Alba DiCenso

Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials

Abstract Objective: To review the effectiveness of primary prevention strategies aimed at delaying sexual intercourse, improving use of birth control, and reducing incidence of unintended pregnancy in adolescents. Data sources: 12 electronic bibliographic databases, 10 key journals, citations of relevant articles, and contact with authors. Study selection: 26 trials described in 22 published and unpublished reports that randomised adolescents to an intervention or a control group (alternate intervention or nothing). Data extraction: Two independent reviewers assessed methodological quality and abstracted data. Data synthesis: The interventions did not delay initiation of sexual intercourse in young women (pooled odds ratio 1.12; 95% confidence interval 0.96 to 1.30) or young men (0.99; 0.84 to 1.16); did not improve use of birth control by young women at every intercourse (0.95; 0.69 to 1.30) or at last intercourse (1.05; 0.50 to 2.19) or by young men at every intercourse (0.90; 0.70 to 1.16) or at last intercourse (1.25; 0.99 to 1.59); and did not reduce pregnancy rates in young women (1.04; 0.78 to 1.40). Four abstinence programmes and one school based sex education programme were associated with an increase in number of pregnancies among partners of young male participants (1.54; 1.03 to 2.29). There were significantly fewer pregnancies in young women who received a multifaceted programme (0.41; 0.20 to 0.83), though baseline differences in this study favoured the intervention. Conclusions: Primary prevention strategies evaluated to date do not delay the initiation of sexual intercourse, improve use of birth control among young men and women, or reduce the number of pregnancies in young women.

The Use of Triangulation in Qualitative Research

Triangulation refers to the use of multiple methods or data sources in qualitative research to develop a comprehensive understanding of phenomena (Patton, 1999). Triangulation also has been viewed as a qualitative research strategy to test validity through the convergence of information from different sources. Denzin (1978) and Patton (1999) identified four types of triangulation: (a) method triangulation, (b) investigator triangulation, (c) theory triangulation, and (d) data source triangulation. The current article will present the four types of triangulation followed by a discussion of the use of focus groups (FGs) and in-depth individual (IDI) interviews as an example of data source triangulation in qualitative inquiry.

Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model

The application of high-quality evidence to clinical decision making requires that we know how to access that evidence. In years past, this meant literature searching know-how and application of critical appraisal skills to separate lower from higher quality clinical studies. However, over the past decade, many practical resources have been created to facilitate ready access to high-quality research. We call these resources “pre-appraised” because they have undergone a filtering process to include only those studies that are of higher quality and they are regularly updated so that the evidence we access through these resources is current. To facilitate use of the many pre-appraised resources, Haynes proposed a “4S” model,1 which he then refined into a “5S” model.2 The 5S model begins with original single studies at the foundation, and building up from these are syntheses (systematic reviews such as Cochrane reviews), synopses (succinct descriptions of selected individual studies or systematic reviews, such as those found in the evidence-based journals), summaries , which integrate best available evidence from the lower layers to develop practice guidelines based on a full range of evidence (eg, Clinical Evidence, National Guidelines Clearinghouse), and at the peak of the model, systems, in which the individual patient’s characteristics are automatically linked to the current best evidence that matches the patient’s specific circumstances and the clinician is provided with key aspects of management (e.g., computerised decision support systems).2 When we described the 5S model to colleagues at home and abroad, some queried whether a synopsis of a single study and a synopsis of a systematic review are equivalent as indicated by their single appearance in the model. In the hierarchy of evidence, a systematic review bests a single study, so we are adding a layer to the model to distinguish the 2 types of synopses. …

Randomized trials versus observational studies in adolescent pregnancy prevention

The objective of this study is to compare the results of randomized trials and observational studies of interventions to prevent adolescent pregnancy. We identified published and unpublished reports through computerized searches of CATLINE, CINAHL, CONFERENCE PAPERS INDEX, DISSERTATION ABSTRACTS ONLINE, EMBASE, ERIC, MEDLINE, NTIS, POPLINE, PsycINFO, and SOCIOLOGICAL ABSTRACTS; manual searches of eight relevant journals; reference lists from primary articles; and contact with content experts. We included randomized trials and observational studies that evaluated the impact of primary prevention interventions including sex education classes, school-based clinics, free-standing clinics, physician/nurse practitioner practice-based service, improved access, and community-based programs on four outcomes: sexual intercourse, birth control use, responsible sexual behavior, or pregnancy in adolescents. One investigator abstracted the data and a second conducted a detailed review of the abstraction. We identified 13 randomized trials and 17 observational studies. We generated estimates of the impact of the interventions separately for males and females for all four outcomes for both observational studies and randomized trials. For six of the eight outcomes the summary odds ratios for the observational studies showed a significant intervention benefit (P<0.05) while the randomized trials did not show a benefit for any outcome in either females or males. The difference between the results of the observational studies and randomized trials was statistically significant in two of the eight outcomes (P<0.05 for initiation of intercourse and pregnancy in females). Observational studies yield systematically greater estimates of treatment effects than randomized trials of adolescent pregnancy prevention interventions. Public policy or individual patient treatment decisions should be based on observational studies only when randomized trials are unavailable and only with careful consideration of possible biases.

Resources to Enhance Evidence-based Nursing Practice

Evidence-based practice means integrating the best available research evidence with information about patient preferences, clinician skill level, and available resources to make decisions about patient care. Barriers to the use of research-based evidence occur when time, access to journal articles, search skills, critical appraisal skills, and understanding of the language used in research are lacking. Resources are available to overcome these barriers and support an evidence-based nursing practice. This article highlights available resources and describes strategies that nurses can use to develop and sustain an evidence-based nursing practice.

Teaching nursing students evidence-based nursing.

Nurse educators face many challenges in the current healthcare environment. Educational methods, philosophies, and the content of curricula need to be reexamined to meet the needs of professional nurses who will practice in the next millennium. Evidence-based nursing is one approach that may enable future healthcare providers to manage the explosion of new literature and technology and ultimately may result in improved patient outcomes. The authors provide an introduction to evidence-based nursing as well as a description of the process in two separate undergraduate nursing programs.

Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review.

AIM To review the literature about the Canadian experience with nurse practitioner role implementation and identify influencing factors. BACKGROUND Although nurse practitioners have been in existence for more than 40 years, their integration into healthcare systems has been challenging. While frameworks exist to guide implementation of these roles, clear identification of factors influencing role implementation may inform best practices. Given that Canada has witnessed considerable growth in nurse practitioner positions in the past decade, an exploration of its experience with role implementation is timely. DATA SOURCES A review of Canadian literature from 1997 to 2010 was conducted. Electronic databases including CINAHL, Cochrane Database of Systematic Reviews, Health Source: Nursing Academic Edition, Medline, Social Science Index, PubMed, Web of Science and PsychINFO and government and professional organization websites were searched. METHODS An integrative review was performed guided by Whittemore and Knafls method. RESULTS Ten published studies and two provincial reports were included. Numerous facilitators and barriers to implementation were identified and analysed for themes. Three concepts influencing implementation emerged: involvement, acceptance and intention. Involvement is defined as stakeholders actively participating in the early stages of implementation. Acceptance is recognition and willingness to work with nurse practitioner. Intention relates to how the role is defined. CONCLUSION This integrative review revealed three factors that influence nurse practitioner role implementation in Canada: involvement, acceptance and intention. Strategies to enhance these factors may inform best practice role implementation processes.

A systematic review of the effectiveness of advanced practice nurses in long-term care.

AIM To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long-term care residential settings. BACKGROUND Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted. DESIGN Quantitative systematic review. DATA SOURCES Twelve electronic databases were searched (1966-2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group. REVIEW METHODS Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria. RESULTS Four prospective studies conducted in the USA and reported in 15 papers were included. Long-term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services. CONCLUSION Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long-term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.

Primary health care nurse practitioners in Canada

Canada, like many countries, is in the midst of primary health care reform. A key priority is to improve access to primary health care, especially in remote communities and areas with physician shortages. As a result, there is an increased emphasis on the integration of primary health care nurse practitioners. As of March 2006, legislation exists in all provinces and two territories in Canada that allows nurse practitioners (NPs) to implement their expanded nursing role. In this paper, we will briefly review the historical development of the NP role in Canada and situate it in the international context; describe the NP role, supply of NPs in the country, and the settings in which they work; propose an NP practice model framework; summarize facilitators and barriers to NP role implementation in primary health care delivery; and outline strategies to address the barriers.

Evaluation of a system for providing information resources to nurses

The authors describe a study to plan and implement an information system for nurses. The objectives were to (1) determine the clinical information needs of nurses; (2) adapt an existing clinical information system (CLINT) to address their expressed needs; and (3) evaluate nurses’ use of and satisfaction with the enhanced system. Thirty-nine nurses on a medical teaching unit in a tertiary hospital in Canada participated in the project. A needs assessment influenced the design of the nursing interface to CLINT and the development of educational and participatory strategies to promote its use. Data were collected before, after, and throughout the implementation period. Qualitative and quantitative methods, including focus groups, online questionnaires, and automated usage data collection, were used to describe nurses’ use of and satisfaction with the system. The results suggested that peer mentorship, organizational support, and collaboration were the most effective strategies for promoting system use. The hospital information system (IHIS), Netscape, drug information and basic texts were the most frequently used databases. Nurses were satisfied with the system and reported progress in changing clinical practice. CLINT helped them to keep up with educational and professional development. In conclusions, nurses are willing to use information systems that are relevant to their needs and user friendly. There is, however, a paucity of resources available for evidence-based clinical decision making.