Nurse practitioner and practice nurses' use of research information in clinical decision making: findings from an exploratory study

Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities

HIGHLIGHTS

The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.

Temporal search persistence, certainty, and source preference in dentistry: Results from the National Dental PBRN

Objectives

The primary goal of this paper was to investigate an old question in a new way: what are the search patterns that professionals demonstrate when faced with a specific knowledge gap?

Methods

We examine data from a cascading survey question design that captures details about searching for information to answer a self-nominated clinical question from 1027 dental professionals enrolled in the National Dental Practice Based Research Network. Descriptive and conditional logistical regression analysis techniques were used.

Results

61% of professionals in our sample choose informal sources of information, with only about 11% looking to formal peer reviewed evidence. The numbers of professionals turning to general internet searches is more than twice as high as any other information source other than professional colleagues. Dentists with advanced training and specialists are significantly more likely to consult peer-reviewed sources, and women in the sample were more likely than men to continue searching past a first source.

Conclusions

Speed/availability of information may be just as, or in some cases, more important than credibility for professionals’ search behavior. Additionally, our findings suggest that more insights are needed into how various categories of professionals within a profession seek information differently.

Naturopaths' mobilisation of knowledge and information in clinical practice: an international cross-sectional survey

BACKGROUND

The contemporary evidence-based practice model acknowledges the importance of patient preferences and clinician experience when applying evidence within a clinical setting. Knowledge mobilisation (KM) acknowledges the complexities of knowledge translation by recognising and respecting diversity in types of knowledge and how such diversity can influence health care and health care choices. While there has been considerable discussion on KM in health care, it has received little attention in the field of naturopathy. Despite naturopathy's widespread international use, it is unclear how naturopathic practitioners (NPs) use and share knowledge and information in clinical practice. This study examines the mobilisation of knowledge amongst NPs internationally.

METHODS

Online, international, cross-sectional survey of a self-selected sample of NPs from any country, that were either currently in clinical practice or had been in practice within the previous 12 months. The survey was administered in five languages (English, French, Portuguese, Spanish, German). Descriptive statistics were prepared for all survey items.

RESULTS

The survey was completed by 478 NPs who reported using an average of seven (median = 7, SD = 2.6) information sources to inform patient care. NPs also drew on knowledge gained through patients sharing their perspectives of living with their health condition (Always/Most of the time: 89.3%). They mostly sought knowledge about how a treatment might benefit a patient, as well as knowledge about treatment safety and a better understanding of a patient's health condition. NPs frequently reported sharing knowledge developed through consideration of the patient's unique needs (83.3%), and primarily shared knowledge by producing information for the public (72.6%) and for patients (72.2%).

CONCLUSIONS

Based on these findings, it may be argued that NPs practice knowledge mobilisation; employing multiple forms and sources of knowledge, and mobilising knowledge to - as well as from - others. Due to their active engagement in patient and community education, NPs also may be considered knowledge brokers. In the context of the growing understanding of the complexities of knowledge translation and mobilisation in contemporary health care - and particularly within the context of implementation science - this study provides novel insights into an under-researched element of health services accessed by the community.

The association between professional stratification and use of online sources: Evidence from the National Dental Practice-Based Research Network

The use of online information sources in most professions is widespread, and well researched. Less understood is how the use of these sources vary across the strata within a single profession, and how question context affects search behaviour. Using the dental profession as a case of a highly stratified discipline, we examine search preferences for sources by professional strata among dentists in a practice-based network. Results show that variation exists in information search behaviour across professional strata of dental clinicians. This study highlights the importance of addressing information literacy across different levels of a profession. Findings also underscore that search behaviour and source preference vary with perceived question relevance.

Barriers and facilitators to clinical information seeking: a systematic review

OBJECTIVE

The study sought to identify barriers to and facilitators of point-of-care information seeking and use of knowledge resources.

MATERIALS AND METHODS

We searched MEDLINE, Embase, PsycINFO, and Cochrane Library from 1991 to February 2017. We included qualitative studies in any language exploring barriers to and facilitators of point-of-care information seeking or use of electronic knowledge resources. Two authors independently extracted data on users, study design, and study quality. We inductively identified specific barriers or facilitators and from these synthesized a model of key determinants of information-seeking behaviors.

RESULTS

Forty-five qualitative studies were included, reporting data derived from interviews (n = 26), focus groups (n = 21), ethnographies (n = 6), logs (n = 4), and usability studies (n = 2). Most studies were performed within the context of general medicine (n = 28) or medical specialties (n = 13). We inductively identified 58 specific barriers and facilitators and then created a model reflecting 5 key determinants of information-seeking behaviors: time includes subthemes of time availability, efficiency of information seeking, and urgency of information need; accessibility includes subthemes of hardware access, hardware speed, hardware portability, information restriction, and cost of resources; personal skills and attitudes includes subthemes of computer literacy, information-seeking skills, and contextual attitudes about information seeking; institutional attitudes, cultures, and policies includes subthemes describing external individual and institutional information-seeking influences; and knowledge resource features includes subthemes describing information-seeking efficiency, information content, information organization, resource familiarity, information credibility, information currency, workflow integration, compatibility of recommendations with local processes, and patient educational support.

CONCLUSIONS

Addressing these determinants of information-seeking behaviors may facilitate clinicians' question answering to improve patient care.

Exploring the use of curbside consultations for interprofessional collaboration and clinical decision-making

Nurse practitioners utilize curbside consultation, an interprofessional collaboration communication process in which one clinician seeks advice from another, in clinical decision-making practices. Nevertheless, this process is not well-understood. A qualitative design with individual open-ended interviews was used to explore the phenomenon of curbside consultation among nurse practitioners for clinical decision-making. Twenty primary care and specialty nurse practitioners participated. Participants were recruited via purposive sampling from in-patient and out-patient settings in order to reach saturation of themes. Using inductive content analyses, the findings revealed that nurse practitioners made multiple decisions in the course of information-seeking and its application during the curbside consultation process. Motivated by the patient's best interest, nurse practitioners provided advice in the curbside consultation exchange and sought answers to questions encountered in clinical decision-making. Multiple resources were often utilized with curbside consultation frequently evolving into formal consultation. Dynamics of curbside consultation included (a)synchronous approaches including text, e-mail, telephone, or face-to-face processes. Once information was received, nurse practitioners decided whether they (dis)agreed with advice and if validation was necessary. Nurse practitioners utilized curbside consultation for clinical decision-making and means for interprofessional collaboration, thereby increasing clinical competency and promoting quality patient outcomes. Implications of curbside consultation for education and practice require further exploration to enhance outcomes of curbside consultation processes.

Attitudes of Nurses Towards Searching Online for Medical Information for Personal Health Needs: Cross-Sectional Questionnaire Study

BACKGROUND

Use of online clinical health care information has become part of the skill set required by medical teams. Nurses believe that information quality and availability affect nursing care and methods. However, nurses tend not to exploit professional medical databases for evidence-based medical information for their personal needs. This phenomenon has received little research attention.

OBJECTIVE

This study aimed to address the knowledge gap around nurses' attitudes towards searching online for medical information for their personal needs (ie, for themselves and their families) by (1) evaluating the level of exposure to medical information and the effect on attitudes towards the use of online search options, (2) assessing the effect of the choice of a primary means of searching for medical information on the attitudes towards the use of online search options, and (3) gauging the influence of sociodemographic data and health status on nurses' attitudes towards searching online for medical information.

METHODS

Nurses employed in general departments in a general hospital (34/210, 16.2%), nursing home (42/200, 21.0%), and geriatric medical center (45/180, 25.0%) in Israel were invited to complete the eHealth Impact Questionnaire (alpha=.95). Questionnaires were distributed by nurses in charge of the general hospitalization wards. The data collection period was February to March 2018. The response rate was 40.3% (121/300).

RESULTS

Nurses tended to search for medical information for personal needs on social media (24/121, 19.8%) and TV (eg, health programs, health news; 23/121, 19.0%). Nurses who chose social media as their primary means of receiving general information had a positive attitude about using the online environment as a source for medical information compared to nurses who found information through other means (t119=4.44, P<.001). Nurses exposed to medical information via social media had a positive attitude towards the use of the internet to find medical information compared to nurses who were not exposed to social media (t119=3.04, P=.003). The attitudes of nurses towards the utility of online medical information for personal needs increased with better participant health status (F2,118=3.63, P=.03). However, the attitudes of participants with a chronic disease did not differ from those of healthy participants.

CONCLUSIONS

Nurses in Israel are less likely to use their professional skills and knowledge to search in professional databases for evidence-based medical information for their personal needs. Instead, they prefer medical information that is easy to access and not evidence-based, such as that on social media and TV. However, these search patterns for personal use may affect their clinical role, impair quality of care, and lead to incorrect medical decisions for their patients in the health care system. Therefore, during nursing education, training for searching skills, retrieval skills, and online search techniques for evidence-based medical information is vital for evidence-based practice.

Use of antimicrobial dressings in England and the association with published clinical guidance: interrupted time series analysis

OBJECTIVES

In healthcare systems, practices and products of unproven value and cost-effectiveness can decrease value and increase waste. Using the management of complex wounds, this study investigates temporal trends in the use of antimicrobials dressings, places this in the context of available evidence and discusses the potential impacts on the UK National Health Service (NHS).

DESIGN

Secondary descriptive and interrupted time series (ITS) analysis of NHS prescription data.

SETTING

Prescribing Cost Analysis (PCA) details all NHS prescriptions dispensed in the community in England.

INTERVENTIONS

An ITS design was used to compare annual changes in the expenditure and use of antimicrobial and non-antimicrobial dressings before and after the publication of the 'intervention' of key evidence-based Scottish Intercollegiate Guidelines Network (SIGN) guidance in 2010.

PRIMARY AND SECONDARY OUTCOME MEASURES

Trends in use and expenditure of antimicrobial dressings in relation to published clinical guidance.

RESULTS

There was a large increase in the prescribing of, and expenditure on, antimicrobial wound dressings between 1997 and 2016. In 1997, the total number of dressings prescribed was 5 792 700; increasing to 11 447 102 in 2009 with expenditure increasing from £1 960 386 to £32 841 263. During the year of the SIGN intervention (2010), there was a significant drop in the use of silver but there was no consistent ongoing reduction from 2011 to 2015.

CONCLUSIONS

Prescribing data can be used to identify products of unproven benefit, which also impose a significant financial burden. This study quantifies the huge increase in the use of antimicrobial wound dressings over a 20-year period despite the lack of compelling evidence to support their routine use. There is some suggestion, however that the use and expenditure decreased after the publication of key guidance. Routine data can be used to as part of more systematic efforts to increase value and reduce waste in health systems.

What factors influence community wound care in the UK? A focus group study using the Theoretical Domains Framework

OBJECTIVES

Research has found unwarranted variation across community wound care services in the North of England, with underuse of evidence-based practice and overuse of interventions where there is little or no known patient benefit. This study explored the factors that influence care in community settings for people with complex wounds, to develop a deeper understanding of the current context of wound care and variation in practice.

DESIGN

Qualitative focus group study using the Theoretical Domains Framework (TDF) to structure the questions, prompts and analyses.

SETTING

Community healthcare settings in the North of England, UK.

PARTICIPANTS

Forty-six clinical professionals who cared for patients with complex wounds and eight non-clinical professionals who were responsible for procuring wound care products participated across six focus group interviews.

RESULTS

We found the TDF domains: environmental context and resources, knowledge, skills, social influences and behaviour regulation to best explain the variation in wound care and the underuse of research evidence. Factors such as financial pressures were perceived as having a negative effect on the continuity of care, the availability of wound care services and workloads. We found practice to be mainly based on experiential knowledge and personal preference and highly influenced by colleagues, patients and the pharmaceutical industry, although not by research evidence.

CONCLUSIONS

Our study provides new insight into the role that experiential learning and social influences play in determining wound care and on the limited influence of research. Workforce pressures and limited resources are perceived to impede care by reducing patient access to services and the ability to provide holistic care. Participative collaboration between university and healthcare organisations may offer a supportive route to addressing issues, implementing sustainable changes to practice and service delivery and a resolute commitment to research use among clinical professionals.

Preferences for peer-reviewed versus other publication sources: a survey of general dentists in the National Dental PBRN

Background

Medical professionals have access to a broad range of resources to address clinical information needs. While much attention is given to new sources of data such as those available on the internet, it is less clear how clinicians choose between peer-reviewed research literature and other publication-based sources. This analysis distinguishes between possible drivers of publication type preference (namely, practice setting, advanced training, professional development experiences). Dentists enrolled in the National Dental Practice-Based Research Network (PBRN) are the population for this study. Theories of human and intellectual capital and institutional logics theory are used to understand how advanced training and other clinical experiences may explain the choices that dentists make when faced with clinical questions.

Methods

An online questionnaire was implemented with general dentists in the US National Dental PBRN. A series of logistic and Ordinary Least Squares (OLS) regression models were used to explain the use of peer-reviewed and other publications. Measures of knowledge-based human capital distinctions (advanced clinical training and research engagement, advanced professional status, personal motivation for professional advancement) were used to explain preferences for research literature as a clinical resource.

Results

General dentists with advanced training, as well as those with a skill advancement motivation, show a preference for peer-reviewed materials. General dentists who have been practicing longer tend to favor other dental publications, preferring those sources as a resource when faced with clinical challenges. Human capital and professional motivation distinguish the information preferences among general dentists. Further, these factors explain more variance in use of peer-reviewed materials than practice setting does. Few differences by demographic groups were evident.

Conclusions

Results point to a distinct variation in the general dentistry professional community. Advanced training among general dentists, as well as the types of procedures typically conducted in their practice, distinguishes their information preferences from other general dentists, including those with more years of clinical experience.

Patientenbezogene Komplexität in der Pflege – Kollektive Case Studies im Akutspital

Zusammenfassung. Hintergrund: Die patientenbezogene Komplexität der Pflege ist durch die Merkmale „Instabilität“, „Unsicherheit“ und „Variabilität“ definiert. Aufgrund der reduzierten Aufenthaltsdauer und der steigenden Zahl chronisch und mehrfach erkrankter Personen erhöht sich die Komplexität der Pflege. Ziel: In dieser Studie untersuchten wir das Phänomen patientenbezogener Komplexität aus Sicht von Pflegefachpersonen und Pflegeexpertinnen im Akutspital. Methode: Im Rahmen eines kollektiven Case-Study-Designs schätzten Pflegefachpersonen und Pflegeexpertinnen die Komplexität von Pflegesituationen mit einem Fragebogen ein. Danach befragten wir sie in Einzelinterviews zu ihrer Einschätzung. Mittels Within-Case-Analyse verdichteten wir die Daten induktiv zu Fallgeschichten. In der Cross-Case-Analyse verglichen wir die Fallgeschichten hinsichtlich deduktiv abgeleiteter Merkmale. Ergebnisse: Die Ausprägung der Komplexität hing in den vier Cases im Wesentlichen davon ab, ob klinische Probleme kontrollierbar und prognostizierbar waren. Je nach individuellen Ressourcen der Patientinnen und Patienten stieg bzw. sank die Komplexität. Schlussfolgerungen: Komplexe Patientensituationen fordern von Pflegefachpersonen Fachwissen, Erfahrung, kommunikative Kompetenzen sowie die Fähigkeit zur Reflexion. Berufsanfänger und Berufsanfängerinnen werden zur Entwicklung dieser Fähigkeiten idealerweise durch erfahrene Berufskolleginnen oder -kollegen unterstützt und beraten.

Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis

Objective

To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research.

Materials and Methods

We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research.

Results

The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process.

Discussion

The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations.

Conclusion

The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.

Clinicians' perceptions of usefulness of the PubMed4Hh mobile device application for clinical decision making at the point of care: a pilot study

BACKGROUND

Although evidence-based practice in healthcare has been facilitated by Internet access through wireless mobile devices, research on the effectiveness of clinical decision support for clinicians at the point of care is lacking. This study examined how evidence as abstracts and the bottom-line summaries, accessed with PubMed4Hh mobile devices, affected clinicians' decision making at the point of care.

METHODS

Three iterative steps were taken to evaluate the usefulness of PubMed4Hh tools at the NIH Clinical Center. First, feasibility testing was conducted using data collected from a librarian. Next, usability testing was carried out by a postdoctoral research fellow shadowing clinicians during rounds for one month in the inpatient setting. Then, a pilot study was conducted from February, 2016 to January, 2017, with clinicians using a mobile version of PubMed4Hh. Invitations were sent via e-mail lists to clinicians (physicians, physician assistants and nurse practitioners) along with periodic reminders. Participants rated the usefulness of retrieved bottom-line summaries and abstracts and indicated their usefulness on a 7-point Likert scale. They also indicated location of use (office, rounds, etc.).

RESULTS

Of the 166 responses collected in the feasibility phase, more than half of questions (57%, n = 94) were answerable by both the librarian using various resources and by the postdoctoral research fellow using PubMed4Hh. Sixty-six questions were collected during usability testing. More than half of questions (60.6%) were related to information about medication or treatment, while 21% were questions regarding diagnosis, and 12% were specific to disease entities. During the pilot study, participants reviewed 34 abstracts and 40 bottom-line summaries. The abstracts' usefulness mean scores were higher (95% CI [6.12, 6.64) than the scores of the bottom-line summaries (95% CI [5.25, 6.10]). The most frequent reason given was that it confirmed current or tentative diagnostic or treatment plan. The bottom-line summaries were used more in the office (79.3%), and abstracts were used more at point of care (51.9%).

CONCLUSIONS

Clinicians reported that retrieving relevant health information from biomedical literature using the PubMed4Hh was useful at the point of care and in the office.

Do systematic reviews address community healthcare professionals' wound care uncertainties? Results from evidence mapping in wound care

Background

Complex wounds such as leg and foot ulcers are common, resource intensive and have negative impacts on patients’ wellbeing. Evidence-based decision-making, substantiated by high quality evidence such as from systematic reviews, is widely advocated for improving patient care and healthcare efficiency. Consequently, we set out to classify and map the extent to which up-to-date systematic reviews containing robust evidence exist for wound care uncertainties prioritised by community-based healthcare professionals.

Methods

We asked healthcare professionals to prioritise uncertainties based on complex wound care decisions, and then classified 28 uncertainties according to the type and level of decision. For each uncertainty, we searched for relevant systematic reviews. Two independent reviewers screened abstracts and full texts of reviews against the following criteria: meeting an a priori definition of a systematic review, sufficiently addressing the uncertainty, published during or after 2012, and identifying high quality research evidence.

Results

The most common uncertainty type was ‘interventions’ 24/28 (85%); the majority concerned wound level decisions 15/28 (53%) however, service delivery level decisions (10/28) were given highest priority. Overall, we found 162 potentially relevant reviews of which 57 (35%) were not systematic reviews. Of 106 systematic reviews, only 28 were relevant to an uncertainty and 18 of these were published within the preceding five years; none identified high quality research evidence.

Conclusions

Despite the growing volume of published primary research, healthcare professionals delivering wound care have important clinical uncertainties which are not addressed by up-to-date systematic reviews containing high certainty evidence. These are high priority topics requiring new research and systematic reviews which are regularly updated. To reduce clinical and research waste, we recommend systematic reviewers and researchers make greater efforts to ensure that research addresses important clinical uncertainties and is of sufficient rigour to inform practice.

Nurses' perceptions of health beliefs and impact on teaching and practice: a Q-sort study

AIM

To understand Chinese nurses' perceptions of health beliefs, their content, origin and the influence of sociocultural factors, as a basis of their evidence-based practice. This study contributes to a larger study to establish the health beliefs of Japanese, Australian, Chinese, South Korean and Thai nurses.

BACKGROUND

Registered nurses teach patients and students about maintaining or attaining health are subject to the same range of influences and their health beliefs may be antithetical to current health evidence.

METHODS

Q-method design using q-sort and interview was used to explore the perspectives on a range of health beliefs of 60 nurses in four cities in China.

FINDINGS

Three factors arose from the perceptions of the participants about health and accounted for 50.2% of the total variance: (1) social impact, (2) 'the importance of evidence', and (3) beliefs rooted in culture.

DISCUSSION

Influence on nurses' health beliefs was explored in terms of the internalized and frequently unconscious beliefs, values and norms tying them to their communities, reflecting the need for nurses to be aware of their health beliefs and behaviours.

CONCLUSIONS

Education for nurses in practice needs to acknowledge that individual practitioners' beliefs strongly influence health teaching for patients and families. In order to implement evidenced-based practice and teach in line with current evidence nurses need to critically examine and reflect on the impact of culture, society and the media on their own health beliefs.

IMPLICATIONS FOR NURSING POLICY AND HEALTH POLICY

Education policy needs to consider that culture and societal pressures affect nurses' health beliefs and practice. Critical thinking, reflective and evidence-based practice need to be emphasized in clinical training and nurse education. China also needs to develop policies to allow nurses to be able to assess the reliability of health information on the Internet and to make quality health research more available.

Advanced practice nursing, health care teams, and perceptions of team effectiveness

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

An analysis of nursing students' decision-making in teams during simulations of acute patient deterioration

AIM

The aim of this study was to examine the decision-making of nursing students during team based simulations on patient deterioration to determine the sources of information, the types of decisions made and the influences underpinning their decisions.

BACKGROUND

Missed, misinterpreted or mismanaged physiological signs of deterioration in hospitalized patients lead to costly serious adverse events. Not surprisingly, an increased focus on clinical education and graduate nurse work readiness has resulted.

DESIGN

A descriptive exploratory design.

METHODS

Clinical simulation laboratories in three Australian universities were used to run team based simulations with a patient actor. A convenience sample of 97 final-year nursing students completed simulations, with three students forming a team. Four teams from each university were randomly selected for detailed analysis. Cued recall during video review of team based simulation exercises to elicit descriptions of individual and team based decision-making and reflections on performance were audio-recorded post simulation (2012) and transcribed.

RESULTS

Students recalled 11 types of decisions, including: information seeking; patient assessment; diagnostic; intervention/treatment; evaluation; escalation; prediction; planning; collaboration; communication and reflective. Patient distress, uncertainty and a lack of knowledge were frequently recalled influences on decisions.

CONCLUSIONS

Incomplete information, premature diagnosis and a failure to consider alternatives when caring for patients is likely to lead to poor quality decisions. All health professionals have a responsibility in recognizing and responding to clinical deterioration within their scope of practice. A typology of nursing students' decision-making in teams, in this context, highlights the importance of individual knowledge, leadership and communication.

Dual agency in critical care nursing: Balancing responsibilities towards colleagues and patients

AIM

To explore critical care nurses' decisions to seek help from doctors.

BACKGROUND

Despite their well-documented role in improving critically ill patients' outcomes, research indicates that nurses rarely take decisions about patients' treatment modalities on their own and constantly need to seek advice or authorization for their clinical decisions, even for protocol-guided actions. However, research around the factors related to, and the actual process of, such referrals is limited.

DESIGN

A grounded theory study, underpinned by a symbolic interactionist perspective.

METHODS

Data collection took place in a general intensive care unit between 2010 - 2012 and involved: 20 hours of non-participant and 50 hours of participant observation; ten informal and ten formal interviews; and two focus groups with ten nurses, selected by purposive and theoretical sampling. Data analysis was guided by the dimensional analysis approach to generating grounded theory.

FINDINGS

Nurses' decisions to seek help from doctors involve weighing up several occasionally conflicting motivators. A central consideration is that of balancing their moral obligation to safeguard patients' interests with their duty to respect doctors' authority. Subsequently, nurses end up in a position of dual agency as they need to concurrently act as an agent to medical practitioners and patients.

CONCLUSION

Nurses' dual agency relationship with patients and doctors may deter their moral obligation of keeping patients' interest as their utmost concern. Nurse leaders and educators should, therefore, enhance nurses' assertiveness, courage and skills to place patients' interest at the forefront of all their actions and interactions.

'An exploration of the health beliefs of Chinese nurses' and nurse academics' health beliefs: A Q-methodology study'

Q-methodology was used to investigate the health beliefs of Chinese clinical nurses and nurse academics. Twenty-eight participants from one hospital and nursing school in China were involved. The four stages of this study included: (i) concourse development from literature review, Internet searches, and key informant interviews; (ii) A pilot study to develop the Q-sample from the concourse; (iii) participants sorted the Q-sample statements along a continuum of preference (Q-sorting); and (iv) PQ data analysis using principal component analysis and varimax rotation. Five viewpoints were revealed: (i) factor 1--health management and the importance of evidence; (ii) factor 2--challenging local cultural belief, and Eastern and Western influences; (iii) factor 3--commonsense; (iv) factor 4--health and clinical practice; and (v) factor 5--health and nursing education. This study presents a need for nurses and nurse academics to think critically, examine their long-held health beliefs, and promote the use of evidence-based practice.

ELEMENTS AND STRATEGIES FOR ETHICAL DECISION-MAKING IN NURSING

ABSTRACT This study aimed to identify the elements and strategies that facilitate the ethical decision-making of nurses faced with ethical problems, from publications on the theme. An integrative literature review was carried out. Data collection was performed between the months of April and May 2014, in the databases: SciELO, CINAHL, LILACS and MEDLINE. Original, theoretical and case study articles, with a health team that included nurses, published in Portuguese, English and Spanish were included. A total of 19 studies were selected, the analysis of which resulted in three categories: external factors of ethical decision-making in nursing, individual factors of ethical decision-making in nursing and facilitating strategies of ethical decision-making in nursing. It was concluded that nurses need to use strategies that develop sensitivity, ability and ethical competence, in order to make prudent ethical decisions, contributing to the quality of health care.

Nurses’ and midwives’ information behaviour: a review of literature from 1998 to 2014

Purpose

– This paper aims to provide an overview of recent literature on nurses’ and midwives’ information behaviour, with a particular focus on sources used and barriers encountered.

Design/methodology/approach

– Comprehensive searching was undertaken and an analysis of the appropriate literature carried out.

Findings

– Practitioners within the nursing profession have a marked preference for interactive and human sources of information. They habitually associate information seeking with professional development rather than with clinical practice. Lack of time is the most frequently reported problem; also, they frequently lack confidence in searching and appraising the professional literature and in applying research in practice. Cultural factors may inhibit information seeking in the workplace, and access to appropriate information technology may be limited.

Practical implications

– As a group, nurses and midwives present significant challenges to health library and information professionals seeking to design services to meet their needs. A perceived lack of access to information resources may be associated with pervasive information literacy skill deficits, with the inability to undertake critical appraisal of material that is retrieved, or with the lack of a workplace culture that is supportive of information seeking. To reach nurses and midwives, more than diligent marketing is required; library and information professionals need to work closely with the holders of nursing and midwifery research, practice development and educational roles within their institutions on “embedded”, specific information initiatives.

Originality/value

– An overview of recent work is presented on the information behaviour of nurses and midwives within developed economies, focusing particularly on the UK. It may be of interest and value to health librarians and to nursing and midwifery educators in facilitating evidence-based practice.

Exploring Factors Affecting Emergency Medical Services Staffs' Decision about Transporting Medical Patients to Medical Facilities

Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs' decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed using a content analysis approach. The data analysis revealed the following theme: "degree of perceived risk in EMS staffs and their patients." This theme consisted of two main categories: (1) patient's condition' and (2) the context of the EMS mission'. The patent's condition category emerged from "physical health statuses," "socioeconomic statuses," and "cultural background" subcategories. The context of the EMS mission also emerged from two subcategories of "characteristics of the mission" and EMS staffs characteristics'. EMS system managers can consider adequate technical, informational, financial, educational, and emotional supports to facilitate the decision making of their staffs. Also, development of an effective and user-friendly checklist and scoring system was recommended for quick and easy recognition of patients' needs for transportation in a prehospital situation.

Exploration and classification of intensive care nurses' clinical decisions: a Greek perspective

AIM

The recording, identification, coding and classification of clinical decisions by intensive care nurses.

BACKGROUND

Clinical decision-making is an essential dimension of nursing practice as through this process nurses make choices to meet the goals of patient care. Intensive care nurses' decision-making has received attention because of the complexity and urgency associated with it, however, the types of nurses' clinical decisions have not been described systematically.

METHODS

Qualitative content analysis of daily diaries of clinical decisions recorded during nursing work by 23 purposefully selected intensive care nurses from three major hospitals of Greece. The process of data collection and analysis continued until the point of theoretical saturation.

FINDINGS

Eight categories of nursing clinical decisions emerged including decisions related to: (1) evaluation, (2) diagnosis, (3) prevention, (4) intervention, (5) communication with patients, (6) clinical information seeking, (7) setting of clinical priorities and (8) communication with health care professionals. Psychological assessment and support decisions were scarce, whereas patient input in care decisions appeared to be limited. The most frequent types of decisions were regarding intervention (29%), evaluation (25%) and clinical setting of priorities (17%), while clinical information seeking (3%) and communication with patients decisions (2%) were the least frequent. Additionally, recorded decisions were ranked in order of degree of urgency and of dependency on medical order. Non-urgent decisions were 78% of the total and 60% of nurses' intervention decisions were independent of medical order and were related to basic nursing care.

CONCLUSIONS

Intensive care nurses make multiple decisions that seem to be in line with the nursing process, although the latter is not officially implemented in Greek ICUs.

RELEVANCE TO CLINICAL PRACTICE

The types and frequency of clinical decisions made by intensive care nurses are related to features of ICU work environment, their professional autonomy and accountability, as well as their perceptions of their clinical role.

Sources of knowledge used by intensive care nurses in Norway: an exploratory study

This study explored the sources of knowledge that intensive care nurses used in their daily nursing practice. It used a qualitative design based on four focus group interviews with 20 intensive care nurses, from four intensive care units in Norway. Data were analysed using systematic text condensation. The following condensed meaning units were identified: research, theoretical knowledge, experiential knowledge, work place culture, clinical expertise and patient participation. This study illustrates the complexity and variety of the knowledge bases of intensive care nurses. Despite some variation in nurses' familiarity with research literature, nursing interventions found by research to be useful were given priority, and research affected daily practice through changes in guidelines and procedures.

Family nurse practitioner student perception of journal abstract usefulness in clinical decision making: a randomized controlled trial

PURPOSE

To assess family nurse practitioner (FNP) student perception of research abstract usefulness in clinical decision making.

DATA SOURCES

A randomized controlled trial conducted in a simulated environment with graduate FNP students of the Graduate School of Nursing, Uniformed Services University of the Health Sciences. Given a clinical case study and modified MEDLINE search tool accessible via an iPad device, participants were asked to develop a treatment plan and complete a data collection form. The primary measure was perceived usefulness of the research abstracts in clinical decision making regarding a simulated obese patient seeking to prevent type 2 diabetes. Secondary measures related to participant demographics and accessibility and usefulness of full-text manuscripts.

CONCLUSIONS

The majority of NP students identified readily available research abstracts as useful in shaping their clinical decision making. The presence or absence of full-text manuscripts associated with the abstracts did not appear to influence the perceived abstract usefulness. The majority of students with full-text manuscript access in the timed simulated clinical encounter read at least one paper, but cited insufficient time to read full-text as a constraint.

IMPLICATIONS FOR PRACTICE

Research abstracts at point of care may be valuable to FNPs if easily accessible and integrated into clinical workflow.

Clinical credibility and trustworthiness are key characteristics used to identify colleagues from whom to seek information

AIMS AND OBJECTIVES

To explore the use of information by nurses making decisions in clinically uncertain situations in one aspect of critical care nursing practice (enteral feeding). In this paper, we report the characteristics, which participants identified as important, of the people from whom they sought information for the purpose of making clinical decisions.

BACKGROUND

Registered nurses have a plethora of information sources available to assist them in making clinical decisions. Identifying and selecting the best information to support these decisions can be difficult and is influenced by factors such as accessibility, usefulness and variations in quality of the information.

DESIGN

An instrumental case study design using multiple case study analysis.

METHOD

Twenty-two critical care nurses from two intensive care units contributed to the data through multiple methods of data collection including concurrent verbal protocols (think aloud), retrospective probing and focus group interviews.

RESULTS

Nurses preferentially used colleagues as a source of information when faced with uncertainty about their clinical practice. Most participants placed greater emphasis on evaluating the individual providing the information rather than on evaluating the information itself. Key features used for identifying an individual as a source of information included experience, clinical role, trust and approachability.

CONCLUSION

Establishing clearly what clinical credibility means, and to what extent trustworthiness and expertise play a role in the establishment of credibility, is an important debate for nursing. We need to carefully consider what defines the construct of clinical credibility and how this aligns with the concept of clinical currency, to allow clinicians to determine in others the characteristics associated with clinical credibility to access quality information through social interaction.

RELEVANCE TO CLINICAL PRACTICE

Processes to focus on determining the quality of information obtained from colleagues should be emphasised. What these processes are and how they could be implemented into clinical practice remains unknown and is highlighted as an area for future research.

Understanding the role of communities of practice in evidence-informed decision making in public health

In this article we report on qualitative findings that describe public health practitioners' practice-based definitions of evidence-informed decision making (EIDM) and communities of practice (CoP), and how CoP could be a mechanism to enhance their capacity to practice EIDM. Our findings emerged from a qualitative descriptive analysis of group discussions and participant concept maps from two consensus-building workshops that were conducted with public health practitioners (N = 90) in two provinces in eastern Canada. Participants recognized the importance of EIDM and the significance of integrating explicit and tacit evidence in the EIDM process, which was enhanced by CoP. Tacit knowledge, particularly from peers and personal experience, was the preferred source of knowledge, with informal peer interactions being the favored form of CoP to support EIDM. CoP helped practitioners build relationships and community capacity, share and create knowledge, and build professional confidence and critical inquiry. Participants described individual and organizational attributes that were needed to enable CoP and EIDM.

The role of ICT in supporting disruptive innovation: a multi-site qualitative study of nurse practitioners in emergency departments

BACKGROUND

The disruptive potential of the Nurse Practitioner (NP) is evident in their ability to offer services traditionally provided by primary care practitioners and their provision of a health promotion model of care in response to changing health trends. No study has qualitatively investigated the role of the Emergency NP in Australia, nor the impact of Information and Communication Technology (ICT) on this disruptive workforce innovation. This study aimed to investigate ways in which Nurse Practitioners (NP) have incorporated the use of ICT as a mechanism to support their new clinical role within Emergency Departments.

METHODS

A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior physicians and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the ED nurse practitioner role and the influences of ICT upon the role. Member checking of results was achieved by revisiting the sites to clarify findings with participants and further explore emergent themes.

RESULTS

The role of the ENP was distinguished from those of Emergency nurses and physicians by two elements: advanced practice and holistic care, respectively. ICT supported the advanced practice dimension of the NP role in two ways: availability and completeness of electronic patient information enhanced timeliness and quality of diagnostic and therapeutic decision-making, expediting patient access to appropriate care. The ubiquity of patient data sourced from a central database supported and improved quality of communication between health professionals within and across sites, with wider diffusion of the Electronic Medical Record holding the potential to further facilitate team-based, holistic care.

CONCLUSIONS

ICT is a facilitator through which the disruptive impact of NPs can be extended. However, integration of ICT into work practices without detracting from provider-patient interaction is crucial to ensure utilisation of such interventions and realisation of potential benefits.

Oncology team members' perceptions of a virtual navigation tool for cancer patients

OBJECTIVES

The Internet has become an important source of health information for patients and health care providers (HCPs) alike. Whereas studies have begun to document the effects of the internet on health behaviors and outcomes, surprisingly few studies have explored HCPs' perceptions of the internet as a key resource accessed by patients. However, as HCPs are seen as pivotal in guiding patients toward these resources, it is timely to study their perceptions. Therefore, the present inquiry explores HCPs' views of a recently developed high quality virtual navigation tool called the Oncology Interactive Navigator™ (OIN).

DESIGN

Using a qualitative approach, in-depth interviews were conducted with 16 members of a multidisciplinary colorectal oncology team and volunteers at a large Cancer Centre in Montreal, Quebec, Canada.

RESULTS

Content analysis revealed emerging themes centering on key benefits including: perceptions of a highly accessible, comprehensive high quality repository of cancer information; a means to further enhance HCP-patient communication and trust; and a significant catalyst to patient-family communication and support. Perceived drawbacks included patient (e.g., socio-demographic profile) and system's (e.g., professional roles and time constraints) characteristics that may limit OIN™ full implementation and uptake.

CONCLUSIONS

The findings underscore the relevance of virtual navigation tools to ensure optimal person-centred care in cancer. Findings also suggest how virtual tools such as the OIN™ can best be used in practice as well as they guide strategies to adopt to optimize implementation of similar innovations in health care.

P = nothing, or why we should not teach healthcare students about statistics

Tests of statistical significance are ubiquitous in the nursing and medical literature, and yet they are widely misunderstood and misinterpreted. This paper discusses this, with particular reference to null hypothesis significance testing and the associated p-value. It concludes that the assumptions behind these tests are too stringent for most undergraduate nursing students, and this, alongside the poor understanding of their meaning means that their teaching should have a limited place in the curriculum, which should instead concentrate upon exploratory analysis and understanding measures of effect.

Profiling information behaviour of nursing students: part 1: quantitative findings

Purpose

The aim of this paper is to profile the information seeking behaviour of nursing students, according to learning style, personality and self‐efficacy in information literacy. Such profiles should help students to reflect on their information seeking, and should help librarians in designing information literacy programmes that are targeted to student needs.

Design/methodology/approach

A questionnaire using existing validated scales for learning styles, personality, and information literacy self‐efficacy was developed. The information seeking portion was based on an information behaviour model with core processes (opening, orientation and consolidation) and corresponding micro‐processes. The questionnaire was administered to nursing students (n=261, response rate 74 per cent, 194/261) at one UK university.

Findings

Neither information literacy self‐efficacy, nor learning style on their own appeared to change as students progressed. There is a significant association between learning style and self‐efficacy. There appears to be some associations between personality and learning style, and between personality, learning style and preferred information seeking processes. Odds ratios analyses were used to help in preliminary development of profiles. Students with a higher degree of confidence about their information literacy are more likely to: think about their search; work out strategies; and build and adapt their searches. Deep learners take a broad, exploratory approach to searching and score highest for the openness personality trait; whilst strategic learners think about their search, adapt as they progress and score highest for conscientiousness and emotional stability. Surface learners do less planning. Additionally, personality traits (which are essentially stable over time) are positively or negatively associated with various aspects of information seeking.

Research limitations/implications

The sample size limits the extent of statistical analyses and possible generalizations. The planned qualitative research may help in confirmation of the information seeking profiles.

Originality/value

The research extends existing research evidence on the impact of personality and learning style on student information behaviour by including an information literacy scale and information seeking micro‐processes.

The interface between tradition and science: naturopaths' perspectives of modern practice

OBJECTIVES

Although there has been much international commentary, little is known about the interface between traditional knowledge and scientific research in modern naturopathic practice. This study aimed to explore this interface from the perspective of naturopaths.

DESIGN

Semistructured interviews were conducted with naturopaths in current practice. The participants were selected using purposive sampling, and the data from the interviews were interpreted using thematic analysis.

SETTINGS/LOCATION

Interviews were conducted in a place suitable to each participant.

SUBJECTS

Twelve (12) naturopaths in current clinical practice were interviewed. The participants represented a diversity of characteristics including gender, time in practice, level of qualification, and clinical contact hours per week.

OUTCOME MEASURES

Thematic analysis was used to identify common themes from the interviews.

RESULTS

Analysis identified a disparity in practitioner definition of what constitutes traditional information. However, it also identified that traditional knowledge is considered a valid source of information, whereas the validity and value of modern research is questioned. There is also tension between these two information sources, with science being argued to both support traditional knowledge, while also undermining its value. This tension seems to be overcome by practitioners' use of traditional knowledge to direct their own research, as well as drawing upon their knowledge of science to explain traditional knowledge as yet not researched.

CONCLUSIONS

The findings of this qualitative study reveal tensions and ambiguities around the interface between tradition and science with regard to naturopathic clinical practice. Understanding these findings may assist individuals and groups within the naturopathic profession, as well as those outside the profession engaging and collaborating with naturopaths.

Standards of care: are they being used?

Electronic access to standards of care is viewed as a promising strategy for increasing evidence-based practice. Before determining whether electronic access to standards will increase nurses' use of standards of care, data on their current rate of utilization are needed. Using 2 standards of care, Fluid Volume Excess and Manic Behavior, we used retrospective chart reviews to gather baseline information. Insights from these findings are presented.

Information requisition is the core of guideline-based medical care: which information is needed for whom?

RATIONALE, AIMS AND OBJECTIVES

It is mandatory for the design of an efficient software product to know the different groups of users of a software tool, the tasks the users want to perform with it, and the information that is required for it. Our goal is to establish a comprehensive information source for the development of a consistent software environment supporting all tasks emerging from the creation to the execution of a computerized clinical practice guideline (CPG) for different user groups.

METHODS

We conducted a comprehensive literature review to investigate the different user groups of a computerized CPG as well as their specific information needs.

RESULTS

We provide a complete catalogue of every single aspect that may be related to information needs of any party concerned. In particular, we give detailed information on the tasks of guideline modellers on the one hand, and clinical information needs (i.e. information needs of physicians, nurses, nurse practitioners and patients) on the other hand.

CONCLUSION

By providing categorized information from several studies and publications, we establish an exhaustive information basis for the design of a useful software tool facilitating the formalization and the execution of a CPG.

Using concept mapping to describe sources of information for public health and school nursing practice

Concept-mapping methodology was used to construct a conceptual model of information access for public health and school nursing practice. Concept mapping is an integrated mixed-methods approach that combines familiar group processes with multivariate statistical analyses to represent a group’s understanding of a phenomenon. In this project, 36 public health and school nurses brainstormed 207 unique information sources that were collated and reduced to 57 sources to allow sorting of the statements. A subgroup of 25 public health ( n = 16) and school nurses ( n = 9) sorted and rated the 57 statements to generate an eight-cluster concept map. The two-dimensional concept map revealed a sophisticated multivariate framework of information access occurring within an intricate, interrelated network of human and data-driven sources that intersect with community and professionally focused systems. Clusters of information sources included those from community groups, healthcare providers, professional organisations, educational tools, state resources, online resources, surveillance data and government-based resources. Ratings of importance, credibility and usefulness by public health and school nurses revealed overall agreement; however, some important differences of specific sources were noted. More complex than previously described, the map represents sources, means of access and systems of health information available to community-based nurses that influence their practice.

Who determines the patient mix of GP trainees? The role of the receptionist

BACKGROUND

During their specialty training, Dutch GP trainees work at a GP under the supervision of a GP trainer. Research suggests that the patient mix of GP trainees differs from that of their trainers. Receptionists assign patients to either the trainee or the trainer, thereby influencing the patient mix of the trainees. The decision to which doctor to assign is complex and depends on the latitude the receptionists have. Their considerations when assigning patients are unknown.

OBJECTIVE

To study receptionists' assigning behaviour.

METHODS

This was a questionnaire survey. To design the questionnaire, topics about assigning behaviour were identified in a focus group. The resulting questionnaire was sent to 478 GP training practices in the Netherlands.

RESULTS

Response rate was 68%. Of the receptionists, 95% asked for the reason for the consultation at least 'sometimes'. Most (86.3%) of the receptionists considered the patient mix of trainees and trainers to be similar. Almost all receptionists (97%) reported 'often' or 'always' assigning 'every possible problem' to the trainee and a similar picture arose regarding specific subpopulations. However, the receptionists reported that they assigned complex and new patients to the trainers more often than to trainees.

CONCLUSION

With some exceptions, receptionists try to assign trainees a varied patient mix.

The application and value of information sources in clinical practice: an examination of the perspective of naturopaths

BACKGROUND

The approach of evidence-based medicine (EBM), providing a paradigm to validate information sources and a process for critiquing their value, is an important platform for guiding practice. Researchers have explored the application and value of information sources in clinical practice with regard to a range of health professions; however, naturopathic practice has been overlooked.

OBJECTIVES

An exploratory study of naturopaths' perspectives of the application and value of information sources has been undertaken.

METHODS

Semi-structured interviews with 12 naturopaths in current clinical practice, concerning the information sources used in clinical practice and their perceptions of these sources.

RESULTS

Thematic analysis identified differences in the application of the variety of information sources used, depending upon the perceived validity. Internet databases were viewed as highly valid. Textbooks, formal education and interpersonal interactions were judged based upon a variety of factors, whilst validation of general internet sites and manufacturers information was required prior to use.

CONCLUSIONS

The findings of this study will provide preliminary aid to those responsible for supporting naturopaths' information use and access. In particular, it may assist publishers, medical librarians and professional associations in developing strategies to expand the clinically useful information sources available to naturopaths.