Kate Gerrish

Developing evidence‐based practice: experiences of senior and junior clinical nurses

AIM This paper is a report of a study to compare factors influencing the development of evidence-based practice identified by junior and senior nurses. BACKGROUND Assessing factors influencing the achievement of evidence-based practice is complex. Consideration needs to be given to a range of factors including different types of evidence, the skills nurses require to achieve evidence-based practice together with barriers and facilitators. To date, little is known about the relative skills of junior and senior clinical nurses in relation to evidence-based practice. METHOD A cross-sectional survey was undertaken at two hospitals in England, using the Developing Evidence-Based Practice Questionnaire administered to Registered Nurses (n = 1411). A useable sample of 598 (response rate 42%) was achieved. Data were collected in 2003, with comparisons undertaken between junior and senior nurses. FINDINGS Nurses relied heavily on personal experience and communication with colleagues rather than formal sources of knowledge. All respondents demonstrated confidence in accessing and using evidence for practice. Senior nurses were more confident in accessing all sources of evidence including published sources and the Internet, and felt able to initiate change. Junior nurses perceived more barriers in implementing change, and were less confident in accessing organizational evidence. Junior nurses perceived lack of time and resources as major barriers, whereas senior nurses felt empowered to overcome these constraints. CONCLUSION Senior nurses are developing skills in evidence-based practice. However, the nursing culture seems to disempower junior nurses so that they are unable to develop autonomy in implementing evidence-based practice.

Decision-making in teams: issues arising from two UK evaluations

Interagency and interprofessional working has often been operationalised through the development of integrated, multiprofessional teams in the UK. However, there is considerable ambivalence reported about the success of such teams. This paper reports on two evaluations of different types of inter-agency/intra-agency, interdisciplinary/unidisciplinary teams. One study used a soft systems methodology to evaluate a health and social care team for people with enduring mental health needs and the other used a pluralistic framework to examine integrated nursing teams in primary care. In both studies, the team-working arrangements influenced the decisions made by the team members such that client care became increasingly responsive and proactive. These changes were made possible by two processes. First, information transaction was augmented and was instrumental in supporting effective client-related decision-making. Second, there was enhanced support for decision-making, especially in respect of problem solving. However, the increased autonomy of the team members had the potential to marginalise those outside the team from decision-making. It is suggested that working within a team can impact on the decisions made by team members, which exceeds a collection of individual decisions. The strengths of complex multiprofessional teams for service users may be realised if the processes of decision-making are respected.Interagency and interprofessional working has often been operationalised through the development of integrated, multiprofessional teams in the UK. However, there is considerable ambivalence reported about the success of such teams. This paper reports on two evaluations of different types of inter-agency/intra-agency, interdisciplinary/unidisciplinary teams. One study used a soft systems methodology to evaluate a health and social care team for people with enduring mental health needs and the other used a pluralistic framework to examine integrated nursing teams in primary care. In both studies, the team-working arrangements influenced the decisions made by the team members such that client care became increasingly responsive and proactive. These changes were made possible by two processes. First, information transaction was augmented and was instrumental in supporting effective client-related decision-making. Second, there was enhanced support for decision-making, especially in respect of problem solving. However, the increased autonomy of the team members had the potential to marginalise those outside the team from decision-making. It is suggested that working within a team can impact on the decisions made by team members, which exceeds a collection of individual decisions. The strengths of complex multiprofessional teams for service users may be realised if the processes of decision-making are respected.

Using the Knowledge to Action Framework in practice: a citation analysis and systematic review

BackgroundConceptual frameworks are recommended as a way of applying theory to enhance implementation efforts. The Knowledge to Action (KTA) Framework was developed in Canada by Graham and colleagues in the 2000s, following a review of 31 planned action theories. The framework has two components: Knowledge Creation and an Action Cycle, each of which comprises multiple phases. This review sought to answer two questions: ‘Is the KTA Framework used in practice? And if so, how?’MethodsThis study is a citation analysis and systematic review. The index citation for the original paper was identified on three databases—Web of Science, Scopus and Google Scholar—with the facility for citation searching. Limitations of English language and year of publication 2006-June 2013 were set. A taxonomy categorising the continuum of usage was developed. Only studies applying the framework to implementation projects were included. Data were extracted and mapped against each phase of the framework for studies where it was integral to the implementation project.ResultsThe citation search yielded 1,787 records. A total of 1,057 titles and abstracts were screened. One hundred and forty-six studies described usage to varying degrees, ranging from referenced to integrated. In ten studies, the KTA Framework was integral to the design, delivery and evaluation of the implementation activities. All ten described using the Action Cycle and seven referred to Knowledge Creation. The KTA Framework was enacted in different health care and academic settings with projects targeted at patients, the public, and nursing and allied health professionals.ConclusionsThe KTA Framework is being used in practice with varying degrees of completeness. It is frequently cited, with usage ranging from simple attribution via a reference, through informing planning, to making an intellectual contribution. When the framework was integral to knowledge translation, it guided action in idiosyncratic ways and there was theory fidelity. Prevailing wisdom encourages the use of theories, models and conceptual frameworks, yet their application is less evident in practice. This may be an artefact of reporting, indicating that prospective, primary research is needed to explore the real value of the KTA Framework and similar tools.

A reflection on seven years as editors and welcome to the new editors

With this volume, Ethnicity and Health has entered its 14th year of publication and has moved into the stewardship of its third editorial team Drs Atkin, Bradby and Harding. The journal started under the visionary editorship of Professor Balarajan, whose commitment to research was an important factor in establishing this field in the UK in the 1980s and who, by establishing the journal, provided an important route for the dissemination of research that did not easily catch the eye of mainstream journals at a time when ethnicity research was ‘unfashionable’. As with any new journal, progress was not always easy, but the publishers saw the academic value of the journal and remained fully committed to it. When we were approached to become editors in 2001, the publisher’s commitment helped to persuade us that continuing Professor Balarajan’s hard work in establishing and running the journal was worthwhile. The fact that we remained in this role for seven years indicates that the decision was the right one. Editing a journal is not easy. Finding the time, as an extra-curricular activity, to read papers, identify reviewers, persuade them to review the papers, etc. is often difficult. And rejecting papers, including papers that are important and have clear potential (often simply because of the competition for space in the journal) can be a painful choice (although we are well aware that the decision is harder for the author than the editor). But the reward is immense. Not least has been the success of the journal. During our time as editors we have had the opportunity to read many innovative and interesting papers and we have seen a constant rise in the number and quality of papers submitted to the journal. This has enabled us to increase the number of pages per issue and develop the journal from four issues per year to six issues in this current volume. The journal secured its first impact factor rating under our editorship and this has steadily risen in successive years. This reflects a vibrant and high quality academic community. We have also been particularly pleased to see the range of papers that are submitted to the journal from all parts of the world, reflecting its truly international status, from a very wide range of disciplines, and using a variety of methods. The interdisciplinary and international nature of the journal is vital to address concepts as complex as ethnicity and health. In our first editorial for the journal (Gerrish and Nazroo 2002), we highlighted our desire to publish papers in Ethnicity and Health that would advance our knowledge of the relationship between ethnicity and health by:

The role of advanced practice nurses in knowledge brokering as a means of promoting evidence-based practice among clinical nurses.

AIM To identify approaches used by advanced practice nurses to promote evidence-based practice among clinical nurses. BACKGROUND Barriers encountered at individual and organizational levels hinder clinical nurses in their ability to deliver evidence-based practice. Advanced practice nurses are well placed to promote evidence-based practice through interactions with clinical nurses. However, little is understood about how advanced practice nurses might realize this potential. METHOD A multiple instrumental case study of 23 advanced practice nurses from hospital and primary care settings across seven Strategic Health Authorities in England was undertaken in 2006. Data collection comprised interviews and observation of advanced practice nurses and interviews with clinical nurses and other healthcare professionals. Data were analysed using the Framework approach. FINDINGS Advanced practice nurses acted as knowledge brokers in promoting evidence-based practice among clinical nurses. Knowledge management and promoting the uptake of knowledge were key components of knowledge brokering. Knowledge management involved generating different types of evidence, accumulating evidence to act as a repository for clinical nurses, synthesizing different forms of evidence, translating evidence by evaluating, interpreting and distilling it for different audiences and disseminating evidence by formal and informal means. Advanced practice nurses promoted the uptake of evidence by developing the knowledge and skills of clinical nurses through role modelling, teaching, clinical problem-solving and facilitating change. CONCLUSION The role of advanced practice nurses in knowledge brokering is complex and multi-faceted. It extends beyond the knowledge management, linkage and capacity building identified in the literature to include active processes of problem-solving and facilitating change.

Identifying the core components of cultural competence: findings from a Delphi study

AIM To identify the core components of cultural competence from a Swedish perspective. Background. The cultural diversity of Swedish society raises challenges for nursing practice. Nurses need to be culturally competent, i.e. demonstrate the effective application of knowledge, skills and attitudes to practice safely and effectively in a multicultural society. Existing frameworks of cultural competence reflect the socio-cultural, historical and political context they were developed in. To date, there has been no research examining cultural competence within a Swedish context. DESIGN A Delphi survey. METHODS A purposeful sample of 24 experts (eight nurses, eight researchers and eight lecturers) knowledgeable in multicultural issues was recruited. Interviews were undertaken to identify the knowledge, skills and attitudes that formed the components of cultural competence. Content analysis yielded statements which were developed into a questionnaire. Respondents scored questionnaire items in terms of perceived importance. Statements which reached consensus were removed from questionnaires used in subsequent rounds. Three rounds of questionnaires were distributed during 2006. RESULTS A total of 118 out of 137 components reached a consensus level of 75%. The components were categorised into five areas, cultural sensitivity, cultural understanding, cultural encounters, understanding of health, ill-health and healthcare and social and cultural contexts with 17 associated subcategories. CONCLUSIONS There are some similarities between the issues raised in the current study and existing frameworks of cultural competence from the USA and the UK. However, Swedish experts placed less emphasis on ethnohistory and on developing skills to challenge discrimination and racism. RELEVANCE TO CLINICAL PRACTICE This study identified the core components of cultural competence important to nurses practising within a multicultural society such as Sweden. Acquisition of the knowledge, skills and attitudes identified should enable nurses to meet the needs of patients from different cultural backgrounds. The components of cultural competence can form the basis of nursing curricula.

Preparation of nursesto meet the needs of an ethnically diverse society: educational implications

In recognizing the multiethnic composition of contemporary society in the UK, this paper considers the implications for nurse education in respect of preparing practitioners who are capable of meeting the needs of an ethnically diverse population. It begins by considering briefly some contextual issues relating to the health needs of ethnic minorities and how they impact upon nursing practice. The literature clearly indicates some of the complexities that nurses face in attempting to deliver care which is responsive to the individual needs of patients in a multicultural context. The question then arises as to how nurse education can most effectively prepare future practitioners. Consideration is given to the curriculum content, methods and approaches that may be utilized together with different teaching and learning strategies. The case is made for the need for nurse educators to also consider the recruitment and support of students from ethnic minority groups, if nursing is to make progress in responding more appropriately to the needs of ethnic minority groups in the UK.

Testing the Consolidated Framework for Implementation Research on health care innovations from South Yorkshire

RATIONALE, AIMS AND OBJECTIVES There is an international imperative to implement research into clinical practice to improve health care. Understanding the dynamics of change requires knowledge from theoretical and empirical studies. This paper presents a novel approach to testing a new meta theoretical framework: the Consolidated Framework for Implementation Research. METHOD The utility of the Framework was evaluated using a post hoc, deductive analysis of 11 narrative accounts of innovation in health care services and practice from England, collected in 2010. A matrix, comprising the five domains and 39 constructs of the Framework was developed to examine the coherence of the terminology, to compare results across contexts and to identify new theoretical developments. RESULTS The Framework captured the complexity of implementation across 11 diverse examples, offering theoretically informed, comprehensive coverage. The Framework drew attention to relevant points in individual cases together with patterns across cases; for example, all were internally developed innovations that brought direct or indirect patient advantage. In 10 cases, the change was led by clinicians. Most initiatives had been maintained for several years and there was evidence of spread in six examples. Areas for further development within the Framework include sustainability and patient/public engagement in implementation. CONCLUSION Our analysis suggests that this conceptual framework has the potential to offer useful insights, whether as part of a situational analysis or by developing context-specific propositions for hypothesis testing. Such studies are vital now that innovation is being promoted as core business for health care.

Improving clinical effectiveness through an evidence-based approach: meeting the challenge for nursing in the United Kingdom.

Improving clinical effectiveness is a major challenge facing nurses working in the United Kingdom and requires a coordinated approach in order to ensure that the information about which interventions work is made available to those in a position to use it. This means that policy makers, administrators, and nurses need to base decision making on the best available evidence. In this article we explore the background to the drive for evidence-based practice and discuss how a group of nurse researchers have begun working with nurse administrators and practitioners in a large acute hospital to help change the rhetoric of evidence-based practice in nursing into reality.

Experiences of the diagnosis and management of tuberculosis: a focused ethnography of Somali patients and healthcare professionals in the UK

AIM To explore experiences of the diagnosis and management of tuberculosis from the perspective of Somali patients and healthcare professionals involved in their care. BACKGROUND The Somali population has the third highest incidence of tuberculosis occurring in persons born outside the UK. Tuberculosis is a disease with sociocultural as well as physical consequences. Nurses should understand how the disease is experienced by people from different ethnic backgrounds to implement strategies for prevention and management of tuberculosis. DESIGN A focused ethnography. METHOD Individual interviews with 14 Somali patients and 18 healthcare professionals with experience of providing care to Somalis were undertaken in 2008-2009. Interviews explored the patient experience from onset of symptoms to completion of treatment. Data were analysed using Framework approach. FINDINGS Despite presenting in primary care early, patients experienced diagnostic delays due to low clinical suspicion of tuberculosis among general practitioners. Although patients reported felt and enacted stigma, it did not adversely affect concordance with treatment. Patients were reticent about sharing their diagnosis among wider networks due to perceived stigma. Psychological support from families and specialist nurses was valued highly. Healthcare professionals perceived that stigmatization of tuberculosis was diminishing among Somalis leading to improved management of tuberculosis. Patients and healthcare professionals raised concerns about the longer term physical and psychosocial implications of tuberculosis once treatment was completed. CONCLUSION Nurses have a role in promoting early presentation, timely diagnosis, and treatment adherence through supporting Somali patients and raising awareness of the disease among primary care practitioners.