Cinahal, BioMed, Trip, Dare) and the following up of references provided within texts and articles. This paper asks the reader to consider the topic from the perspective of the nature of research produced, the barriers perceived, and the use of research evidence by SLTs and the allied health professions.

OUTCOMES & RESULTS

The uptake of research evidence in the profession is similar to other health professions and continues to be problematic. There are multiple reasons why this is so, originating from both the nature and use of research.

CONCLUSIONS & IMPLICATIONS

Research evidence is one of the pillars of EBP. Despite problems with the nature and use of such evidence, it has a positive contribution to make to clinical practice as it provides for a scientific touchstone. However, it may be that the speech and language therapist and not the research evidence is the primary pivot upon which scientific practice is based.

A qualitative investigation of the views of primary care dentists on participating in prospective studies in the North-West of England

BACKGROUND

There is a poor understanding of to how to recruit and involve primary care dentists in clinical trials.

AIM

To use a qualitative paradigm to explore the views of primary care dentists towards participating in clinical trials and develop an understanding of the factors that facilitate and prevent their involvement. DESIGN, SETTING, SUBJECTS AND METHODS: An iterative approach was undertaken using a focus group (n = 6) followed by phased semi-structured interviews (n = 18). Data were analysed using thematic analysis and constant comparative analysis.

FINDINGS

The semi-structured interviews generated nine codes which were organised into three themes: technical issues for trials in primary dental care, practical issues for research in primary dental care and primary care dentists as research consumers. Overall, primary care dentists had a poor understanding of research methodology and clinical research. Barriers to participation included loss of clinical freedom and control, practice disruption, patient welfare, staff workload, financial loss and time.

CONCLUSIONS

Barriers to primary dental care research need to be overcome through appropriate protocols, funding, training and support. Joint working of primary dental care teams and academic researchers is essential, along with a constructive and open dialogue, if clinical trials are to be successfully undertaken in a practice environment.

Development of a prototype personal digital assistant-decision support system for the management of adult obesity

OBJECTIVE

The purpose of this study was to develop a prototype personal digital assistant-decision support system (PDA-DSS) based on a clinical practice guideline (CPG) for the management of obesity.

DESIGN

The study was composed of four phases: (1) analysis of advanced practice nurse (APN) students' documentation related to the management of obesity using the Clinical Log-APN (CL-APN), (2) identification of functional requirements and data modeling through use case analysis and unified modeling language (UML), (3) evaluation of representation of obesity-related concepts with standardized terminologies, and (4) design of a web-based prototype user interface.

RESULTS

The analysis revealed the documentation rate of obesity as an assessment diagnosis and adherence to the CPG for obesity was low. Through use case analysis and UML modeling, the functional requirements - screening, assessment, and documentation of CPG-based obesity treatment plan - were identified and a data model was built. Overall, the standardized terminologies that are used in the database for the CL-APN could represent about 80% of the obesity-related concepts. However, the terms of these standardized terminologies were not specific enough to represent all the concepts. The systematized nomenclature of medicine-clinical terms (SNOMED CT) could represent 83% of the concepts and was used to extend the knowledge base. Based on the functional requirements specification, four prototype screens were designed.

CONCLUSION

The PDA-DSS for the management of obesity has potential uses for education, nursing practice, and research. As an educational tool, it can be used to improve APN students' adherence to the CPG's recommendations and to enhance informatics competencies. The PDA-DSS has the potential to improve APN students' clinical decision making at the point-of-care and delivery of CPG-based care, thereby improving patients' outcomes related to the management of obesity. A randomized trial is underway to investigate the PDA-DSS's impact on APN students' screening rates and adherence to obesity CPG recommendations, and users' acceptance of the system.

Implementing nursing practice guidelines: a complex undertaking

Clinical practice guidelines have been proposed to significantly reduce the gap between available scientific evidence and clinical practice. Evidence-based guidelines are also being produced at an ever-increasing pace. However, guidelines do not implement themselves, and the research to support implementation does not provide straightforward answers. What works in one setting does not necessarily work in another. In short, guideline implementation and change of practice is complex and messy. The purpose of this article is to discuss the implementation of clinical practice guidelines using the Promoting Action on Research Implementation in Health Services framework. More specifically, 3 key components are highlighted: (1) the evidence base for guideline recommendations, (2) the clinical context where guidelines are to be implemented, and (3) the nature of facilitation needed to ensure a successful change process. An overview of the literature in the field is provided, and the authors' experiences are shared, and a few recommendations are tentatively provided.

Appraising and comparing pressure ulcer guidelines

BACKGROUND

Whilst considerable activity has been related to guideline development for nurses regarding pressure ulcer prevention and management, no attempt has been made to comparatively evaluate these guidelines against some form of quality indicators.

AIM

To compare and contrast four national pressure ulcer guidelines, and identify similarities and differences in their quality and content.

METHODS

An international comparative appraisal method, using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument, was undertaken to appraise four published pressure ulcer guidelines. Two further domains were added to the AGREE instrument to assess comparability of the guidelines and their perceived contribution to practice. An international group undertook the comparative appraisal.

RESULTS

The domain scores for each guideline show some but not total agreement among reviewers. One particular set of guidelines was identified as scoring highest in a majority of AGREE domains. Overall, evidence of variability exists between pressure ulcer guidelines and common areas of development to consider for all guidelines.

IMPLICATIONS FOR PRACTICE

The results raise many questions concerning the "best" pressure ulcer guideline to use, particularly related to the AGREE scoring. Some notable shortcomings exist in all the pressure ulcer guidelines reviewed and these shortcomings need to be addressed from a quality perspective. However, other issues such as style of reporting and potential contribution to practice might more fully affect choice by practitioners as opposed to guideline developers.

CONCLUSIONS

Notable differences exist among the four guidelines that are possibly explained by different approaches to development and also because of different cultural factors and intentions for use. Whilst the AGREE tool identifies the quality of the guideline development process it still requires local engagement with practitioners to determine which guideline should be implemented.

Using action research to construct national evidence-based nursing care guidance for gerontological nursing

AIM

This paper explores the development of a low-cost, involving methodology for constructing nursing-focused evidence-based national care guidance, known as Best Practice Statements, the intended users of which are gerontological nurses practising throughout Scotland.

DESIGN

The Best Practice Statement construction methodology forms one cycle in a five-year longitudinal action research study that aims to achieve evidence-based nursing, facilitate professional networking to support practice development and promote the principles and practice of gerontological nursing. Achieving these aims involved designing a virtual Practice Development College.

METHODS

A Community of Practice comprising practising gerontological nurses, expert advisors, academic teaching and research nurses collaborated in face-to-face meetings and in the virtual Practice Development College to delineate and refine the procedural model for Best Practice Statement construction. Focus groups, telephone interviews, analysis of on-line archives and documentary outputs formed the analytic dataset.

RESULTS

Qualitative analysis indicated that, from the perspective of the community of practice, the emerging methodology facilitated the melding of knowledge sources reflecting the dominant evidence hierarchy with other forms of evidence valued by gerontological nurses, in the Best Practice Statement.

RELEVANCE TO CLINICAL PRACTICE

Current methods of care guidance construction rarely address the concerns of nurses and the evidence from which guidelines are developed is narrowly defined with regard to inclusion and acceptability. In contrast this model focuses on nursing issues, embraces a wider definition of evidence and ensures that the published Best Practice Statements are credible and achievable in gerontological practice, where they are tested and refined as an inherent aspect of the development process.

Making sure the residents get their tablets: medication administration in care homes for older people

AIM

This paper reports an exploratory study of issues concerning the nursing practice of altering medication dose forms prior to administration of medicines to residents in homes for older people.

BACKGROUND

Medication use and administration is a major issue in residential homes for older people. Research suggests that the alteration of medication dose forms in these homes is a widespread practice. Despite its prevalence, there is limited nursing or pharmaceutical literature exploring the decision-making processes surrounding this practice, the methods by which medicines are altered, or the types of medicines which are modified.

METHOD

Semi-structured interviews were carried out with 11 Registered Nurses working in a purposive sample of 10 residential homes for older people drawn from each of the six regions of South Australia. The data were collected in 2000.

FINDINGS

Nurses felt constrained to ensure that prescribed medication was administered to residents, despite their concern that this was not without risk. Nurses were concerned that they were working in an information vacuum, due to limited information resources and informal communication with other healthcare professionals such as speech pathologists, pharmacists and general practitioners. There was also concern about the difficulty of coordinating information and policies about altering medications and of implementing appropriate procedures in individual facilities.

CONCLUSION

Clinical guidelines for the processes surrounding the alteration of medication dose forms and relevant pharmaceutical information are needed in all residential homes for older people. Ongoing education for nurses in this area is also required.

Analysis of the impact of a national initiative to promote evidence-based nursing practice

Best Practice Statements (BPS) are designed to facilitate evidence-based practice. This descriptive, exploratory study evaluated the impact of five of these statements in Scotland. A postal survey of 1,278 registered nurses was undertaken to determine use of these statements and their perceived benefits (response rate: 42%). Use of the BPS differed across clinical sites and some statements were more likely to be used than others. Identified barriers and drivers to their use were similar to factors known to encourage or hinder evidence-based practice generally. Although approximately 25% of clinical respondents reported using the BPS, most respondents reported perceived benefits to patients usually through quality improvement. Results highlight the importance of facilitation and supportive contexts in encouraging clinical use of these statements. Findings suggest that variation in clinical implementation of the BPS need to be addressed locally and nationally if their benefits are to be maximized.

Impact of introducing a sedation management guideline in intensive care

To ensure that sedative agents in the intensive care unit are used for maximum benefit, a guideline that promotes the accurate and continuous assessment of patients' needs is indicated. This observational 24-month prospective study investigated the effect of introducing a sedation management guideline into a 10-bedded multidisciplinary intensive care unit on length of stay, severity of illness, mortality and the number of bed days provided. Costs for all sedative drugs were calculated as cost per bed day. Intensive care unit mortality remained constant before and after guideline introduction. The length of stay of non-cardiac surgery patients was mean (SD) 4.6 (4.4) and 5.1 (4.3) days, respectively (p = 0.2). Monthly sedative cost before guideline introduction was pound 6285 compared to pound 3629 afterwards (p< or =0.0001), representing a real saving of pound 63 759 in sedative costs over the 2 years following introduction of the guideline. Guideline-directed management for sedation significantly reduces the cost of sedative drugs per bed day without any negative effect on length of ICU stay and outcome.

Nursing best practice statements: an exploration of their implementation in clinical practice

AIMS AND OBJECTIVES

To explore implementation of the first five Best Practice Statements from the perspective of nurses involved in their development.

BACKGROUND

Best Practice Statements were introduced in Scotland to encourage consistent evidence-based nursing practice. As a new initiative, research was required to investigate their clinical implementation.

DESIGN AND METHODS

In this descriptive study, semi-structured interviews of a purposive sample of nurses (n = 15) were undertaken. Content analysis was used to identify themes emerging from the interview data.

FINDINGS

Four main themes emerged from analysis of transcripts: variations in use of the Best Practice Statements; benefits to patients; benefits to practitioners; and, barriers and drivers to use. Amongst participants, personal users adopted the statements in their own practice but enablers also actively encouraged others to use the statements. Whether participants acted as enablers depended on individual, team and organizational factors. The ability of participants to act as leaders was influential in determining their ability both to facilitate local implementation and to encourage others to regard the Best Practice Statements as a priority for implementation.

CONCLUSIONS

This exploratory study highlighted examples of patients and practitioners benefiting from the Best Practice Statements. Such findings suggest these statements could become a useful tool in promoting evidence-based nursing practice. However, implementation of the Best Practice Statements varied between participants and their organizations. Nurses who were most effective in promoting local implementation of the Best Practice Statements adopted facilitator and leadership roles within their organizations.

RELEVANCE TO PRACTICE

By relating research findings to the literature on guideline and research utilization, this study gives further insight into the implementation of evidence-based practice by nurses. In particular, it supports the conclusion that to be truly effective, initiatives to promote evidence-based practice require nurses to act as local facilitators and leaders.

Introduction of standardised emergency department paediatric asthma clinical guidelines into a general metropolitan hospital

'Aiming for Asthma Improvement in Children' is a South East Sydney Area Health Service (SESAHS) initiative. It is funded by the Commonwealth Government, under the Chronic & Complex Care Programmes, which is linked to New South Wales (NSW) Government Action Plan. One specific objective of the programme is to implement standardised paediatric asthma guidelines across the Emergency Departments of an area tertiary and local area hospitals. This paper will focus on the process of piloting, implementing and evaluating the guidelines into one local area hospital within SESAHS. SESAHS includes Sydney Children's Hospital, Randwick, a major paediatric referral and tertiary teaching hospital in Sydney. The paediatric asthma clinical practice guidelines (CPG) were developed, piloted and disseminated from Sydney Children's Hospital, Randwick, for local implementation and adaptation. The successful introduction of these guidelines at the local hospital promoted evidence-based practice and reduced the admission rate for children with asthma.

Guidelines for clinical practice: development, dissemination and implementation

Clinical guidelines are one of the most promising and effective advances for defining and improving the quality of care. However, their development, dissemination and implementation in practice are rarely straightforward. Within nursing practice, guidelines have the potential to ensure the clinical application of research findings, thus ensuring that the profession rejects ineffective practices while employing those shown to work. Nevertheless, the benefits and limitations of clinical guidelines should be carefully considered by practitioners, managers and consumers of health care alike.

A discharge protocol for the postanaesthetic recovery unit

Despite guidelines from the Royal College of Anaesthetists, some hospitals still do not have a formal discharge policy. The author of this article works within an operating department in the dual role of anaesthetic and recovery sister and has a particular interest in discharge criteria for postanaesthetic recovery patients. She suggests that a discharge protocol, developed in a multidisciplinary setting, should be in place in the postanaesthetic recovery unit.

Academic nursing education guidelines: tool for bridging the gap between theory, research and practice

The aim of the present study was to develop educational guidelines to be used as a tool for the integration of theory, research and practice to ensure that nursing knowledge and practical skills form the basis of academic nursing education. An additional aim was to describe the nursing competence expected of the students at four academic levels: introductory, intermediate and advanced levels I and II. Clinical nursing education plays a crucial role in assisting nursing students to integrate the theory and practice of nursing at the baccalaureate level, as well as in further specialization and in-depth nursing studies at the advanced level. A research group consisting of lecturers from the Institute of Nursing, Göteborg University, Sweden, was given the objective to formulate educational guidelines for clinical practice within nursing education. The study took the form of a literature search. In addition, the Delphi method, aimed at reaching a consensus of opinion among colleagues, was used. Based on the literature review and the collegial discussions, four core concepts emerged: professional stance, reflective processes, problem-solving processes, and practical skills, from which the educational guidelines were developed. Guidelines were formulated both in general and abstract form. They were not connected to a specific care context, specific patient group or specific nursing problems. The most important objective of academic education is that the student develops abilities and techniques necessary for life-long learning. Students will, in their professional life as nurses, continuously meet situations where they are challenged to take appropriate decisions and actions. This demands training in problem-solving, reflection, decision-making and the ability to use both deductive and inductive learning strategies. The guidelines describe what is expected of the students in terms of nursing competence and personal qualifications to ensure that they will be ready to meet the demands of their future profession.

ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand

This study explores Thai physicians' rationales about their prescribing practices for treating childhood diarrhoea within the public hospital system in central Thailand. Presented first are findings of a prospective clinical audit and observations of 424 cases treated by 38 physicians used to estimate the prevalence of sub-optimal prescribing practices according to Thai government and WHO treatment guidelines. Second, qualitative interview data are used to identify individual, inter-personal, socio-cultural and organisational factors influencing physicians' case management practices. Importantly, we illustrate how physicians negotiate between competing priorities, such as perceived pressure by caretakers to over-prescribe for their child and the requirement of health authorities that physicians in the public health system act as health resource gatekeepers. The rationales offered by Thai physicians for adhering or not adhering to standard treatment guidelines for childhood diarrhoea are contextualised in the light of current clinical, ethical and philosophical debates about evidence-based guidelines. We argue that differing views about clinical autonomy, definitions of optimal care and optimal efficiency, and tensions between patient-oriented and community-wide health objectives determine how standard practice guidelines for childhood diarrhoea in Thailand are implemented.

Practice nurses and clinical guidelines in a changing primary care context: an empirical study

BACKGROUND

Practice Nurses form an increasingly large proportion of the English National Health Service primary care workforce and the delegation to them of clinical work from General Practitioners has attracted some academic attention. Central to this process are clinical guidelines, which provide the interface between the movement towards 'evidence-based practice' and a range of government-driven policy developments in primary care.

AIMS

To identify the attitudes of practice nurses to clinical guidelines; to investigate the impact of guidelines on nurse/physician relationships; and to describe the impact of the changing primary care context on nurses.

METHODS

We interviewed a sample of 29 Practice Nurses three times during a 16-month period to clarify their attitudes towards guidelines, their use of guidelines in practice and their assessment of guidelines' importance. We gathered further data on organizational culture and perceptions of national reforms of primary care structures.

RESULTS

We found that practice nurses are generally supportive of clinical guidelines. Moreover, nurses' role and influence within primary care is in a process of transition to one in which they may undertake responsibility for influencing General Practitioners' clinical behaviour so as to adhere to guidelines. Practice nurses themselves recognize and welcome this, though with some reservations.

CONCLUSIONS

Our findings support the proposal that explicit codification of the scientific basis of the work of lower paid groups may enhance their relative professional status.

Quality improvement projects: finding a pathway through policies

It is increasingly common for mental health nurses to develop and implement quality improvement and/or research projects. The requirement that these activities be conducted in accordance with local, state and national policy; organizational accreditation frameworks; and within ethical frameworks is daunting. This paper aims to define relevant terms, relate some of the competing demands to each other and outline a pathway for developing nurse-based quality-related projects. When a specific exemplar is required, protocols from Central Sydney Area Mental Health Service will be drawn upon as it is likely that policy developed in this health area will not be significantly different to that of other health areas in New South Wales and other Australian States.

Research and organizational issues for the implementation of family work in community psychiatric services

BACKGROUND

The need for evidence-based practice (EBP) to guide and develop mental health services remains fundamental for modern services. Aim. To discuss issues that impact upon implementation of EBP and practice development using family work (FW) as an example.

METHODS

A selection of the FW literature was reviewed drawing on sources including the Cochrane Library, Cinahl and Medline. Keywords used were FW, community mental health team and research design.

FINDINGS

Centralized policy initiatives and guidelines that are themselves guided by evidence of randomized controlled trials predominantly risk alienating practitioners and clients/carers. Family work has some demonstrable clinical benefits although models differ and the active therapeutic agent remains unclear. Its adoption into routine care is also hindered by a productivity management outlook that seeks to maximize stretched resources and whose values are likely to be internalized by practitioners. The dichotomous position of previous research and practice development make implementation of EBP difficult and highlights the need for strategic planning that embraces both factors.

CONCLUSION

The current drive to increase EBP requires a bi-directional process of influence that allows individual practitioners and clients/carers to become producers of evidence and not simply recipients. The authors support wider adoption of case study research designs to reflect the unpredictable nature of mental health care. Adoption of assertive community treatment models within community services is most likely to promote the excellence management model and accommodate EBP such as FW.

Improving the management of breathlessness using a clinical effectiveness programme

Breathlessness represents a significant problem for the person with advanced cancer. Uncontrolled breathlessness ranks highly in terms of uncomfortable symptoms experience, causing pain and distress to the patient and resulting in significant anxiety to their carers. The key to the provision of effective care lies in the informed application of the nursing process, underpinned by a sound knowledge base in relation to the nursing management of breathlessness. Theoretical knowledge enables nursing staff to offer appropriate interventions for the management of breathlessness in collaboration with other members of the multidisciplinary team. This article will discuss the cause and management of breathlessness in the person with advanced cancer; the discussion focuses on the application of research-based interventions and the evaluation of clinical outcomes in a UK clinical governance context.

Benchmarking best practice for external ventricular drainage

Sharing of best practice and use of all available evidence is important in developing effective clinical guidelines for nursing practice. This can be achieved through benchmarking. Sharing of good practice and achieving consensus guidelines can avoid repetition of effort by nurses engaged in similar fields of practice. The Pan London Neuroscience Practice Development Forum was established in 1998 to share best practice within the field of neuroscience nursing across London. The Pan London Forum has now achieved consensus and developed evidence-based clinical guidelines for the management of external ventricular drainage. Within the scope of this article, the principles of external ventricular drainage will be highlighted, before identifying the evidence base for nursing management of patients. Approaches for troubleshooting common problems will also be discussed and the benchmarked clinical guidelines will be presented.

The implementation of venous leg ulcer guidelines: process analysis of the intervention used in a multi-centre, pragmatic, randomized, controlled trial

The production and implementation of clinical practice guidelines is currently a high political priority and a rapidly developing field within healthcare in the United Kingdom (UK). Their purpose is to provide clinicians with a synthesis of the best available external evidence and operationalize the implementation of evidence-based practice. Despite indications that clinical guidelines can make a difference to the quality of patient care, there is some evidence that practitioners struggle with their application. The aim of this paper is to report one element of a trial undertaken by three collaborating universities in the Northern and Yorkshire Region of the UK health service during 1997-1998. The objective was to understand what makes guidelines acceptable and usable, or otherwise, to health professionals. The findings reported in this paper describe the process of care in those general practices that elected to implement guidelines for the management of patients with venous leg ulcers. We conclude that planning for training, resource and quality improvement processes must be built into a team's guidelines implementation procedures. A preliminary needs analysis of the contextual 'hurdles and levers' within each primary healthcare team is also necessary to identify individual issues that must be addressed if the process is to succeed. These findings provide some lessons for successful implementation of clinical guidelines in general. Recommendations for nursing policy makers, managers, practitioners and researchers are included.