Rick Wiechula

The JBI model of evidence‐based healthcare

Evidence-based healthcare as it is contemporarily conceived is based on the view that clinical decisions should be based on the best available scientific evidence but recognising patient preferences, the context of healthcare and the judgement of the clinician. The ongoing debate on the nature of evidence for practice across all of the health professions is influenced by the experience of clinicians in everyday practice who, in using the evidence, assert that there are diverse sources of research-based and non-research-based evidence and that the process of evidence-based practice should be placed within a broader context that is grounded in practice; recognises different evidentiary bases; and is directed towards improving global health across vasty different practice contexts. We present a developmental framework of evidence-based practice that builds and expands on the work of leaders in the field of evidence-based healthcare; is contextualised; is inclusive of diverse forms of evidence; and incorporates understandings of knowledge transfer and utilisation. The conceptual model attempts to situate healthcare evidence and its role and use within the complexity of practice settings globally.

A Re-Consideration of What Constitutes “Evidence” in the Healthcare Professions

The dominant discourses surrounding the debate on evidence-based healthcare takes for granted that the concept evidence is exclusively derived from randomized controlled trials. However, influenced by the experience of practicing clinicians, who assert that there are diverse sources of evidence, we contend that evidence-based practice can properly be inclusive of diverse forms of evidence including the results of all forms of rigorous research, expert opinion, and experience. The Joanna Briggs Institute model illustrates this broader definition of what counts as evidence which is seen as critical to developing the role and use of evidence-based healthcare within the complexity of practice settings globally.

Improving the fundamentals of care for older people in the acute hospital setting: facilitating practice improvement using a Knowledge Translation Toolkit

This paper reports on a structured facilitation program where seven interdisciplinary teams conducted projects aimed at improving the care of the older person in the acute sector. Aims  To develop and implement a structured intervention known as the Knowledge Translation (KT) Toolkit to improve the fundamentals of care for the older person in the acute care sector. Three hypotheses were tested: (i) frontline staff can be facilitated to use existing quality improvement tools and techniques and other resources (the KT Toolkit) in order to improve care of older people in the acute hospital setting; (ii) fundamental aspects of care for older people in the acute hospital setting can be improved through the introduction and use of specific evidence-based guidelines by frontline staff; and (iii) innovations can be introduced and improvements made to care within a 12-month cycle/timeframe with appropriate facilitation. Methods  Using realistic evaluation methodology the impact of a structured facilitation program (the KT Toolkit) was assessed with the aim of providing a deeper understanding of how a range of tools, techniques and strategies may be used by clinicians to improve care. The intervention comprised three elements: the facilitation team recruited for specific knowledge, skills and expertise in KT, evidence-based practice and quality and safety; the facilitation, including a structured program of education, ongoing support and communication; and finally the components of the toolkit including elements already used within the study organisation. Results  Small improvements in care were shown. The results for the individual projects varied from clarifying issues of concern and planning ongoing activities, to changing existing practices, to improving actual patient outcomes such as reducing functional decline. More importantly the study described how teams of clinicians can be facilitated using a structured program to conduct practice improvement activities with sufficient flexibility to meet the individual needs of the teams. Conclusions  The range of tools in the KT Toolkit were found to be helpful, but not all tools needed to be used to achieve successful results. Facilitation of the teams was a central feature of the KT Toolkit and allowed clinicians to retain control of their projects; however, finding the balance between structuring the process and enabling teams to maintain ownership and control was an ongoing challenge. Clinicians may not have the requisite skills and experience in basic standard setting, audit and evaluation and it was therefore important to address this throughout the project. In time this builds capacity throughout the organisation. Identifying evidence to support practice is a challenge to clinicians. Evidence-based guidelines often lack specificity and were found to be difficult to assimilate easily into everyday practice. Evidence to inform practice needs to be provided in a variety of forms and formats that allow clinicians to easily identify the source of the evidence and then develop local standards specific to their needs. The work that began with this project will continue - all teams felt that the work was only starting rather than concluding. This created momentum, motivation and greater ownership of improvements at local level.

The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project).

BackgroundMalnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital.Methods/DesignA pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool.DiscussionUnplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.Trial registrationACTRN12611000020987

Using holistic interpretive synthesis to create practice-relevant guidance for person-centred fundamental care delivered by nurses.

Nursing policy and healthcare reform are focusing on two, interconnected areas: person-centred care and fundamental care. Each initiative emphasises a positive nurse-patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse-patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice-relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse-patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse-patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person-centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.

Are we providing the best possible pain management for our elderly patients in the acute-care setting?

BACKGROUND During 2008 seven practice improvement projects were conducted in an acute-care hospital under the banner of The Older Person and Improving Care (TOPIC 7). Each project team examined a discrete aspect of care of the elderly and this project focus was on pain management and in particular assessment of the older person with communication difficulties. AIMS The project intended to assess current practice and implement changes to match best practice in the management of pain in the older person within an acute-care setting. METHODS A multidisciplinary team was recruited to conduct the project. The pain team with the other six TOPIC 7 teams was facilitated by a coordinating team. The project was divided into four phases. Phase one was designated as Describing, where the clinical issue was identified and focused to priority areas. It was decided to focus on the elderly who were unable to verbally communicate their pain management needs. Standards of practice relevant to the area of practice were sourced to guide practice improvement. Phase two was Measuring activity where clinical audits were used to measure current practice and compare this with the appropriate standards. Phase three was Taking action where a range of practice improvement activities were implemented including the introduction of the Abbey Pain Scale. The final phase was designated as Review and share where the impact of the project activities was measured with a follow-up audit and the results were disseminated. RESULTS Initial results showed a need for increased awareness of the difficulties in the pain assessment and management of older persons who cannot verbally communicate their needs. Seventy-eight per cent of patients had a documented pain assessment in the previous 24 h on audit. However, 83% of these assessments were only a general comment in the patient records. No tools were available for completing a systematic assessment that was reliable and reproducible. Sixty-two per cent of patients did not have analgesia administered 1 h before mobilising or having a significant dressing completed. Reaudit, posteducation sessions, showed an increase in the awareness in the complexities involved in caring for this group of patients. An alternate, specific tool (Abbey Pain Scale) was utilised well by staff and acted as a prompt in reminding staff to assess the pain levels of their elderly patients. CONCLUSIONS Globally, pain in the older person is poorly managed. Pain in older persons who are unable to communicate or who have difficulty in communicating their needs is even more poorly managed. However, the availability of an appropriate tool and an increased awareness of this issue can have a significant and real impact on the pain management of this group of patients.

Clinical placement and case study methodology: A complex affair

Clinical placement is a valuable component of nursing education, helping students to authenticate, integrate and develop a range of nursing skills and knowledge. The diversity of nursing curricula throughout the world and the many models of clinical placement make this a difficult subject to research using typical qualitative and quantitative research methodologies. The potential for case study methodology to address the complexity of learning in the clinical environment is significant. This paper argues that Complexity Theory provides an interpretive paradigm that articulates well with case study methodology. This paper also provides an example of the development of a theoretical proposition based on pattern matching. Pattern matching is an approach to data analysis that encourages a consideration of predicted patterns with those that are empirically based.

Reducing functional decline of older people in an acute-care setting: are we providing adequate care to maintain/optimise the functional status of our elder patients?

AIMS To improve practice in the care of the older person to ensure their functional status has not declined at the point of discharge by: determining available standards of care in relation to assessment of functional ability in the elderly; measuring current practice against standards of care based on the best available evidence; establishing priority areas for practice/improvement; implementing the practice/improvement plan; measuring practice to determine improvement in the management of functional decline in older patients and identifying further areas for investigation. METHODS A multidisciplinary team used a range of knowledge translation tools and strategies in order to reduce functional decline of the older person in the acute-care setting. Audit was used to determine compliance with best practice standards and to determine the level of functional decline. A novel intervention was introduced in the form of a communal dining room and this was evaluated by the project team. The project was part of a program of seven projects (The Older Person and Improving Care) facilitated by a team with expertise in knowledge translation. Facilitation was provided though a structured education program and ongoing support. RESULTS It was identified for this organisation that it was necessary to develop specific standards of care for the elderly in relation to functional decline. It was confirmed that there were unacceptable levels of functional decline in the elderly particularly in relation to mobility. The project team were able to show the feasibility and potential benefits of a communal dining room in reducing functional decline. CONCLUSIONS It has been recognised that practice improvement activities are complex and that despite good planning and facilitation things do not always go to plan. This stated, it should be recognised that a great deal was achieved. Standards of care were able to be developed from an evidence base. These standards were used to develop an audit tool that confirmed deficits in practice. The outcome was a trial of a new intervention, a communal dining room, which showed considerable potential in reducing functional decline in the elderly.

Developing effective and caring nurse-patient relationships

Establishing positive and trusting therapeutic relationships with patients has long been recognised as an essential component of nursing practice and is important for effective care. There are various challenges in clinical practice that make it increasingly difficult to deliver effective care centred on such relationships. Understanding and addressing these challenges is crucial to ensure a positive experience of care for patients, families, carers and nurses. This article outlines how nurses can use a framework to develop therapeutic relationships with patients and use the best available evidence to deliver effective care. It also explores the challenges in developing effective therapeutic relationships with patients at the healthcare system level, and considers how these challenges can be addressed.

Current status of palliative care services in Indonesia: a literature review.

AIM To review healthcare literature in relation to the provision of palliative care in Indonesia and to identify factors that may impact on palliative care development. BACKGROUND People living with life-limiting illness benefit from access to palliative care services to optimize quality of life. Palliative care services are being expanded in developing countries but in Indonesia such services are in their infancy with many patients with life-limiting illnesses having access to appropriate health care compromised. METHODS Relevant healthcare databases including CINAHL, PubMed, Science Direct and Scopus were searched using the combinations of search terms: palliative care, terminal care, end-of-life care, Indonesia and nursing. A search of grey literature including Internet sites was also carried out. RESULTS Nine articles were included in the review. Facilitating factors supporting the provision of palliative care included: a culture of strong familial support, government policy support, volunteering and support from regional organizations. Identified barriers to palliative care provision were a limited understanding of palliative care among healthcare professionals, the challenging geography of Indonesia and limited access to opioid medications. CONCLUSIONS There are facilitators and barriers that currently impact on the development of palliative care in Indonesia. Strategies that can be implemented to improve palliative care include training of nurses and doctors in the primary care sector, integrating palliative care in undergraduate medical and nursing curriculum and educating family and community about basic care. Nurses and doctors who work in primary care can potentially play a role in supporting and educating family members providing direct care to patients with palliative needs.