Building qualitative study design using nursing's disciplinary epistemology

AIM

To discuss the implications of drawing on core nursing knowledge as theoretical scaffolding for qualitative nursing enquiry.

BACKGROUND

Although nurse scholars have been using qualitative methods for decades, much of their methodological direction derives from conventional approaches developed for answering questions in the social sciences. The quality of available knowledge to inform practice can be enhanced through the selection of study design options informed by an appreciation for the nature of nursing knowledge.

DESIGN

Discussion paper.

DATA SOURCES

Drawing on the body of extant literature dealing with nursing's theoretical and qualitative research traditions, we consider contextual factors that have shaped the application of qualitative research approaches in nursing, including prior attempts to align method with the structure and form of disciplinary knowledge. On this basis, we critically reflect on design considerations that would follow logically from core features associated with a nursing epistemology.

IMPLICATIONS FOR NURSING

The substantive knowledge used by nurses to inform their practice includes both aspects developed at the level of the general and also that which pertains to application in the unique context of the particular. It must be contextually relevant to a fluid and dynamic healthcare environment and adaptable to distinctive patient conditions. Finally, it must align with nursing's moral mandate and action imperative.

CONCLUSION

Qualitative research design components informed by nursing's disciplinary epistemology will help ensure a logical line of reasoning in our enquiries that remains true to the nature and structure of practice knowledge.

Surveys of Cancer Patients and Cancer Health Care Providers Regarding Complementary Therapy Use, Communication, and Information Needs

BACKGROUND

Complementary therapies (CTs) are increasingly utilized by cancer patients. Nonetheless, patients report insufficient support from health care practitioners (HCPs) and there is a general lack of patient-practitioner communication about CT use. Best care practices suggest that HCPs should address the needs of patients, including CT use. This study examined current practices of patients and HCPs as well as their interactions relating to CTs.

METHODS

A total of 481 cancer outpatients and 100 HCPs completed questionnaires. Patient questions addressed CT use and information needs; HCP questions addressed knowledge, opinions and beliefs about complementary and alternative medicine. Patient-practitioner communication around CT was also examined.

RESULTS

47% of patients reported using CTs since diagnosis. Many commenced CT use to improve quality of life (65%) based on recommendations from family or friends. Patients acknowledged the need for trusted sources of information and would attend a hospital-based education program (72%). HCPs reported limited training about CTs but most (90%) expressed interested in receiving more training. The majority of HCPs (>80%) reported limited knowledge about the role of CTs in cancer care or evidence to support CT use. Questions about communication and interactions revealed that 80% of patients reported not having had an HCP speak to them about CTs. However, 63% of HCPs reported addressing CT use.

CONCLUSION

Results demonstrate a need for improved CT education and training for patients and HCPs. increasing HCP knowledge and clinical skills will ensure patients' information needs about CTs are acknowledged and attended to, thereby providing safer and comprehensive cancer care.

Decision making related to complementary therapies: a process of regaining control

The process by which women with breast cancer make decisions related to using complementary therapies was investigated using grounded theory. Open-ended interviews were conducted with 16 women receiving orthodox treatment from across the breast cancer trajectory and who used a wide range of complementary therapies. Constant comparative analysis revealed that decision making regarding complementary therapies involved three interconnected sequential phases: (1) Getting something in place: covering all the bases, (2) hand-picking complementary therapies that fit: getting a personalized regimen in place and (3) living with the security of complementary therapies: fine-tuning a regimen to live with. Factors that influenced the decision-making process, both positively and negatively, were identified. Decision making related to the use of complementary therapies was perceived as a means of regaining control during experiences of uncertainty associated with breast cancer; the outcome of which was the maintenance of hope. Implications for supporting women's decision-making efforts regarding complementary therapies are presented.

Evaluation of Online Learning Modules for Improving Physical Activity Counseling Skills, Practices, and Knowledge of Oncology Nurses

PURPOSE/OBJECTIVES

To examine the effectiveness of online learning modules for improving physical activity counseling practices among oncology nurses. 
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DESIGN

Randomized, controlled trial.
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SETTING

Online.
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SAMPLE

54 oncology nurses.
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METHODS

Oncology nurses were randomly assigned to the learning modules group or control group. The learning modules group completed six online learning modules and quizzes focused on physical activity for cancer survivors, general physical activity principles, and motivational interviewing.
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MAIN RESEARCH VARIABLES

Percentage of cancer survivors counseled, self-efficacy for physical activity counseling, knowledge of physical activity, and perceived barriers and benefits of physical activity counseling.
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FINDINGS

Analyses of covariance revealed no significant difference between the learning modules and control groups in the percentage of cancer survivors that oncology nurses counseled. Significant differences were found in self-efficacy for physical activity counseling and perceived barriers to physical activity counseling at postintervention. 
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CONCLUSIONS

The online learning intervention tested in this study improved some parameters of physical activity counseling but did not increase the percentage of cancer survivors that oncology nurses counseled. Additional pilot work is needed to refine the intervention.
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IMPLICATIONS FOR NURSING

This study suggests the potential utility of an evidence-based online learning strategy for oncology nurses that includes information on physical activity and its benefits in cancer survivorship. The findings offer a framework on how to implement physical activity counseling skills in oncology nursing practice.

Implementation of Symptom Protocols for Nurses Providing Telephone-Based Cancer Symptom Management: A Comparative Case Study

Background

The pan‐Canadian Oncology Symptom Triage and Remote Support (COSTaRS) team developed 13 evidence‐informed protocols for symptom management.

Aim

To build an effective and sustainable approach for implementing the COSTaRS protocols for nurses providing telephone‐based symptom support to cancer patients.

Methods

A comparative case study was guided by the Knowledge to Action Framework. Three cases were created for three Canadian oncology programs that have nurses providing telephone support. Teams of researchers and knowledge users: (a) assessed barriers and facilitators influencing protocol use, (b) adapted protocols for local use, (c) intervened to address barriers, (d) monitored use, and (e) assessed barriers and facilitators influencing sustained use. Analysis was within and across cases.

Results

At baseline, >85% nurses rated protocols positively but barriers were identified (64‐80% needed training). Patients and families identified similar barriers and thought protocols would enhance consistency among nurses teaching self‐management. Twenty‐two COSTaRS workshops reached 85% to 97% of targeted nurses (N = 119). Nurses felt more confident with symptom management and using the COSTaRS protocols (p < .01). Protocol adaptations addressed barriers (e.g., health records approval, creating pocket versions, distributing with telephone messages). Chart audits revealed that protocols used were documented for 11% to 47% of patient calls. Sustained use requires organizational alignment and ongoing leadership support.

Linking Evidence to Action

Protocol uptake was similar to trials that have evaluated tailored interventions to improve professional practice by overcoming identified barriers. Collaborating with knowledge users facilitated interpretation of findings, aided protocol adaptation, and supported implementation. Protocol implementation in nursing requires a tailored approach. A multifaceted intervention approach increased nurses’ use of evidence‐informed protocols during telephone calls with patients about symptoms. Training and other interventions improved nurses’ confidence with using COSTaRS protocols and their uptake was evident in some documented telephone calls. Protocols could be adapted for use by patients and nurses globally.

Will designated patient navigators fix the problem? Oncology nursing in transition

With increasing concern for equity and access across the cancer care system, we have seen expanding enthusiasm for various forms of designated patient "navigators" to facilitate coordination. While the intention is laudable, many of the popular implementation strategies risk accentuating strain upon the system and further complicating the coordination problem. These authors claim the motivation underlying the navigator movement can be reframed as an emerging recognition of the value of nursing work when it is optimally positioned to support patients, as they experience the cancer care system. This paper calls on Canadian oncology nurses to critically challenge navigation strategies, and adopt only those consistent with the significant reforms required to ensure a cancer care system so effective that external navigators are no longer necessary.

Interprofessional education about patient decision support in specialty care

Specialty care involves services provided by health professionals who focus on treating diseases affecting one body system. In contrast to primary care - aimed at providing continuous, comprehensive care - specialty care often involves intermittent episodes of care focused around specific medical conditions. In addition, it typically includes multiple providers who have unique areas of expertise that are important in supporting patients' care. Interprofessional care involves multiple professionals from different disciplines collaborating to provide an integrated approach to patient care. For patients to experience continuity of care across interprofessional providers, providers need to communicate and maintain a shared sense of responsibility to their patients. In this article, we describe challenges inherent in providing interprofessional patient decision support in specialty care. We propose ways for providers to engage in interprofessional decision support and discuss promising approaches to teaching an interprofessional decision support to specialty care providers. Additional evaluation and empirical research are required before further recommendations can be made about education for interprofessional decision support in specialty care.

Research priorities for the pan-Canadian Oncology Symptom Triage and Remote Support practice guides: a modified nominal group consensus

Introduction

The pan-Canadian Oncology Symptom Triage and Remote Support (costars) team is studying how to improve the quality and consistency of cancer symptom management.

Methods

A 1-day invitational meeting was held 24 October 2017 in Ottawa, Ontario, to review the current evidence from costars projects and to establish research priorities for a future largescale implementation study. The meeting included 36 participants who were clinicians from adult oncology, pediatric oncology, and homecare; policymakers from national, provincial, and regional organizations; researchers; and a patient. Half the day involved summarizing evidence from four costars studies and experiences with implementing the costars symptom practice guides. The second half of the day used a modified nominal group technique to generate research questions within small groups, presentation of research questions to all participants, and two rounds of voting to reach consensus on research priorities.

Results

Participants proposed 4 research categories:■ User-centred augmentation to enhance usability (for example, designing a mobile costars solution)■ Outcome measurement (for example, determining key competencies for clinicians)■ Regular renewal of costars to keep pace with evolving evidence (for example, updates for novel therapies)■ Integration into clinical practice (for example, meaningful engagement of patients and caregivers in study design).

Conclusions

Across categories, the top 3 priorities were effect on health services use, competency development, and a mobile costars solution. Future research will address identified priorities, reflecting the needs and perspectives of diverse stakeholders. Stakeholder collaboration will continue to guide our approach to operationalizing this priority research agenda.

Global Perspectives on Cancer Health Disparities: Impact, Utility, and Implications for Cancer Nursing

This paper examines cancer health disparities and contributing factors at national, regional, and international levels. The authors all live in different countries and regions with different health-care systems and practices. Despite the shared cancer nursing perspective, each country or global region approaches cancer disparities differently. With globalization the world is becoming smaller, and in turn becoming interconnected and interdependent. This article focuses on cancer health disparities and global cancer nursing, exemplifying these concepts about the impact and implications of person-centered care.

Managing Symptoms During Cancer Treatments: Barriers and Facilitators to Home Care Nurses Using Symptom Practice Guides

Nurses are instrumental in helping clients safely manage at home and triage potentially life-threatening symptoms from cancer. The purpose of this study was to assess factors influencing home care nurses’ use of 15 evidence-informed symptom practice guides for providing telephone or in-home nursing services to clients with cancer. A mixed-methods descriptive study was guided by the Knowledge-to-Action Framework. All six nursing agencies within a regional home care authority participated. Data collection included retrospective audit of symptom management in 50 patient records, 14 interviews, and barriers survey from 150 of 243 (61.7%) registered nurses and registered practical nurses providing cancer symptom support in home care. Chart audit revealed more than 80% of clients were on chemotherapy and common symptoms were nausea/vomiting (44%), constipation (32%), fatigue (32%), loss of appetite (32%), and pain (20%). Nurses had positive intentions ( M = 5.4 out of 7; SD = 1.3) and felt capable of using the symptom practice guides ( M = 5.4; SD = 1.0), held strong beliefs about the consequences ( M = 5.8; SD = 1.1) and moral norms of using them ( M = 5.7; SD = 1.1), and identified neutral to low social influence ( M = 3.0; SD = 1.6). Common barriers were inadequate time in practice, learning curve, need to integrate into documentation, and competing system changes. Common facilitators were being comprehensive, an evidence-based resource for use in practice, and having consistent symptom management guides across settings. Overall, the symptom guides were well received by the nurses. Interventions nurses identified to overcome barriers were education, clear organizational mandate for implementation, and integration with documentation.

Implementing Practice Guides to Improve Cancer Symptom Management in Homecare: A Comparative Case Study

Symptoms experienced by clients with cancer often occur at home and can become life-threatening, posing serious safety concerns. This study evaluated implementation of evidence-informed symptom practice guides to enhance quality of cancer symptom support by homecare nurses. A comparative case study was conducted using the Knowledge to Action Framework. Case were created for each of six agencies providing nursing care within a regional homecare authority. A team of researchers and knowledge users (e.g., managers, educators, family member): (1) assessed factors influencing practice guide use (survey, interviews) at six agencies, (2) adapted 15 practice guides for local use, (3) implemented with interventions to address barriers, and (4) monitored use. Analysis was within and across cases. Of six nursing agencies, one withdrew and five participated. In the baseline survey, 51% of nurses reported using guidelines but nurses did not describe using them in their current practice during the interviews. To overcome barriers, 489 nurses in five agencies were trained in how to use the practice guides, principles were established for documenting cancer symptom management, and practice guides were made available in various formats. Success with implementation varied across the participating cases. Chart audits conducted in three agencies revealed evidence of practice guide use for 16%, 22%, and 70% client visits, respectively. Implementation of evidence-informed practice guides in nursing required an approach tailored for each agency. Training, integration in documentation, and easy access to practice guides increased use for some nurses but ongoing support and reinforcement from nurse leaders is required.