Developing best practice in critical care nursing: knowledge, evidence and practice

How experienced wound care nurses conceptualize what to do in pressure injury management

BACKGROUND

Conceptual understanding of the perceptions that wound care nurses use to determine how to manage pressure injuries may provide information for improving their pressure injury care competency. The aim of this study is to explore and describe the way wound care nurses experience and perceive pressure injury management.

METHODS

A qualitative, phenomenographic approach, a method designed to explore the different ways in which people comprehend a phenomenon and develop a practical knowledge-based framework, was used in this study. Semi-structured interviews were used for data collection with twenty wound care nurses. All participants were female with a mean age of 38.0, mean total clinical experience of 15.2 years and mean clinical experience as wound care nurse of 7.7 years. The eight steps of qualitative data analysis for a phenomenographic study were employed to develop an understanding of participants' experience of pressure injury management.

RESULTS

The analysis resulted in an assessment domain and an intervention domain, each containing three descriptive categories based on five identified conceptions. The categories were as follows: "comparison", "consideration", and "monitoring" in assessment, and "creation", "conversation" and "judgement" in intervention.

CONCLUSIONS

This study has created a framework for understanding pressure injury management based on practical knowledge. This framework of the nurses' pressure injury care reflected the need for an awareness of a harmonious approach to patients and wounds. There is a pattern of transcending a reliance on only theoretical knowledge, and this key factor in the framework should be considered when developing education programs and tools for improving nurse pressure injury care competency and patient safety.

Exploring of clinical decision making in care of patients with acute care in critical nurses: A qualitative content analysis

"The appropriate clinical decision-making of the nurses can improve the patient outcome and reduce costs, otherwise delaying the recovery and preferably the death of the patient especially in acute care setting. The aim of this study was to describe the clinical decision making in care of patients with acute care in critical nurses. This study was a qualitative study conducted in 2020. Purposive sampling was used and continued until saturation. The study involved sixteen semi-structured interviews were conducted with critical nurses who had experience providing care for acute patients in critical care units. Interviews transcript and analyzed by qualitative content analysis. Two major themes were generated from the data included instantaneous decision-making and life-saving of the patient. This process was depended on the nurse’s ability to summarize in the moment, to consider everything, to focus on the patient, to combine experience and knowledge, to concern the patient's life, to prevent the deterioration of the patient's conditions and responsibility to their patients "

Practical knowledge of experienced nurses in critical care: a qualitative study of their narratives

BACKGROUND

Scholars of nursing practices have claimed practical knowledge is source of knowledge in its own right, nevertheless we know little about this knowledge associated with day-to-day practice. The purpose of this study is to describe knowledge that the more experienced nurses the in ICU make use of and discover the components of care it includes. Understanding this knowledge can contribute to improving the working practices of nurses with less experience.

METHODS

We used a phenomenologic and hermeneutic approach to conduct a qualitative study. Open in-depth dialogue interviews were conducted with 13 experienced ICU nurses selected by intentional sampling. Data was compiled on significant stories of their practice. The data analysis enabled units of meaning to be categorised and grouped into topics regarding everyday practical knowledge.

RESULTS

Knowledge related to everyday practice was evaluated and grouped into seven topics corresponding to how the ICU nurses understand their patient care: 1) Connecting with, calming and situating patients who cannot communicate; 2) Situating and providing relief to patients in transitions of mechanical respiration and non-invasive ventilation; 3) Providing reassurance and guaranteeing the safety of immobilised patients; 4) The "connection" with patients in comas; 5) Taking care of the body; 6) The transition from saving life to palliative care; and 7) How to protect and defend the patient from errors. The components of caretaking that guarantee success include: the calm, care and affection with which they do things; the time devoted to understanding, situating and comforting patients and families; and the commitment they take on with new staff and doctors for the benefit of the patient.

CONCLUSIONS

These results show that stories of experiences describe a contextual practical knowledge that the more experienced nurses develop as a natural and spontaneous response. In critical patients the application of everyday practical knowledge greatly influences their well-being. In those cases in which the nurses describe how they have protected the patients from error, this practical knowledge can mean the difference between life and death. The study highlights the need to manage practical knowledge and undertake further research. The study is useful in keeping clinical practice up-to-date.

Profile of an intensive care nurse in different regions of Brazil

The aim of this quantitative study was to identify the socio-demographic and academic profile of intensive care registered nurses and participants of the events organized by the Department of Nursing of the Brazilian Association of Intensive Care Medicine. Data were collected by means of 400 questionnaires applied between January and July of 2010, however only 324 questionnaires were returned and 295 questionnaires were considered for the analysis. Data were analyzed with descriptive statistics resources with absolute relative frequency and simple mean, presented in tables. Results show the predominance of women, with specific graduate degrees. The skills and values highlighted include technical and scientific knowledge, and leadership. These professionals seek work in intensive care because of the high technological complexity. The study emphasized the existence of the professional profile required to work in the intensive care unit. The qualification of these professionals must prioritize the mastering of the technological language and the comprehensive and safe care.

Assessment of a training programme for the prevention of ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units (ICUs). Most published studies have analysed nurses' theoretical knowledge about a specific procedure; however, the transfer of this knowledge to the practice has received little attention.

AIM

To assess the impact of training session on nurses' knowledge regarding VAP, compliance with VAP preventive measures, VAP incidence and determining whether nursing workload affects compliance.

METHOD

A prospective, quasiexperimental, pre- and post-study of the nursing team in a 16-bed medical/surgical ICU. Pre-intervention phase: a questionnaire to assess nurses' knowledge of VAP prevention measures, direct observation and review of clinical records to assess compliance. Intervention phase: eight training sessions for nurses. The post-intervention phase mirrored the pre-intervention phase.

FINDINGS

Nurses answered more questions correctly on the post-intervention questionnaire than on the pre-intervention (17·87 ± 2·69 versus 15·91 ± 2·68, p = 0·002). Compliance with the following measures was better during the post-intervention period (p = 0·001): use of the smallest possible nasogastric tube, controlled aspiration of subglottic secretions and endotracheal tube cuff pressure, use of oral chlorhexidine and recording the endotracheal tube fixation number. VAP incidence remained unchanged throughout the study. However, a trend towards lower incidence of late (>4 days after intubation) VAP was observed (4·6 versus 3·1 episodes/1000 ventilation days, p = 0·37).

CONCLUSION

The programme improved both knowledge of and compliance with VAP preventive measures, although improved knowledge did not always result in improved compliance.

Irish psychiatric nurses' self-reported sources of knowledge for practice

Evidence-based practice (EBP) is an approach to health care in which health professionals use the best evidence available to guide their clinical decisions and practice. Evidence is drawn from a range of sources, including published research, educational content and practical experience. This paper reports the findings of a study that investigated the sources of knowledge or evidence for practice used by psychiatric nurses in Ireland. The paper is part of a larger study, which also investigated barriers, facilitators and level of skills in achieving EBP among Irish psychiatric nurses. Data were collected in a postal survey of a random sample of Irish psychiatric nurses using the Development of Evidence-Based Practice Questionnaire. The findings revealed that the majority of survey respondents based their practice on information which was derived from interactions with patients, from their personal experience and from information shared by colleagues and members of the multidisciplinary team, in preference to published sources of empirically derived evidence. These findings are consistent with those of the previous similar studies among general nurses and suggest that Irish psychiatric nurses face similar challenges to their general nursing counterparts in attaining of EBP.

The ventilator care bundle and its impact on ventilator-associated pneumonia: a review of the evidence

AIMS AND OBJECTIVES

The aim of this review was to critically analyse recent research that has investigated ventilator care bundle (VCB) use, with the objective of analysing its impact on ventilator-associated pneumonia (VAP) outcomes.

BACKGROUND

The VCB is a group of four evidence-based procedures, which when clustered together and implemented as an 'all or nothing' strategy, may result in substantial clinical outcome improvement. VAP is a nosocomial lung infection associated with endotracheal tube use in ventilated patients. Since the VCB was introduced there have been several studies that have reported significant VAP rate reductions.

SEARCH STRATEGY

A comprehensive search for research, published between 2004 and 2009, was conducted using Medline and PubMed. Key words were used to identify English language studies reporting VCB implementation within adult intensive care units (ICU) and associated clinical outcomes. Studies that implemented bundle variations that did not include all four elements were excluded.

CONCLUSIONS

Because of the limitations of the observational designs used in the studies retrieved, a definitive causal relationship between VCB use and VAP reduction cannot be stated. However, the evidence to date is strongly indicative of a positive association. Several studies reported the use of additional VCB elements. In these cases it is difficult to establish which elements are related to the measured outcomes. Further research is recommended to establish baseline outcome measures using the four-element VCB, before adding further processes singly, as well as research investigating the effect of audit and feedback on VCB compliance and its effect on clinical outcomes.

RELEVANCE TO CLINICAL PRACTICE

A reduction in VAP is associated with VCB use. The evidence to date, whilst not at the highest experimental level, is at the highest ethically permissible level. In the absence of contradictory research, the current evidence suggests that use of the VCB represents best practice for all eligible adult ventilated patients in ICU.

A survey of European intensive care nurses' knowledge levels

BACKGROUND

The application of knowledge to the care of critically ill patients is a hallmark of professional nursing practice. However, the educational preparation of intensive care nurses varies from country to country, and there has been little research that has investigated knowledge levels of European critical care nurses.

OBJECTIVE

The aim of this study was to examine the knowledge levels of European intensive care nurses.

DESIGN

The study was an international cross-sectional survey, with data collected from 20 European countries.

SETTING AND PARTICIPANTS

318 European intensive care units participated, and data were collected from 1142 intensive care nurses.

METHODS

Data were collected between May and December 2009 using a 100-item multiple choice online questionnaire to assess intensive care nursing knowledge. The questionnaire was available in 16 languages, and data were collected in 11 knowledge areas.

RESULTS

A response rate of 60% was achieved; the majority of participants was female (77%). The largest groups of nurses had more than five years' experience and were under 30 years of age. The overall mean knowledge score was 66% (SD 12). The main factor that contributed to variance in scores was nurses' length of intensive care experience; in ten categories knowledge scores were progressively higher according to experience. If 50% is considered to be a pass mark, 90% of participants would have passed. However, in only six countries did all participants achieve a 'pass' score, and in five countries more than 10% of participants failed to meet this 'pass' criterion. The knowledge category which scored lowest was respiration and ventilation (mean score 56%, SD 15).

CONCLUSIONS

Although knowledge levels differed among countries, there were no major differences. However, the relatively low scores achieved in the respiration/ventilation category are a cause of concern, and suggest that this is an education area that should be prioritised. The results should be considered within the context of each country's healthcare and professional education systems, and strategies should be developed to improve knowledge in several key areas.

Best practices: understanding nurses' perspectives

Understanding the perspectives of nurses is a critical, initial step in developmental efforts targeting the integration of evidence into practice. The authors discuss the outcomes of a study that assessed nurses' views of best practice, including organizational supports, barriers, and recommended strategies to successfully navigate practice changes in demanding work environments.

Using consensus methods to develop clinical practice guidelines for intensive care: the intensive care collaborative project

BACKGROUND

Clinical practices or procedures based on the best available evidence are an essential resource within an intensive care unit (ICU). Maintaining the currency of a local clinical practice manual is challenging however, particularly in relation to the time required, other workload pressures and the availability of staff with relevant skills to interrogate the literature. The aim of the Intensive Care Collaborative (ICC) project was to use the synergism of group processes to develop state-based clinical guidelines for six common intensive care practices - eye care, oral care, endotracheal tube management, suctioning, arterial line management, and central venous catheter (CVC) management.

METHODS

Participants were 55 senior nurse clinicians from all nine area health services in NSW, seven academic facilitators, and staff from the Intensive Care Coordination and Monitoring Unit (ICCMU). A range of approaches were used to develop the six clinical practice guidelines (CPG) and related systematic literature reviews, including a preparatory educational seminar for participants, formation of working groups of clinicians, with subsequent teleconferences, e-mail and online forums to identify the scope of each guideline and review the literature. A consensus development conference (CDC) was conducted to finalise the reviews with a nominal group technique (NGT) used to develop recommendations for practice. External Validation Panels (EVP) verified the recommendations in each clinical practice guideline. Group voting was undertaken using a Likert scale (1-3 disagree, 4-6 neutral, 7-9 agree) with consensus agreement set as a median of at least seven.

RESULTS

Eighty-three recommendations for practice were developed for the six Clinical Practice Guidelines; 50% were based on research literature evidence (23% with high levels of evidence). The balance were based on consensus opinion of the panel members. Only five recommendations were not validated by external validation.

CONCLUSION

This project has demonstrated a method for guideline development that is robust, incorporating evidence from research and clinical expertise utilising an objective egalitarian framework.

Towards tomorrow, today

This year’s World Congress of Enterostomal Therapy (WCET) conference to be held in Glasgow, Scotland, in October, is entitled Towards Tommorrow, Today. The philosophy of WCET highlights the need for nurse specialists in stoma care (or enterostomal therapists) to have dual responsibility for providing individualized care as well as sharing their knowledge, skills and expertise with all healthcare professionals with an interest in the patient with a stoma, wound or incontinence.

Nursing theory and knowledge development: a descriptive review of doctoral dissertations, 2000-2004

Within the profession of nursing, nursing theory, conceptual models, and knowledge development continue to be points of discussion and debate. Some suggest that nursing research must either test or develop nursing theory, whereas others believe that research germane to practice can legitimately incorporate what is commonly referred to as borrowed theory. This descriptive analysis of nursing doctoral dissertations (N = 207) conducted from 2000 to 2004 focused primarily on the inclusion or exclusion of nursing theories. Almost half (45.4%) of the dissertations studied theories from fields other than nursing, 27.1% of the researchers studied nursing theories, and 27.5% of the dissertation studies engaged in theory generation. Implications for nursing knowledge development and research specific to practice are discussed.

Evidence-based practice among Danish cardiac nurses: a national survey

AIMS

This paper presents a survey of evidence-based practice among cardiac nurses exploring nurses' attitudes towards evidence-based practice and the types of knowledge they employ in clinical practice.

BACKGROUND

Research utilization and evidence-based practice are required at hospitals around the world, although the definition of evidence-based practice is still unclear. An ongoing debate exists about the sources of knowledge and the hierarchy of research evidence in clinical practice, and nursing research has been threatened by the dominance of randomized controlled trials. Evidence-based practice has been described as a new paradigm, which promotes patient-centred care by integrating external evidence and patient preferences.

METHODS

The study was a cross-sectional survey with a descriptive and comparative design, using self-administered postal questionnaires. The questionnaires were sent to 33 head nurses and 51 bedside nurses representing one or two units in each cardiac department in Denmark (n = 28). The final response rate was 81%. The study was carried out in 2004.

RESULTS

Respondents had a positive attitude towards evidence-based practice, although they relied upon personal clinical experience. Head nurses were statistically significantly more familiar with the concept of evidence-based practice than bedside nurses, and read scientific journals more frequently. Introductory courses to evidence-based practice are rare and seldom mandatory, and the data suggest that respondents lacked knowledge of the finer points of evidence-based practice and equated the concept with research utilization.

CONCLUSIONS

Barriers to evidence-based practice are inadequate education, unfamiliarity with English, and low organizational position. Facilitators include the implementation of guidelines, provision of continuing education, and an increase in the accountability of bedside nurses.

Sources of practice knowledge among nurses

Several studies have been published listing sources of practice knowledge used by nurses. However, the authors located no studies that asked clinicians to describe comprehensively and categorize the kinds of knowledge needed to practice or in which the researchers attempted to understand how clinicians privilege various knowledge sources. In this article, the authors report findings from two large ethnographic case studies in which sources of practice knowledge was a subsidiary theme. They draw on data from individual and card sort interviews, as well as participant observations, to identify nurses' sources of practice knowledge. Their findings demonstrate that nurses categorize their sources of practice knowledge into four broad groupings: social interactions, experiential knowledge, documents, and a priori knowledge. The insights gained add new understanding about sources of knowledge used by nurses and challenge the disproportionate weight that proponents of the evidence-based movement ascribe to research knowledge.

Advancing the clinical perspective: a practice development project to develop the nurse practitioner role in an acute hospital trust

AIMS

The aims of this project were to investigate awareness and foster understanding of the concept of the nurse practitioner and to facilitate and support the development of nurse practitioner roles within an acute hospital trust.

BACKGROUND

A limited understanding of and minimal support for the development of the nurse practitioner (NP) role were identified within an acute hospital trust in the south of England. This was the impetus for pursuing the project outlined in this paper. THEORETICAL PERSPECTIVE: The project used practice development theory synonymously with action research methodology comprising of four action research cycles.

METHOD

Data were collected in a variety of ways within the four overlapping cycles using formal and informal methods, which were analysed concurrently during the project. Techniques included questionnaires, semi-structured interviews, meetings, discussions and the project leader's field notes' diary.

OUTCOMES

A better understanding of the concept and support for NP posts were enhanced across the trust. A Nurse Practitioner Development Group (NPDG) was established, which helped to facilitate the development of NP posts. An example of such a post was established within a NP-led gynaecology pre-operative assessment clinic, which was a pilot project and constituted Action Research cycle 3.

CONCLUSION

It is concluded that the development of NP roles, with the support of a NPDG, within an agreed strategy offers a robust process for NP development within an acute hospital setting.

RELEVANCE TO CLINICAL PRACTICE

This project demonstrated how practice development and action research might be used together as a systematic process for developing and supporting professional roles that aim to improve the quality of patient care and the effectiveness of health care services.

Aesthetic physical caring - valuing the visible

The aim of this article was to define the term 'aesthetics' in order to demonstrate that aesthetic physical caring is administered to the intensive care patient. Johns's model of structured reflection (10th version) was used to reflect upon three nursing narratives with intensive care unit nurses and relatives and reveals why physical caring is fundamental for the patient.

Evaluación de la competencia práctica y de los conocimientos científicos de enfermeras de UCI en la aspiración endotraqueal de secreciones

Tracheal suctioning is essential to maintain permeability of the artificial airway. This procedure may be associated to risks for the patients. Thus, it is very important to know if the nurses perform it correctly and if the practice is based on scientific evidence. This investigations objectives are: evaluate practical competence of the nurses, as well as the scientific knowledge that they have on this procedures in a Polyvalent Intensive Care Unit and analyze if there are discrepancies between the practice competence and scientific knowledge. This descriptive study, performed in 34 nurses, analyzed the performance of tracheal suctioning by direct observation, using the data collection of a structured grid that included 19 aspects to evaluate, grouped into 6 categories. In the same way, knowledge on the procedure was analyzed, using a 19-item self-administered questionnaire, also grouped into 6 categories, which evaluated the same aspects observed. The total mean score obtained in the practice observation grid (P) was 12.09 for a maximum score of 19, while it was 14.24 in the knowledge questionnaire (Q). When analyzed by categories, discrepancies were obtained in the following aspects: in the need for hand washing prior to suctioning (P = 55.9%; Q = 97.1%), in cleaning of the suction catheter after each suctioning during the procedure (P = 0%; Q = 38.2%), in the correct performance of hyperoxygenation and hyperinsuflation, before, during and after the procedure (P = 11.8%; Q = 941%), in the correct selection of the size suction catheter in relationship with endotracheal tubes internal lumen (P = 0%; Q = 52.9%), in the maximum time the catheter remains in the trachea (P = 100%; Q = 23.5%), in the maximum number of times that the catheter should be introduced in each suctioning (P = 100%; Q = 73.5%) and in the non-instillation of saline solution (P = 29.4%; Q = 58.8%). When the total scores obtained were compared, both in practice and knowledge, with the years of experience in ICU, no statistically significant differences were found. It is concluded that the study nurses have scientific knowledge of the suctioning procedure that are better than their practice competence. Discrepancies between practice and knowledge were also found in several of the aspects evaluated, which orients towards the specific needs of training in this procedure.

Care bundles in critical care: a practical approach to evidence-based practice

The care bundle is a new concept in critical care, which is currently being promoted by the National Health Service Modernisation Agency for Critical Care. Care bundles originated in North America and are described best as groups of evidence-based practice interventions. The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcome. Care bundles are relatively easy to develop, implement and audit, and provide practitioners with a practical method for implementing evidence-based practice. This article describes the care bundle and offers practical suggestions about how to develop, implement and audit them in practice.