Erna Snelgrove-Clarke

Realist synthesis: illustrating the method for implementation research

BackgroundRealist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered.MethodsThe realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses.ResultsBased on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area.ConclusionsRealist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.

A realist review of interventions and strategies to promote evidence-informed healthcare: A focus on change agency

BackgroundChange agency in its various forms is one intervention aimed at improving the effectiveness of the uptake of evidence. Facilitators, knowledge brokers and opinion leaders are examples of change agency strategies used to promote knowledge utilization. This review adopts a realist approach and addresses the following question: What change agency characteristics work, for whom do they work, in what circumstances and why?MethodsThe literature reviewed spanned the period 1997-2007. Change agency was operationalized as roles that are aimed at effecting successful change in individuals and organizations. A theoretical framework, developed through stakeholder consultation formed the basis for a search for relevant literature. Team members, working in sub groups, independently themed the data and developed chains of inference to form a series of hypotheses regarding change agency and the role of change agency in knowledge use.Results24, 478 electronic references were initially returned from search strategies. Preliminary screening of the article titles reduced the list of potentially relevant papers to 196. A review of full document versions of potentially relevant papers resulted in a final list of 52 papers. The findings add to the knowledge of change agency as they raise issues pertaining to how change agents’ function, how individual change agent characteristics effect evidence-informed health care, the influence of interaction between the change agent and the setting and the overall effect of change agency on knowledge utilization. Particular issues are raised such as how accessibility of the change agent, their cultural compatibility and their attitude mediate overall effectiveness. Findings also indicate the importance of promoting reflection on practice and role modeling. The findings of this study are limited by the complexity and diversity of the change agency literature, poor indexing of literature and a lack of theory-driven approaches.ConclusionThis is the first realist review of change agency. Though effectiveness evidence is weak, change agent roles are evolving, as is the literature, which requires more detailed description of interventions, outcomes measures, the context, intensity, and levels at which interventions are implemented in order to understand how change agent interventions effect evidence-informed health care.

The significance of personal learning environments (PLEs) in nursing education: extending current conceptualizations.

BACKGROUND Personal learning environments (PLEs) have been shown to be a critical part of how students negotiate and manage their own learning. Understandings of PLEs appear to be constrained by narrow definitions that focus primarily on technological engagement with a range of web tools and associated applications. This paper addresses a gap in the literature around PLEs for students currently enrolled in undergraduate nursing degrees. PURPOSE To provide in-depth insights into how undergraduate students of nursing manage and experience their learning. METHODS This was an international multi-site qualitative study, utilizing focus groups. A schedule of 10 questions and nominal group techniques were used. FINDINGS Whilst the focus groups took place in very different geographical locations, there were strong similarities in student understandings of effective PLEs. These went well beyond current technological definitions. Findings were organized into three major themes; technologies, learning modalities and influencing factors. DISCUSSION We propose a broader understanding of PLEs that acknowledges individual personal and cultural contexts which we call the personally significant learning environment (PSLE). There is a need for greater investigation of how students understand and systematize their PSLE. CONCLUSIONS This paper and our findings will be of interest to educators, researchers and institutions for developing appropriate frameworks that may maximize learning outcomes, encourage cultural sensitivities and facilitate greater understandings of how to support students to create appropriate PSLEs.

Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings

UNLABELLED Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice. METHODS A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables. RESULTS Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention. CONCLUSIONS This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.

The experiences of midwives and nurses collaborating to provide birthing care: a systematic review

Background Collaboration has been associated with improved health outcomes in maternity care. Collaborative relationships between midwives and physicians have been a focus of literature regarding collaboration in maternity care. However despite the front line role of nurses in the provision of maternity care, there has not yet been a systematic review conducted about the experiences of midwives and nurses collaborating to provide birthing care. Objective The objective of this review was to identify, appraise and synthesize qualitative evidence on the experiences of midwives and nurses collaborating to provide birthing care. Specifically, the review question was: what are the experiences of midwives and nurses collaborating to provide birthing care? Inclusion criteria Types of participants This review considered studies that included educated and licensed midwives and nurses with any length of practice. Nurses who work in labor and delivery, postpartum care, prenatal care, public health and community health were included in this systematic review. Phenomena of interest This review considered studies that investigated the experiences of midwives and nurses collaborating during the provision of birthing care. Experiences, of any duration, included any interactions between midwives and nurses working in collaboration to provide birthing care. Birthing care referred to: (a) supportive care throughout the pregnancy, labor, delivery and postpartum, (b) administrative tasks throughout the pregnancy, labor, delivery and postpartum, and (c) clinical skills throughout the pregnancy, labor, delivery and postpartum. The postpartum period included the six weeks after delivery. Types of studies The review considered English language studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Context This review considered qualitative studies that explored the experiences of collaboration in areas where midwives and nurses work together. Examples of these areas included: hospitals, birth centers, client homes, health clinics and other public or community health settings. These settings were located in any country, cultural context, or geographical location. Search strategy A three‐step search strategy was used to identify relevant published and unpublished studies. English papers from 1981 onwards were considered. The following databases were searched: Anthrosource, CENTRAL (The Cochrane Library), CINAHL, EMBASE, PsycINFO, PubMed, Social Services Abstracts and Sociological Abstracts. In addition to the databases, several grey literature sources were searched. Methodological quality Papers that were selected for retrieval were independently assessed for inclusion in the review by two JBI‐trained reviewers. The two reviewers used a standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Data extraction Qualitative data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Data synthesis Once qualitative studies were assessed using the the Joanna Briggs Institute Qualitative Assessment and Review Instrument critical appraisal tool, findings of the included studies were extracted. These findings were aggregated into categories according to their similarity in meaning. These categories were then subjected to a meta‐synthesis to produce a comprehensive set of synthesized findings. Results Five studies were included in the review. Thirty‐eight findings were extracted from the included studies and were aggregated into five categories. The five categories were synthesized into two synthesized findings. The two synthesized findings were: Synthesized finding1: Negative experiences of collaboration between nurses and midwives may be influenced by distrust, lack of clear roles, or unprofessional or inconsiderate behavior. Synthesized finding 2: If midwives and nurses have positive experiences collaborating thenthere is hope that the challenges of collaboration can be overcome. Conclusions Qualitative evidence about the experiences of midwives and nurses collaborating to provide birthing care was identified, appraised and synthesized. Two synthesized findings were created from the findings of the five included studies. Midwives and nurses had negative experiences of collaboration which may be influenced by: distrust, unclear roles, or a lack of professionalism or consideration. Midwives and nurses had positive experiences of teamwork which can be a source of hope for overcoming the challenges of sharing care. There is clearly a gap in the literature about the collaborative experiences of midwives and nurses, given that only five studies were located for inclusion in the systematic review. More qualitative research exploring collaboration as a process and the interactional dynamics of midwives and nurses in a variety of practice and professional contexts is required. Implications for practice Distrust, unclear roles, and lack of professionalism and consideration must all be addressed. Strategies that address and minimize the occurrences of these three elements need to be developed and implemented in an effort to reduce negative collaborative experiences for midwives and nurses. Postive experiences of teamwork must be acknowleged and celebrated, and the challenges that sharing care present must be understood as a part of the collaborative process. Implications for research More qualitative research is required to explore the collaborative process between midwives and nurses. Further exploration of their interactional dynamics, their relationship between power and collaboration, and the experiences of collaboration in a variety of professional and practice contexts is recommended.

Experiences of emergency department nurses in providing palliative care to adults with advanced cancer: a systematic review protocol.

REVIEW QUESTIONS/OBJECTIVES The objective of this review is to explore the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer so as to contribute to the developing knowledge base on this phenomenon and, in turn, inform future practice and policy changes. Specifically, the review question for this qualitative review is as follows: what are the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer?

Maternal and women's health: evidence-informed practice on a global scale.

The Interagency Gender Working Group (2004) from the Population Reference Bureau in the United States reported that evidence-informed health care interventions may be more effective if they are gender specific. Despite this intervention knowledge, women in Canada continue to experience, at a greater rate than men, chronic disease and the burden of disability (Pederson et al. 2010). Moreover, when considering maternal health globally, the international community at the World Health Organization [WHO] (2008a) Millennium Summit adopted eight Millennium Development Goals. Of these, Goal 5 was the improvement of maternal health (WHO 2011). Within this goal, one target was the reduction of maternal mortality by 75% globally, by 2015 (WHO 2008b). The key working areas included strengthening health systems and promoting interventions that focus on policies and strategies that work. In developed countries, women give birth with minimal risk while in others, particularly African countries, women die regularly from preventable pregnancy-related risks (Piane 2008). Pregnancy or pregnancy-related complications in developing countries result in 1,500 deaths daily (WHO 2008b). If we are to achieve the defined Millennium target that is a reduction of the maternal mortality ratio by 5.5% each year, evidence-informed, gender-specific strategies are required to reduce mortality outcomes. Moving the target to the 5.5% reduction from the current decline of <0.4% (Piane 2008) suggests that significant and focused energy is needed and needed now. But what evidenceinformed strategies should be selected to begin fueling collective energy? The majority of maternal complications occur during the intrapartum period (WHO 2008b). Of these complications, one of the medical preventive strategies that reduces maternal mortality is the administration of magnesium sulfate for preeclampsia or eclampsia (Duley et al. 2006). Acknowledgment of this evidence-informed practice has led to the development of new national maternity guidelines for the use of magnesium sulfate for the management of eclampsia (National Maternity Care Guidelines Committees of the Department of Health 2000; 2002; Moodley 2010). With these guidelines in place, our challenge is to ensure their transfer into communities of practice.

Benefits and challenges in the use of art as an intervention for making sense of the cancer experience: a qualitative systematic review protocol.

REVIEW QUESTION/OBJECTIVE How does art contribute as a psychotherapeutic tool in making sense of the cancer experience? What is the meaningfulness of integrating art (as either creator or consumer) for patients throughout the cancer experience?

Assessing the extent and quality of documentation of fidelity to the implementation strategy: a proposed scoring mechanism

Methods Articles in the Cochrane Database of Systematic Reviews, Effective Practice and Organization of Care (EPOC) that included at least one of the 47 Cochrane Review implementation strategies were retrieved yielding 1158 articles in 337 journals. We selected publications from the 3 journals with the largest number of articles: British Medical Journal (BMJ), Journal of the American Medical Association (JAMA), and Medical Care. We developed an “Implementation Strategy Fidelity Score” based on definitions adapted from Dusenbury (2003) [1]. Adherence (documenting implementation strategies and extent to which they took place), dose (proportion of people receiving each strategy) and participant responsiveness (extent to which individuals were involved in the development or evaluation of strategies or their receptivity to them) were scored on a 3-point scale: 0=no detail, 1=some detail, and 2=great detail.