Protocol-based care: the standardisation of decision-making?

Decreasing Variation to Enhance Accurate Identification of Hypothermic Infants in Pediatric Primary Care

Hypothermia can be the first and only sign of sepsis in young infants, yet there is a paucity of standard recommendations for pediatric primary-care office management of those infants identified. The SMART aim of this study was to standardize the identification and care of infants age 0 to 49 days at risk of hypothermia in pediatric primary care by decreasing the percent of infants with temperatures ≤36.5°C from 24% to 10% within 2 years. Over the course of this project, variation in documented temperatures ≤36.5°C decreased from 24% to 7% of encounters. Temperatures ≤36.5°C were documented for 951 infants or 13.4% (1078 of 8020 encounters). Of the 951 infants with temperatures ≤36.5°C, 96.1% were rewarmed in the office. Thirty-one patients ultimately required hospitalization. Application of quality improvement in a primary-care office decreased low temperatures by standardizing care, empowering staff, and triaging at-risk infants to the most appropriate level of care.

Return to rugby following musculoskeletal injuries: A survey of views, practices and barriers among health and sport practitioners

STUDY DESIGN AND SETTING

Returning rugby players to the sport following musculoskeletal injuries is a multi-factorial and challenging process. A cross-sectional observational study was conducted among health and sport practitioners involved with injured rugby players in South Africa.

OBJECTIVES AND OUTCOME MEASURES

The views, current practices and barriers encountered by health and sport practitioners during return to rugby were investigated using a self-developed online survey.

RESULTS

64 practitioners participated in the survey including physiotherapists, orthopaedic surgeons, biokineticists and sports physicians. Return to sport (RTS) protocols were considered important, however, participants also indicated that they were slightly more likely to use anecdotal protocols compared to published protocols. Time frames, stages of healing, pain and subjective ratings along with functional outcome measures (such as range of motion, muscle function and proprioception) and sport-specific skills were rated as important and commonly utilised in different RTS phases (i.e., return to non-contact, return to contact and return to matches). The most commonly perceived barriers encountered were related to lack of access and time-constraints.

CONCLUSION

Return to rugby guidelines with consideration of a broad range of criteria and common barriers encountered should be developed to facilitate safe, practical and time-efficient return to rugby following musculoskeletal injuries.

Nurses' Utilization of Information Resources for Patient Care Tasks: A Survey of Critical Care Nurses in an Urban Hospital Setting

Critical care nurses manage complex patient care interventions under dynamic, time-sensitive and constrained conditions, yet clinical decision support systems for nurses are limited compared with advanced practice healthcare providers. In this work, we study and analyze nurses' information-seeking behaviors to inform the development of a clinical decision support system that supports nurses. Nurses from an urban midwestern hospital were recruited to complete an online survey containing eight open-ended questions about resource utilization for various nursing tasks and open space for additional insights. Frequencies and percentages were calculated for resource type, bivariate analyses using Pearson's χ2 test were conducted for differences in resources utilization by years of experience, and content analysis of free text was completed. Forty-five nurses (response rate, 19.6%) identified 38 unique resources, which we organized into a resource taxonomy. Institutional applications were the most common type of resource used (35.6% of all responses) but accounted for only 15.4% of respondents' "go-to resources," suggesting potential areas for improvement. Our findings highlight that knowing where to look for information, the existence of comprehensive information, and fast and easy retrieval of information are key resource seeking attributes that must be considered when designing a clinical decision support system.

How much information is 'reasonable'? A qualitative interview study of the prescribing practices of palliative care professionals

BACKGROUND

Prescribing clinicians have to negotiate ambiguities around information provision and consent for medications on a daily basis, despite the availability of professional guidance.

AIM

This study aims to explore some of the many factors prescribing clinicians in the United Kingdom take into account when deciding what information to give to patients about medication choices, and when.

DESIGN

In depth face-to-face interviews, utilising both a hypothetical scenario and semi-structured prompts, were conducted in order to elicit extended reflections on how clinicians individually work through such dilemmas and make decisions.

SETTING/PARTICIPANTS

Ten prescribing clinicians (doctors and nurses) from a large combined team of National Health Service (NHS) secondary and community palliative care providers in England.

RESULTS

Palliative care staff regularly face choices about information provision in prescribing discussions, in particular when considering whether information might increase distress. Participants presented three overlapping framings that helped them assess the range of factors that could potentially be taken into account; (1) assessing the individual patient, (2) tailoring the provision of information and (3) jointly forming a plan.

CONCLUSIONS

Information provision about medication choices and effects is a demanding, ongoing process, requiring nuanced judgements that constitute an unacknowledged yet significant aspect of clinical workload. Although current medical guidelines allow clinical discretion about information provision, this can leave individual clinicians feeling vulnerable. Further evolution of guidelines needs to establish a more sophisticated way to acknowledge professional and legal requirements, whilst also promoting professional autonomy and judgement.

Reducing Venous Thromboembolism Risk Through a Collaborative Team Approach

PURPOSE

Venous thromboembolism (VTE) is a preventable cause of death following surgical procedures and is associated with increased cost and patient complications. The purpose of this article is to outline a collaborative team approach to reducing VTE rates within an organization in an effort to increase the quality and safety of care provided.

DESIGN

An interdisciplinary team collaborated on an approach to reduce VTE rates within the organization following a literature review of best practices related to risk assessment, nurse driven protocols, interdisciplinary collaboration, and autonomy.

METHODS

Through an interdisciplinary collaborative effort, improvements were made toward decreasing rates of the patient safety indicator-12: perioperative pulmonary embolism/deep vein thrombosis.

FINDINGS

Following implementation of several initiatives, the VTE rate within the organization steadily decreased and has remained below benchmark for over 18 months.

CONCLUSION

The successful improvements led by the interdisciplinary VTE Committee demonstrate the impact of best practices implemented through shared decision-making and autonomy.

L’autonomie décisionnelle d’infirmières de soins intensifs lors du sevrage de la ventilation mécanique : une analyse de concept

Nurses have a leading role in weaning patients from mechanical ventilation (WMV) given their constant presence and their continuous monitoring. To promote proper WMV, nurses must exercise autonomy and be involved in decision-making. However, in certain care contexts, there is little involvement of nurses. The purpose of this text is to establish the characteristics of the concept of autonomous decision-making applied to nursing during WMV. An analysis of this concept was carried out according to the evolutionary method of Rodgers. The identification of the attributes, antecedents, and consequences made it possible to note ambiguity in the definition of this concept. Nurses use autonomous decision-making for the execution of assigned tasks and when they make decisions according to a pre-prescribed decision-making algorithm. Significant foundations for the decision-making autonomy of critical care nurses during WMV emerged from this analysis : scope of practice, in-depth knowledge of the patient, and commitment to the success of WMV. Participation in interdependent decision-making allows nurses to bring the patient’s perspective into decisions. Avenues of reflection have also emerged, including decisions based on evidence to provide new avenues for autonomous decision-making.

Cultural Diversity in Nursing Teams: Triggers, Team Process and Contingencies / Kulturelle Vielfalt in Pflegeteams: Triggers, Teamprozesse und Kontext

Introduction

The study explored cultural diversity in nursing teams and the internal and external conditions under which cultural differences represent an asset or a liability for these teams.

Methods

A qualitative design with content analysis was employed. In total, 18 interviews were conducted with nurses and assistant nurses with experience of working in culturally diverse teams in three distinct clinical settings.

Results

Three domains emerged in the study analysis: triggers, team process and contingencies. Each one encompassed a number of themes related to culturally diverse nursing team processes, triggers of team processes and context-specific contingencies, which represent the complexity of culturally diverse nursing team functioning.

Discussion/implications

The study suggests how cultural differences in nursing teams can be managed and further explored from within the team and by individuals leading those teams, taking into account the disablers and enablers of their functioning.

Nurses' protocol-based care decision-making: a multiple case study

AIM

To describe and explain nurses' protocol-based care decision-making.

BACKGROUND

Protocol-based care is a strategy to reduce variability in clinical practice. There are no studies looking at protocol-based care decision-making. Understand this process is key to successful implementation.

METHOD

A multiple embedded case study was carried out. Nurses' protocol-based care decision-making was studied in three inpatient wards (medical, surgical and medical-surgical) of a university hospital in northern Spain. Data collection was performed between 2015 and 2016 including documentary analysis, non-participant observations, participant observations and interviews. Analysis of quantitative data involved descriptive statistics and qualitative data was submitted to Burnard's method of content analysis (1996). The data integration comprised the integration of the data set of each case separately and the integration of the findings resulting from the comparison of the cases. The following the thread method of data integration was used for this purpose. The SRQR guideline was used for reporting.

RESULTS

The multiple embedded case study revealed protocol-based care decision-making as a linear and variable process that depends on the context and consists of multiple interrelated elements, among which the risk perception is foremost.

CONCLUSION

This study has allowed progress in protocol-based care decision-making characterisation. This knowledge is crucial to support the design of educational and management strategies aimed at implementing protocol-based care.

RELEVANCE TO CLINICAL PRACTICE

Strategies to promote protocol-based care should address the contexts of practice and the ability of professionals' to accurately assess the degree of risk of clinical activity. Hence, it will promote quality of care, patient safety and efficiency in healthcare cost.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Brief smoking cessation in acute Welsh hospitals: a realist approach

This implementation study sought to determine what works to support brief smoking cessation (BSC) in acute hospital settings, through exploration of organizational delivery and the role of healthcare professionals (HCPs). We used a realist approach, with embedded stakeholder engagement, within a large health organization. We conducted interviews (n = 27), a survey (n = 279) and organization documentation review (n = 44). The final programme theory suggests HCPs implement BSC when they value it as part of their role in contributing to improved patient outcomes; this is due to personal and professional influences, such as knowledge or experience. Organizational support, training and working in an environment where BSC is visible as standard care, positively influences implementation. However, the context exerts a strong influence on whether BSC is implemented, or not. HCPs make nuanced judgements on whether to implement BSC based on their assessment of the patient's responses, the patient's condition and other acute care demands. HCPs are less likely to implement BSC in dynamic and uncertain environments, as they are concerned about adversely impacting on the clinician-patient relationship and prioritize other acute care requirements. Organizations should actively promote BSC as a core function of the acute hospital setting and improve professional practice through leadership, training, feedback and visible indicators of organizational commitment. HCPs can be persuaded that implementing BSC is an acute care priority and an expectation of standard practice for improving patient outcomes.

Impact of using data from electronic protocols in nursing performance management: A qualitative interview study

Aim

To explore the impact of using electronic data in performance management to improve nursing compliance with a protocol.

Background

Electronic data are increasingly used to monitor protocol compliance but little is known about the impact on nurses’ practice in hospital wards.

Method

Seventeen acute hospital nursing staff participated in semi‐structured interviews about compliance with an early warning score (EWS) protocol delivered by a bedside electronic handheld device.

Results

Before electronic EWS data was used to monitor compliance, staff combined protocol‐led actions with clinical judgement. However, some observations were missed to reduce noise and disruption at night. After compliance monitoring was introduced, observations were sometimes covertly omitted using a loophole. Interviewees described a loss of autonomy but acknowledged the EWS system sometimes flagged unexpected patient deterioration.

Conclusions

Introducing automated electronic systems to support nursing tasks can decrease nursing burden but remove the ability to record legitimate reasons for missing observations. This can result in covert resistance that could reduce patient safety.

Implications for nursing management

Providing the ability to log legitimate reasons for missing observations would allow nurses to balance professional judgement with the use of electronic data in performance management of protocol compliance.

Implementing guideline-checklists: Evaluating health care providers intentional behaviour using an extended model of the theory of planned behaviour

OBJECTIVES

Internationally, clinical guidelines as checklists are increasingly used in acute ward practice to standardize the delivery and raise the quality of care on acute hospital wards. However, when guideline-checklists are implemented repeatedly, health providers' intentions to carry out this type of behaviour are not well understood. Therefore, the objective of this study was to evaluate nurses' and health care assistants' (HCAs) intentions to implement a "care round checklist"; a guideline-intervention repeated hourly on hospital wards. Furthermore, an extended Theory of Planned Behaviour (TPB) model's usefulness in explaining this type of behaviour was also evaluated.

METHODS

A theory-informed questionnaire, guided by the TPB, habit, and clinical context variables, was developed to measure the guideline-checklist behaviour. Quantitative questionnaire data were analysed using descriptive and inferential tests to establish differences in nurses' and HCAs' intentions and the predictive value of the model.

RESULTS

A sample of 270 nurses and HCAs returned questionnaires from 24 wards in a major hospital in England. The extended TPB model explained 20% of nurses and 24% of HCAs reported intentions to implement a care round checklist, a modest proportion of intent. Attitude and perceived control best predicted nurses' intentions, and attitude and practice habit HCAs' intentions. TPB belief variables helped explain why nurses and HCAs intentions were different.

CONCLUSIONS

Statistically, the extended TPB model highlighted that nurses and HCAs intentions to implement this type of guideline are predicted by different variables. This implied professional "role" as an important variable in explaining differences in intentions, which should be evaluated and integrated into the future design of this type of checklist. Further variables could be added to explain and learn more about intentional thinking for this type of behaviour and should help to develop a theoretical understanding of intentions underpinning this type of behaviour and ultimately improve patient care.

The importance of protocol-based eye care in the paediatric intensive care unit

Eye care is a fundamental aspect of personal hygiene that should not be neglected in a critically ill child. This article informs nursing care by linking theory to practice, based on a systematic search and critical review of the literature. It explores the significance of evidence related to the eye care of a ventilated child and considers the role of the children's nurse as an agent for change in developing an eye care protocol for use in the paediatric intensive care unit.

Going home to die from critical care: A case study

Much of the activity in critical care is complex but repetitive. In order to standardize care and maintain safety, delivery of care is often directed by protocols and care bundles. This case study will reflect on an instance where care transcended the standard protocol-directed path to be more individualized, creative and compassionate. Acts like these can be unique for the practitioners involved and require an element of positive risk taking, which happened here. It will look at the decision-making, planning and risk involved in preparing for a terminally ill patient, who was inotrope and high-flow oxygen dependent, to go home to have treatment withdrawn there instead of in the hospital. This was to fulfil his wish to die at home. In unpicking the circumstances where this positive risk taking led to the desired outcome and the relationship between safety, uncertainty and risk, three themes arose. These were the journey to safe uncertainty; decision-making with uncertain outcomes; and the importance of robust human factors, particularly effective communication and inter-professional teamwork. If positive risk taking can result in enhanced outcomes for the patient, then the question of how this behaviour can be fostered and encouraged must be addressed.

"Having the compass-drawing the map": Exploring nurses' management of pain and other discomforts during use of analgosedation in intensive care

AIM

To explore the deliberation and enactment processes of nurses in relation to pain and other discomforts in the critically ill patients after the implementation of an analgosedation protocol.

BACKGROUND

Nurses in intensive care units (ICU) face great challenges when managing pain and other discomforts and distinguishing between patients' needs for analgesics and sedatives. An analgosedation protocol favouring pain management, light sedation and early mobilization was implemented in a university hospital ICU in Norway in 2014. Changing sedation paradigms resulting in an increasing number of awake patients during critical illness is expected to affect nursing practice.

DESIGN

Exploratory, single-unit study in a mixed adult ICU.

METHODS

Data collection with participant observation and semi-structured interviews in sixteen clinical situations in 2014 and 2015. Thirteen experienced certified critical care nurses were included. Thematic content analysis was conducted.

RESULTS

An overall theme "Having the compass-drawing the map" emerged from the analysis. The protocol or strategy of analgosedation appeared to provide a direction for treatment and care, although requiring extensive interpretation of needs and individualization of care, often in challenging situations. The overall theme was abstracted from three themes: "Interpreting a complex whole," "Balancing conflicting goals" and "Experiencing strain from acting across ideals."

CONCLUSION

Nurses seem to attend adequately to patient pain, but the approach to discomforts other than pain appears unsystematic and haphazard. More explicit goals of care and strategies to handle discomfort as distinct from pain are needed. More research is needed to identify effective comfort measures for ICU patients.

Nurse Decision Making in Acute Care

Effective nurse decision making is essential for best patient outcomes in the acute care nurse practice environment. The purpose of this study was to explore acute care RNs' perceptions of clinical decision making for a patient who experienced a clinical event. Clinical events include changes in patient condition and are manifested by fever, pain, bleeding, changes in output, changes in respiratory status, and changes in level of consciousness. Naturalistic decision making framework supported the exploration of important contextual factors associated with decision making, provided new information for nursing science, and served as the conceptual framework for this research. Data collected from interviews of 20 acute care nurses were analyzed using qualitative content analysis. The emergent categories included Awareness of Patient Status, Experience and Decision Making, Following Established Routine, Time Pressure, Teamwork/Support From Staff, Goals, Education, Resources, Patient Education, Consideration of Options to Meet Goals, and Nursing Roles. Acute care nurses incorporated a wide variety of complex factors when decision making. This study sought to improve understanding of the factors nurses found important to their decision making for the potential development of improved decision support in the electronic health record.

Recognition and assessment of resident' deterioration in the nursing home setting: A critical ethnography

AIMS AND OBJECTIVES

To explore the recognition and assessment of resident deterioration in the nursing home setting.

BACKGROUND

There is a dearth of research exploring how nurses and personal-care-assistants manage a deteriorating nursing home resident.

DESIGN

Critical ethnography.

METHODS

Observation and semi-structured interviews with 66 participants (general medical practitioners, nurses, personal-care-assistants, residents and family members) in two Australian nursing homes. The study has been reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.

RESULTS

The value of nursing assessment is poorly recognised in the nursing home setting. A lack of clarity regarding the importance of nursing assessments associated with resident care has contributed to a decreasing presence of registered nurses and an increasing reliance on personal-care-assistants who had inadequate skills and knowledge to recognise signs of deterioration. Registered nurses experienced limited organisational support for autonomous decision-making and were often expected to undertake protocol-driven decisions that contributed to potentially avoidable hospital transfers.

CONCLUSIONS

Nurses need to demonstrate the importance of assessment, in association with day-to-day resident care and demand standardised, regulated, educational preparation of an appropriate workforce who are competent in undertaking this role. Workforce structures that enhance familiarity between nursing home staff and residents could result in improved resident outcomes. The value of nursing assessment, in guiding decisions at the point of resident deterioration, warrants further consideration.

Encouraging interprofessional collaboration: The effects of clinical protocols

AIMS AND OBJECTIVES

To consider the characteristics of protocol documents themselves as a factor influencing the nature of care delivery and their potential to facilitate greater interprofessional collaboration.

BACKGROUND

Healthcare guidelines and clinical protocols provide important guidance and direction to health professionals in their delivery of care. By detailing requirements and actions to be taken in specified circumstances or contexts, these documents may facilitate a broadening of the pool of people able to deliver care.

DESIGN

Critical reading of four clinical protocols representing the range of protocol types in use was carried out to consider the extent to which the documentation of guidelines and protocols and the documents themselves might be considered as vehicles for increased collaboration in health care.

METHODS

A "close reading" rubric was developed directing the researcher to look for evidence in each protocol of the following: authorship, person or group responsible for the protocol's development; stated document purpose; target readers, either stated or implied; the particular subjects, the document names and the objects created by them such as care pathways; the use of specific terminology and imagery, the documents' form and structure; and evidence of intertextuality referring to other documents, for example legislation or policy statements. Tabulation of the coding analysis is presented.

RESULTS

Nurses were the only professional group named in the documents as assignees or subjects. "Patients" and "care" are the objects created, and the scientific-biomedical discourse with its associated procedural language was dominant.

CONCLUSIONS

Many protocols have been developed to standardise practice and increase the effectiveness of teamwork. They may, however, constrain collaboration in healthcare settings because they diminish a nursing "voice" and create the expectation that nurses alone work across the spectrum of protocols.

RELEVANCE TO CLINICAL PRACTICE

An unintended consequence of the global use of clinical protocols and guidelines to support safe and efficient healthcare delivery may be to reduce interprofessional collaboration.

Woman-centered care 2.0: Bringing the concept into focus

INTRODUCTION

Woman-centered care has become a midwifery concept with implied meaning. In this paper we aim to provide a clear conceptual foundation of woman-centered care for midwifery science and practice.

METHODS

An advanced concept analysis was undertaken. At the outset, a systematic search of the literature was conducted in PubMed, OVID and EBSCO. This was followed by an assessment of maturity of the retrieved data. Principle-based evaluation was done to reveal epistemological, pragmatic, linguistic and logic principles, that attribute to the concept. Summative conclusions of each respective component and a detailed analysis of conceptual components (antecedents, attributes, outcomes, boundaries) resulted in a definition of woman-centered care.

RESULTS

Eight studies were selected for analyses. In midwifery, woman-centered care has both a philosophical and a pragmatic meaning. There is strong emphasis on the woman-midwife relationship during the childbearing period. The concept demonstrates a dual and equal focus on physical parameters of pregnancy and birth, and on humanistic dimensions in an interpersonal context. The concept is epistemological, dynamic and multidimensional. The results reveal the concept’s boundaries and fluctuations regarding equity and control. The role of the unborn child is not incorporated in the concept.

CONCLUSION

An in-depth understanding and a broad conceptual foundation of womancentered care has evolved. Now, the concept is ready for research and educational purposes as well as for practical utility.

Decision-making in nursing practice: An integrative literature review

AIMS AND OBJECTIVES

To identify and summarise factors and processes related to registered nurses' patient care decision-making in medical-surgical environments. A secondary goal of this literature review was to determine whether medical-surgical decision-making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM).

BACKGROUND

Decision-making in acute care nursing requires an evaluation of many complex factors. While decision-making research in acute care nursing is prevalent, errors in decision-making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision-making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision-making.

DESIGN

PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data.

RESULTS

Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision-making; education; understanding patient status; situation awareness; and autonomy.

CONCLUSIONS

Acute care nurses employ a variety of decision-making factors and processes and informally identify experienced nurses to be important resources for decision-making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision-making nursing research.

RELEVANCE TO CLINICAL PRACTICE

Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision-making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses' decision-making for enhanced patient outcomes.

Variation in Gentamicin Dosing and Monitoring in Pediatric Units across New South Wales

INTRODUCTION

Gentamicin is an aminoglycoside antibiotic with broad-spectrum bactericidal activity and is widely used in pediatric units to treat infection with susceptible organisms. This study aimed to describe the dosage regimen for gentamicin and approach to its therapeutic drug monitoring (TDM) among the pediatric units within the state of New South Wales (NSW).

METHODS

A questionnaire was sent electronically to representatives of 40 pediatric units in NSW, requesting details of each unit's gentamicin dosing and TDM policy.

RESULTS

A total of 35 units responded to the survey. The majority (63%) of the units used a dose of 7.5 mg/kg of gentamicin in patients with normal renal function. More than half of the units (54%) did not have a local gentamicin dosing protocol and relied on other sources for dosing regimens. Dosing responses varied from a dose of 6 mg/kg once daily for patients more than 10 years of age to 7 mg/kg once daily on day 1, followed by 5 mg/kg once daily for patients over 10 years of age. For TDM of gentamicin, 63% of units indicated use of trough levels and 23% units used the Hartford Nomogram.

CONCLUSIONS

A significant variation exists in clinical practice among pediatric units in NSW on gentamicin dosing and TDM guidelines. There is an urgent need for collaboration among nursing, medical, and pharmacy experts to achieve consensus to develop and adopt statewide uniform guidelines on gentamicin dosing and TDM.

What are health professionals' intentions toward using research and products of research in clinical practice? A systematic review and narrative synthesis

AIM

To explore health professionals' intentional behaviour and what determines their intention to use products of research in clinical practice.

BACKGROUND

Trying to get research and products of research into clinical practice is an enduring problem. A clearer picture is emerging as to how individual practitioners respond toward practical problems of changing clinical practice, but this does not include health professionals' intentions to use products of research and what influences their intentions.

DESIGN

Systematic Review and Narrative Synthesis.

DATA SOURCES

Five databases were searched systematically. This included BNI, HMIC, Psych INFO, CINHAL and MEDLINE; articles published in the English language only were included.

REVIEW METHODS

PRISMA guidelines were used as a framework for structuring the review and methods of narrative synthesis to analyse study outcomes.

RESULTS

Eighteen studies matched the final inclusion criteria. All studies used questionnaires to measure intention. Most studies involved Nurses or Physicians. Nurses' intentions were mostly influenced by their perceived ability to use guidelines in their practice. Physicians' intentions were often influenced by their perceptions of the usefulness and relevance of the guideline and peer pressure amongst the professional group. Practice habits, when added to intentional models were also predictive of intentional behaviour. In studies that compared intentions with behaviour, the level of intention often did not match self-report or actual behaviour.

An exploration of the correlates of nurse practitioners' clinical decision-making abilities

AIMS AND OBJECTIVES

This study investigated nurse practitioners' clinical decision-making abilities and the factors that affect these abilities.

BACKGROUND

Nurse practitioners play an important role in clinical care decision-making; however, studies exploring the factors that affect their decision-making abilities are lacking.

DESIGN

A cross-sectional descriptive survey was employed.

METHODS

A purposive sample of 197 nurse practitioners was recruited from a medical centre in central Taiwan. Structured questionnaires consisting of the Knowledge Readiness Scale, the Critical Thinking Disposition Inventory and the Clinical Decision-Making Model Inventory were used to collect data.

RESULTS

The intuitive-analytical type was the most commonly used decision-making model, and the intuitive type was the least frequently used model. The decision-making model used was significantly related to the nurse practitioners' work unit. Significant differences were noted between the nurse practitioners' clinical decision-making models and their critical thinking dispositions (openness and empathy). The nurse practitioners' years of work experience, work unit, professional knowledge and critical thinking disposition (openness and empathy as well as holistic and reflective dispositions) predicted the nurse practitioners' analytical decision-making scores. Age, years of nurse practitioner work experience, work unit and critical thinking disposition (holistic and reflective) predicted the nurse practitioners' intuitive decision-making scores.

CONCLUSIONS

This study contributes to the topic of clinical decision-making by describing various types of nurse practitioner decision-making. The factors associated with analytic and intuitive decision-making scores were identified. These findings might be beneficial when planning continuing education programmes to enhance the clinical decision-making abilities of nurse practitioners.

RELEVANCE TO CLINICAL PRACTICE

The study results showed that nurse practitioners demonstrated various clinical decision-making types across different work units. Consideration of nurse practitioners' knowledge readiness and their specific needs while planning on-duty education programmes is necessary.

Evidence-Based Practice in the United States: Challenges, Progress, and Future Directions

Scientific literature demonstrates that advances in evidence-based nursing have improved systems of care and women's health outcomes. Experts agree that nurses worldwide can play a key role in building such evidence and working with interdisciplinary health care teams and systems to accelerate its implementation.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Systematic implementation of evidence-based practice in a clinical nursing setting: a participatory action research project

AIMS AND OBJECTIVES

To describe the process of implementing evidence-based practice in a clinical nursing setting.

BACKGROUND

Evidence-based practice has become a major issue in nursing, it is insufficiently integrated into daily practice and its implementation is complex.

DESIGN

Participatory action research.

METHODS

The main participants were nurses working in a lung unit of a rural hospital. A multi-method process of data collection was used during the observing, reflecting, planning and acting phases. Data were continuously gathered during a 24-month period from 2010 to 2012, and analysed using an interpretive constant comparative approach. Patients were consulted to incorporate their perspective.

RESULTS

A best-practice mode of working was prevalent on the ward. The main barriers to the implementation of evidence-based practice were that nurses had little knowledge of evidence-based practice and a rather negative attitude towards it, and that their English reading proficiency was poor. The main facilitators were that nurses wanted to deliver high-quality care and were enthusiastic and open to innovation. Implementation strategies included a tailored interactive outreach training and the development and implementation of an evidence-based discharge protocol. The academic model of evidence-based practice was adapted. Nurses worked according to the evidence-based practice discharge protocol but barely recorded their activities. Nurses favourably evaluated the participatory action research process.

CONCLUSIONS

Action research provides an opportunity to empower nurses and to tailor evidence-based practice to the practice context. Applying and implementing evidence-based practice is difficult for front-line nurses with limited evidence-based practice competencies.

RELEVANCE TO CLINICAL PRACTICE

Adaptation of the academic model of evidence-based practice to a more pragmatic approach seems necessary to introduce evidence-based practice into clinical practice. The use of scientific evidence can be facilitated by using pre-appraised evidence. For clinical practice, it seems relevant to integrate scientific evidence with clinical expertise and patient values in nurses' clinical decision-making at the individual patient level.

Understanding current intensive care unit nursing handover practices

Clinical handover is critical to clinical decision-making and the provision of safe, high quality, continuing care. Incomplete and inaccurate transfer of information can result in poor outcomes. To assess the content and completeness of the intensive care unit nursing shift-to-shift handover, a prospective, observational study design was used. A semistructured observation sheet based on 10 key principles for handover was used to overtly observe 20 bedside nursing handovers. Descriptive statistics were used to analyse the data. Overall, the content handed over was consistent with the key principles of clinical handover. However, there were some key principles that were minimally addressed or absent from clinical handovers. Development and implementation of a handover tool specific to intensive care will assist in ensuring that all key principles are adhered to so that adverse events associated with miscommunication during clinical handover are reduced and a high standard of care is maintained.

The place of standardisation in home care practice: an ethnographic study

AIMS AND OBJECTIVES

To explore the benefits and shortcomings of using standardised work methods in home care nursing.

BACKGROUND

Health care is increasingly shaped by the use of standardised work methods. This trend is reflected in the use of management tools aimed at monitoring service quality and efficiency, as well as in the evidence-based movement that has led to a shift in focus from the practitioner to the knowledge found in guidelines and clinical protocols. This study addressed the impact of this development on home care services.

DESIGN

This is an ethnographic study involving fieldwork in home care nursing in Iceland.

METHODS

The study took place in one neighbourhood in an urban area in Iceland in 2010. Members of five of six home care nursing teams agreed to participate. Team leaders were observed during visits to older person's homes and at team and interdisciplinary meetings. Semi-structured interviews were conducted with the team leaders and 15 older persons.

RESULTS

The results were presented as three themes: For it all to hang together, which referred to attempts on behalf of the team leaders to coordinate complex services and assistance for the benefit of each patient; Working with more advanced cases, which reflected the uptake of standardised methods to address health matters locally; and Being heard, which reflects the politics of using standardised methods.

CONCLUSIONS

Standardised work methods can be helpful and are welcomed by home care nurses as long as they can also use their own discretion and draw on other forms of knowledge when needed.

RELEVANCE TO CLINICAL PRACTICE

This study brought out the importance of flexibility in home care practice. Standardised work methods are welcomed and seen as helpful as long as they can be used based on the discretion of the practitioner.

Decision Making in Stepped Care: How Do Therapists Decide Whether to Prolong Treatment or Not?

Background: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to “step up” patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. Aims: To investigate factors that influence psychological therapists’ decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. Method: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of “holding” non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. Results: A 4-factor solution indicated that clinicians’ decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. Conclusions: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

Initiating artificial nutrition support: a clinical judgement analysis

BACKGROUND

Variations in the practice of artificial nutrition are partly a result of the judgements of clinicians. Little is known about these judgements, the decision processes used or the quality of the decisions that arise. The methodology of clinical judgement analysis describes and explains judgemental differences between clinicians and offers a window into why clinician choices sometimes fail to correspond with current best practice guidelines.

METHODS

A clinical judgement analysis with 27 clinicians using two judgement tasks was carried out. Clinicians expressed their 'likelihood of feeding' and 'whether or not they would initiate artificial nutrition support' in response to 54 patient scenarios. Measures of agreement between clinicians, the degree of linear reasoning employed, their judgemental consistency and concordance with National Institute for Health and Clinical Excellence (NICE) guidelines were assessed.

RESULTS

Clinicians' judgements varied substantially both in the amount of information employed and the weighting given to information. Clinicians had only moderate agreement with NICE recommendations and overestimated the need for artificial nutrition support. Suboptimal judgements were consistently applied by clinicians. When clinicians reasoned in more linear ways, their judgements and decisions improved.

CONCLUSIONS

Overestimating the need for artificial nutritional support may inflate health service costs and increase risks for patients unnecessarily. A better understanding by clinicians of the information needed (as well as how to use it) for artificial nutrition support initiation may help improve clinical decision-making.

Opioid replacement therapy: a wait unmanaged

There has been a rapid increase in members of the Australian population using opioids in recent years. The flow-on effect has been an increase in demand for treatments, particularly opioid replacement therapy (ORT), but the availability of treatments has not increased. This has frequently resulted in delays before treatment can be commenced. Outcomes could improve if health-care professionals had clearer guidelines on how to prioritize access to ORT. This review investigates the triage of consumers in ORT within Australia. Information on triage in ORT was not available, and an understanding of how consumer needs are managed when they present for ORT triage was not identified. In the absence of research to guide this practice, the body of evidence regarding ORT treatment access is weighted on government policies. Triage, as applied in general health and mental health-care service delivery, was reviewed to consider the components of triage and how these might pertain to triage in ORT. Failure to facilitate the needs of consumers accessing ORT can result in further harm to consumers and increased social and financial costs for society. Research is required to investigate how this issue is currently being managed and to lead the way for needed improvements in service delivery.

Information-seeking behaviour of nurses: where is information sought and what processes are followed?

AIM

This paper is a report of a study on how nurses inform their decision-making in the workplace.

BACKGROUND

Despite the growing availability of research evidence, nurses have been slow to adopt it into their daily decision-making.

METHOD

The study was undertaken in Ireland between 2006 and 2007 using a sequential mixed methods approach. In phase 1, the views of a quota sample of 29 nurses were explored using semi-structured interviews incorporating vignettes. Phase 2 involved the design and dissemination of a survey to a disproportionate stratified random sample of 1356 nurses. The response rate was 29%.

FINDINGS

In decision-making, nurses accessed other people, especially nursing colleagues, the most frequently. Sources that provided prepackaged information such as guidelines were favoured over sources that provided access to original research. The process of information-seeking for routine and non-routine decisions was different. Nurses making routine decisions relied mostly on their experience and an assessment of the patient. In non-routine decision-making, participants experienced more uncertainty about their decisions. Accordingly, sources of information used were more varied and the information-seeking process more extensive. The study highlighted the complexities of establishing whether information used in decision-making is research based or not.

CONCLUSION

Routine practices should be reviewed and updated regularly through organizational mandates, as nurses do not generally question them. Research information to inform non-routine decision-making must be easily available to nurses in their workplace, as information searches generally prioritize finding enough, rather than the best, information to make a decision.

Paediatric catheterisation: exploring and understanding children's nurses' perceptions and practice in an acute setting

AIMS AND OBJECTIVES

This research study explored the factors which influenced the ability of children's nurses to urethrally catheterise children in their care.

BACKGROUND

There is currently limited evidence to inform the clinical skills training of children's nurses and the impact of competencies and other educational documents on practice. The project aimed to use data to inform local service provision and the design and development of future training programmes in an acute paediatric hospital.

DESIGN

A mixed method study using questionnaires and focus groups.

METHODS

Data were obtained through two focus groups (n = 10) and questionnaires (n = 34, response rate 88%) with trained children's nurses to explore the influencing factors on their ability to conduct this clinical skill.

RESULTS

The children's nurses discussed that barriers to being competent and confident to catheterise included a lack of exposure to the clinical skill, increasing awareness of the role of competencies and litigation and the presence of specialist roles. Current catheterisation training was evaluated positively with most nurses stating their knowledge and clinical skills had increased; despite this only 55% (n = 18) identified that would feel able to catheterise a child in their care.

CONCLUSIONS

Comprehensive training of all children's nurses in an acute care setting may not provide a workforce, which is competent and confident in urethrally catheterising children, and resources for training may be more appropriately deployed to ensure the optimum care of children and families.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the difficulties encountered for clinical nurses to remain competent in infrequently used clinical skills. This has relevance to the challenges of providing a multi-skilled workforce in children's nursing.

A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework

Background

The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations.

Methods

We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus.

Results

Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.'

Conclusions

While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.