Ania Willman

Promoting the implementation of evidence-based practice : A literature review focusing on the role of nursing leadership

OBJECTIVES Despite a growing interest in evidence-based practice (EBP), the implementation into clinical practice of knowledge derived from research has proved to be a cumbersome process. Additionally, the literature seems to present a fragmented picture with research mainly focusing on a few factors of possible importance, among which leadership appears to be one of the more important. Thus, this study aimed to systematically review the literature regarding leadership and its possible influence on the process of implementing EBP. APPROACH A literature review was conducted. Electronic database searches were conducted to identify studies on leadership, administrators, managers, implementation, evidence-based and nursing. The search identified 43 potentially relevant papers, of which 36 were excluded after an appraisal was performed by two independent reviewers. Results were extracted and synthesised into a narrative text. FINDINGS Seven papers were included in the literature review. The findings can be divided into three major areas: (1) characteristics of the leader, (2) characteristics of the organisation and (3) characteristics of the culture. Our findings indicate that leadership is vital for the process of implementing EBP in nursing and also highlights the possible importance of the organisation and the culture in which the leader operates. These factors together with their characteristics were interpreted to be intrinsic in the creation of a nursing milieu that is open and responsive to the implementation of EBP. CONCLUSIONS Although there seems to be scholarly agreement that leadership is a vital part of the process of implementing EBP, more rigorous research is needed concerning the possible role of the leader. Our findings also indicate that leadership cannot be studied in isolation or without being clearly defined.

Outcomes of evidence-based clinical practice guidelines: A systematic review.

OBJECTIVES This study aimed to investigate whether evidence-based clinical practice in health care improves outcomes for patients, personnel, and/or organizations. METHODS A systematic review of studies was conducted with various quantitative and qualitative methods up to the Spring of 2002. Protocols were used in quality assessment. Data synthesis is descriptive in a narrative form. RESULTS Of 305 assessed articles, eight studies were included. The outcomes in the included studies were related to the experiences of patients and personnel and to organization concerning changed patient care and resource utilization. Because the included studies are heterogeneous in design, focus of research area, and scientific quality, the scientific foundation for the findings is weak. There is some support that evidence-based clinical practice guidelines, when put to use, improve outcomes (i) for patients--less likelihood of showing worsening of skin condition and disruption of skin condition improves more rapidly for infants; (ii) for personnel--support in daily work situation; and (iii) for organizations--decreased admission rates and length of stay, less resource utilization and reduced costs. CONCLUSIONS There is a need for further research as the findings are based on a rather limited number of studies. There is a tendency toward support for the idea that outcomes improve for patients, personnel, or organizations if clinical practice in health care is evidence-based, that is, if evidence-based clinical practice guidelines are used, although these findings could be specific to the settings and context of the studies reported in this systematic review.

Risk factors and prevention among patients with hospital-acquired and pre-existing pressure ulcers in an acute care hospital

AIMS AND OBJECTIVES This study aimed to describe and identify risk factors associated with hospital-acquired pressure ulcers among adults in an acute care hospital compared with patients with pre-existing pressure ulcers present on admission. A further aim was to identify the preventive measures performed with both groups respectively. BACKGROUND Pressure ulcers occur most often in older and immobile persons with severe acute illness and neurological deficits. However, few studies have addressed risk factors that are associated with hospital-acquired pressure ulcers compared with patients with pre-existing pressure ulcers. DESIGN A point prevalence study with a cross-sectional survey design was conducted at a Swedish university hospital. METHOD Data on 535 patients were recorded using a modified version of the protocol developed and tested by the European Pressure Ulcer Advisory Panel, including the Braden scale for risk assessment. RESULTS The prevalence of pressure ulcers was 27% (95% confidence interval, 23-31%). Higher age and a total Braden score below 17 were significantly associated with the presence of pressure ulcers. Among individual risk factors higher age, limited activity level and friction and shear while seated or lying down were associated with hospital-acquired pressure ulcers, whereas only higher age and friction and shear were associated with the presence of pressure ulcers in the overall sample. There was an overall sparse use of preventive measures to relieve pressure. CONCLUSION The findings of the present study revealed that pressure ulcers and the insufficient use of preventive measure to relieve pressure is still a problem in acute care settings. A continued focus must be placed on staff training in identifying patients at risk for pressure ulcers development. RELEVANCE TO CLINICAL PRACTICE Increasing the ability to identify patients who are at risk for pressure ulcer development can assist in preventing unnecessary complications and suffering as well as reduce costs.

The Meaning of Support as Narrated by Family Carers Who Care for a Senior Relative at Home

The authors’ aim in this study is to illuminate the meaning of support as narrated by family members who care for a senior relative at home. This study originates from a context of advanced in-home palliative care in Sweden. Twenty individuals who cared for a senior relative at home participated. Narrative interviews resulted in a text, which the authors analyzed in three recurring phases, naive understanding, structural analyses, and comprehensive understanding, using a phenomenological hermeneutical method. They formulated two themes from the analysis: Experiencing a togetherness with others in caring and Sensing togetherness with oneself in caring. The meaning of support was understood here as Sensing togetherness. In the comprehensive understanding, the authors further illuminate this meaning using literature on the concepts of friendship, inner strength, and manageability through the sense of coherence theory. They provide suggestions for relevance to practice and further research.

The Meaning of Being Supportive for Family Caregivers as Narrated by Registered Nurses Working in Palliative Homecare

The aim of this study was to illuminate the meaning of being supportive to family caregivers who care for a relative at home as narrated by registered nurses. The context used to allow for the meaning of being supportive to be illuminated was palliative home care. The study uses a phenomenological-hermeneutical method inspired by the philosophy of Ricoeur. Data consisted of narrative interviews, which were analyzed in three recurring phases: naive reading, structural analyses and interpreted whole. Twenty nurses from the hospitals in Sweden participated in the study. Two core themes were found: forming a relationship and keeping caregiving at home.

Experiences of the implementation of clinical practice guidelines - interviews with nurse managers and nurses in hospital care

The implementation of clinical practice guidelines (CPGs) has become an increasingly common element of clinical care, but little qualitative research has been conducted in real-life clinical settings. The aim was to elucidate experiences and factors of importance for the implementation of CPGs in hospital care. Twenty interviews were conducted, audio-taped and transcribed verbatim. A manifest and latent content analysis was performed to interpret the text. A system of subcategories related to five categories and one overall theme were developed. The data reveal that the implementation of CPGs is continuous processes of creating reliable and tenable routines that involve all staff members and expect to lead to better and safer patient care as well as to increased knowledge and confidence among staff. The process is initiated by internal or external demands and represents a way to keep abreast of knowledge development. Several factors facilitate the implementation and have an influence on the use and compliance with CPGs. To increase support for and willingness to use the CPG, it appears important to involve all staffs in the implementation process as well as to follow up and give feedback continuously to staff and management. It seems necessary to evaluate the process to supervise compliance with CPGs and to balance priorities and costs. Evaluation can also demonstrate importance of the application.

Developing an instrument for evaluating implementation of clinical practice guidelines: a test-retest study

RATIONALE AND AIMS This study focuses on the development of an instrument for the evaluation of clinical practice guidelines and is one part of a research project about the implementation and use of such guidelines among hospitals in the southern region of Sweden. The aim of the present paper was to investigate the test-retest reliability of a questionnaire. METHOD A questionnaire was designed to gather data about guidelines that have been implemented as well as information about factors, which, according to the Promoting Action on Research Implementation in Health Services (PARIHS)-model, influence the success of implementation. Thirty-nine health professionals at one of the hospitals included in the survey completed the questionnaire on two occasions within a mean time of 5.5 weeks. The test-retest reliability was analysed by means of Cohens Kappa and percentage concordance. RESULTS Eight items had good agreement in terms of strength and high percentage concordance. With regard to the Kappa values, 13 items show moderate and two fair agreement. CONCLUSIONS The test-retest reliability scores show mainly acceptable results indicating a reasonable stability, thus suggesting the possibility of further developing the instrument. The factors described in the PARIHS-model seem relevant for use in evaluating implementation and use of guidelines. The instrument could benefit from a revision of the language in order to enhance clarity and make it less abstract.

Evaluation of nursing documentation. A comparative study using the instruments NoGA and Cat-ch-ing after an educational intervention.

In this article we describe the results of a comparative study focusing on the evaluation of nursing documentation before and after an educational intervention. An additional aim is to report the results of a comparison between quality measurements of nursing documentation using the examination instruments NoGA© and Cat-ch-ing© and, against this background, to recommend an instrument for future examinations. The educational intervention was directed towards nurses at Helsingborg hospital/health care district. The intervention, which comprised supervision, group sessions, lectures and field trips, covered a period of two years and was built on a learning model. In all, the data material examined included 515 nursing records collected from 52 units. The study reports on a comparison of the examination results from four different clinics for the years 1994 and 1997. The results show a statistically significant difference between the four clinics before the intervention, a difference that disappeared after the intervention. Furthermore, the results show a statistically significant improvement in documentation after the intervention. For future examinations, it is recommended that the examination instrument Cat-ch-ing© should be used and that methods for examination of the content of the documentation must be developed.

Promoting Sleep by Nursing Interventions in Health Care Settings: A Systematic Review

BACKGROUND Sleep disturbances are common problems among individuals in hospitals and institutions. Although several studies have explored this phenomenon, there is still a lack of knowledge about the effectiveness of sleep-promoting nursing interventions. This systematic review aims to describe and evaluate the effectiveness of sleep-promoting nursing interventions in health care settings. APPROACH A systematic review was performed. In June 2009, a literature search was carried out in the following databases: Academic Search Elite, CINAHL, the Cochrane Library and MedLine/PubMed. Fifty-two references were identified and after critical appraisal, nine studies were selected. A compilation of the results and the outcomes of the interventions were carried out. Furthermore, the evidence strength of the interventions was assessed. FINDINGS Little evidence for the nursing interventions, sleep hygiene, music, natural sound and vision, stimulation of acupoints, relaxation, massage and aromatherapy is found. However, large effect size of interventions were found when using massage, acupuncture and music, natural sounds or music videos. The use of sleep hygiene and relaxation, on the other hand, produced only small effects. CONCLUSION The lack of high evidence strength for the nursing interventions together with the uncertainty about their effects calls for more research before implementing these interventions into clinical practice.

Standardized care plans in Swedish health care: their quality and the extent to which they are used

OBJECTIVES To investigate the quality of standardized care plans and the extent to which they are used within Swedish in-hospital somatic care. Further, to examine the quality of the knowledge summaries on which existing standardized care plans were supposed to be based. DESIGN Submitted documents were reviewed with study-specific protocols. SETTING A national survey, based on a structured selection of Swedish hospitals. PARTICIPANTS A total of 25 Swedish hospitals participated, and were asked to submit all documents in use that were labelled standardized care plan. RESULTS Only 4% (34 out of 782) of the reviewed documents fulfilled the criteria for being a standardized care plan. None of the 34 knowledge summaries (an accompanying document with a compilation of scientific facts and reliable experience) was evidence-based. CONCLUSIONS There is a lack of knowledge regarding what a standardized care plan is, and how such a document should emanate from evidence-based knowledge. Our results raise the question of how recent developments in research are used to create standardized care plans for the best possible care. In the process of developing standardized care plans it is important to acknowledge that staff who develop these plans need scientific training and experience. Standardized care plans are in the early stages of development, and at this stage it seems appropriate to initiate a discussion regarding possible cooperation at national level when developing standardized care plans for certain large groups of patients suffering from specific diseases, or undergoing the same treatment.