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PubMed1999

The John Charnley Award. Practice surveillance: a practical method to assess outcome and to perform clinical research.

The senior author systematically began collecting preoperative and postoperative data on all the total hip arthroplasties he performed starting in July 1970. The data collected represent a 26-year experience using practice surveillance (preoperative and regular interval postoperative collection and analysis of outcomes) as a method to document the outcome of the total hip arthroplasty procedure and as a method to evaluate the need for changes in the procedure. As the senior author made few selected changes in the operative procedure during the followup period, the primary author has been able to evaluate the change in outcome based on these changes. The six studies reported in the current study show the durability of the long-term results of cemented total hip arthroplasty, the improvement in radiographic reproducibility obtained on the femoral side of the construct with improved cementing techniques, the deleterious effects of using cable to reattach the greater trochanter, the deleterious effects of changing femoral component design that included a change in surface finish, the improvement in acetabular fixation using cementless fixation, and the optimization of bearing surface wear using smaller diameter femoral heads. All of these findings have been incorporated into the primary surgeon's practice based on this practice surveillance. As shown, practice surveillance also has provided a tool for performing clinical research. Although practice surveillance of controlled cohorts never will supplant prospective randomized clinical trials in evidence based medicine, it should help each surgeon with his or her own practice and can be used as an important research tool to study the optimization of outcomes of a surgical procedure.

Adult↗
PubMed2001

Champions for evidence-based practice: a critical role for advanced practice nurses.

Evidence-based practice is emerging as a widely accepted paradigm for contemporary professional nursing practice. Institutions and providers of healthcare services are adopting this framework to guide the structure, process, and outcomes of patient care delivery. Advanced practice nurses are ideally prepared and positioned within healthcare delivery systems to champion the integration of this practice as a model for evidence-based patient care. This article highlights opportunities and suggests strategies for advanced practice nurses to serve as catalysts for optimizing patient care through evidence-based practice.

Evidence-Based Medicine↗
PubMed2005

From workshop to work practice: An exploration of context and facilitation in the development of evidence-based practice.

BACKGROUND: This article examines the process of translating evidence into practice using a facilitation model developed by the Western Australian Centre for Evidence Based Nursing and Midwifery. AIMS: Using the conceptual framework Promoting Action on Research Implementation in Health Services (PARIHS), the aims of the study were (1) to explore the relative and combined importance of context and facilitation in the successful implementation of a new evidence-based clinical practice protocol and (2) to examine the establishment of more lasting change to individuals and organizations that resulted in greater incorporation of the principles of evidence-based practice (EBP). METHODS: A pre-workshop, semi-structured telephone survey with 16 nurse managers in six rural hospitals; a summative evaluation immediately post-workshop with 54 participants; and follow-up, semi-structured interviews with 23 workshop participants. FINDINGS: The contexts in each of the participating hospitals were very different; of the six hospitals, only one had not implemented the new protocol. Five had reviewed their practices and brought them in line with the protocol developed at the workshop. The rate of adoption varied considerably from 2 weeks to months. The participants reported being better informed about EBP in general and were positive about their ability to improve their practice and search more efficiently for best practice information. Underlying motivations for protocol development should be included in the PARIHS framework. IMPLICATIONS FOR EDUCATION: Good facilitation appears to be more influential than context in overcoming the barriers to the uptake of EBP.

Diffusion of Innovation↗
PubMed2004

Technical, practical, and emancipatory reflection for practicing holistically.

The intention to practice holistically brings with it many complexities in deciding how to manage the contingencies of practice in such a way as to embody the central tenets of holistic nursing. The challenge of making sense of daily work procedures, interpersonal interactions, and issues of power can be eased by attention to reflective processes designed for nursing practice. Reflective nurses who practice holistically optimize the likelihood of thinking systematically through practice issues as they encounter the world of nursing and the people and events within it. This article is an exploration of the phenomena of holism and reflection as they relate to technical, practical, and emancipatory reflective processes used by nurses in their daily work.

Clinical Competence↗
PubMedDate not supplied

Parallels in practice: palliative nursing practice and Parse's theory of human becoming.

Nurses experienced in the art and science of palliative nursing will find many elements of congruence between the principles and philosophy of palliative practice and the theory of human becoming. In this brief exploration of parallels in practice between Parse's theory of human becoming and traditional palliative and hospice nursing practice, the author suggests that the theory of human becoming is consistent and consonant with the values that shape palliative nursing practice. The theory is briefly described, and four parallels of practice are identifed: whole person care; the presence of paradox in human experience; primacy of the person; and presence and dialogue, or "being with, " dying persons. The theory of human becoming holds relevance and promise in its capacity to provide palliative and hospice nurses with a theoretical framework with which to inform and guide nursing practice with dying persons.

Holistic Health↗
PubMed2005

District and practice nurses' public health practice and training needs.

In 2000, the UK government set out its plan to tackle poor health in 'Saving Lives: Our Healthier Nation'. Practice and district nurses were recognized as key health professionals in achieving the integration of health improvement into the local delivery of health care. In order to respond to these changes, North Tyneside PCT undertook a training needs and skills analysis of local practice and district nurses. Thirty practice nurses and 39 district nurses returned completed questionnaires. Practice and district nurses rated their competence as lower in public health skills than in clinical skills and also rated them of less importance. Senior practice and district nurses indicated that they perceived low value in skills required to move forward public health practice within community nursing. The findings of this study have been used to develop a 5-day training programme. The approach has relevance to those concerned with making public health a reality within community services.

Community Health Nursing↗
PubMedDate not supplied

Best practice using Excellence in Practice Accreditation Scheme.

This article describes how the University of Teesside School of Health and Social Care practice development team, in partnership with local professional colleagues and organizations, have addressed the issue of providing continuous quality evidence-based practice within the context of clinical governance. The newly devised Excellence in Practice Accreditation Scheme (EPAS) measures the standard of practice for a given health and social care setting by providing objective data indicating the level of clinical excellence obtained for the team or organization. The EPAS differs from other organizational accreditation schemes by facilitating excellence based upon a comprehensive set of measurable core standards: working in organizations, collaborative working, user-focused care, continuous quality improvements, performance management, and measuring efficiency and effectiveness. The standards are derived from a professional peer review of best practices. The uniqueness of EPAS is in consolidating the various organizational standards to elicit the core themes related to best practice where individuals, teams and organizations can be benchmarked and accredited for a level of excellence.

Accreditation↗
PubMed2001

Application of admissions criteria to applicants with practice versus non-practice career goals in North American schools /colleges of veterinary medicine.

PURPOSE: The study was intended to determine whether North American veterinary schools/colleges apply admissions criteria differently to applicants with practice versus non-practice career goals. METHODOLOGY: A written questionnaire with seven queries on admissions criteria was sent to the associate deans for academic affairs at each of the 31 North American veterinary schools/colleges. RESULTS: Questionnaires were completed and returned by 25 of the 31 institutions. The responses were summarized and individual comments were compiled. For veterinary and animal experience, similar amounts but different types of experiences were acceptable to most institutions for applicants with practice versus non-practice career goals. The required pre-veterinary course work was not different for the two groups of applicants. The backgrounds of mentors providing written evaluations were often allowed to be different for the two groups of applicants. The responses expected in applicant interviews were different for the two groups for queries related to veterinary and career experiences and knowledge of specific career areas but were similar for various basic qualities and skills expected of all applicants. CONCLUSION: Although institutions vary, North American veterinary schools/colleges tend to apply admissions criteria differently to applicants with practice versus non-practice goals, except for pre-veterinary course requirements.

Career Choice↗
PubMed1998

Introduction of the blood pressure cuff into U.S. medical practice: technology and skilled practice.

The history of the sphygmomanometer, or blood pressure cuff, raises useful questions about the acceptance of new medical technologies. When the blood pressure cuff first appeared in U.S. medical practice in the first decade of the 1900s, it generated some concern and debate among physicians. Review of the medical literature, a systematic study of patient records from Massachusetts General Hospital, and consideration of events in Boston during this period suggest that physicians faced several important choices associated with the early acceptance of the cuff. The introduction of the blood pressure cuff presented physicians with several different, competing methods for assessing the force of a patient's blood flow. Physicians chose to use the cuff in a manner that preserved their exclusive use of the new tool and maintained a high level of skill for their individual practices. An early proposal to introduce the new blood pressure cuff as a simple tool for nursing use met with resistance. Many physicians initially favored a competing practice of assessing the force of blood flow by pulse palpation. Physicians eventually dropped the practice of subjectively palpating the force of blood flow and came to rely increasingly on the measurement of blood pressure using auscultation. Even after adopting the cuff into practice, however, they had little interest in completely standardizing the use of the blood pressure cuff across the practices of individual physicians.

History, 20th Century↗
PubMed1999

Assessing the practicality of research findings for clinical practice.

Reading research articles can be challenging, but it also can be stimulating. Once you get a system for reviewing articles and interpreting their worth and value to your practice, you will find much usable information. Reviewing articles with the focus of assessing their importance to clinical practice could be done with a research committee of your local AORN chapter. It also would be an interesting and informational chapter program to have a panel discuss the relevance of two or three studies to perioperative practice. This process and type of information also can be used if your institution is developing research teams. Assessing the practicality of research to your practice is essential. Research is not a mystery; it is the answer to a mystery. It is necessary to the future of perioperative nursing. Change practice with empirical evidence!

Data Interpretation, Statistical↗
PubMedDate not supplied

Advanced practice issues: results of the ONS Advanced Practice Nursing survey.

PURPOSE/OBJECTIVES: To ascertain the critical issues in current advanced practice nurse (APN) roles in oncology. DESIGN: Descriptive. SETTING: National. SAMPLE: 368 Oncology Nursing Society (ONS) APNs in oncology practice. METHODS: Subjects completed an 11-page self-administered questionnaire comprised of 62 multiple-choice and open-ended questions. Subjects were asked to identify level of importance for ONS to address selected issues in each section. MAIN RESEARCH VARIABLES: Demographic information and APN issues regarding practice, outcomes, prescriptive authority, reimbursement, education, continuing education, licensure and certification, legislation, and challenges facing oncology APNs. FINDINGS: The majority of APNs were nurse practitioners working in a hematology/oncology practice in an urban setting providing direct patient care. Priority practice issues were lack of agreement among state boards of nursing related to privileges, lack of understanding of the role by patients and healthcare professionals, and lack of an APN definition. Important APN outcomes were symptom management, quality of life, patient/family satisfaction, and cost of care. Priority educational topics were oncology disease management, pharmacology, advanced physical assessment, and reimbursement. Challenges facing oncology APNs were lack of an APN definition, reimbursement issues, documentation of outcomes, prescriptive authority, variance in education, merging of current roles, certification, loss of cancer specialty, and second licensure. CONCLUSIONS: Numerous APN issues continue to be unresolved. APN outcomes research is needed to validate the oncology APN role in cancer care. IMPLICATIONS FOR NURSING PRACTICE: Survey results and specific recommendations have been forwarded to the ONS Steering Council and Board of Directors for implementation decisions.

Attitude of Health Personnel↗
PubMed2000

Evidence-based practice and the advanced practice nurse: a curriculum for the future.

The concept of evidence-based practice has gained increased attention throughout the 1990s as a strategy for linking the best scientific findings with clinical judgment to improve health outcomes. Because the concept implies finding, evaluating, summarizing, and using research results, a high level of clinical reasoning skills is required. Effective evidence-based practice also requires the incorporation of new practices into clinical and organizational settings, thereby demanding advanced leadership skills. Competencies in clinical reasoning, leadership, and clinical practice are critical for advanced practice nurses. This article describes a master's-level curriculum supportive of evidence-based practice and includes recommendations for developing curricula of this type.

Curriculum↗
PubMed2005

Do guidelines guide pneumonia practice? A systematic review of interventions and barriers to best practice in the management of community-acquired pneumonia.

Successful guideline implementation programs need to understand local barriers, incorporate multiple component interventions, and proceed within a framework of continuous quality improvement. We found few intervention studies to improve CAP guideline adherence and no controlled studies that used certain practice changes strategies that have proven effective for other conditions, such as face-to-face educational outreach, use of local opinion leaders, and individualized audit with peer-comparison feedback. Future studies in CAP management need to use rigorous study designs, use multiple evidence-based strategies to change practice, and convincingly demonstrate to front-line health care providers that the suggested interventions are safe and improve patient outcomes. Paper does not change practice, and the creation and mailing out of a practice guideline for the treatment of CAP is only the first necessary step in translating good evidence into everyday clinical practice.

Alberta↗
PubMed2003

The impact of stroke practice guidelines on knowledge and practice patterns of acute care health professionals.

RATIONALE, AIMS AND OBJECTIVES: The Agency for Healthcare Research and Quality's Post-Stroke Rehabilitation Guidelines were developed to improve the quality, appropriateness and effectiveness of rehabilitation practices. An important goal of the guidelines process is to disseminate information to practitioners in order to encourage adoption of effective practices. To date, no systematic evaluation of these guidelines has been completed, nor has a programme been designed to evaluate the effectiveness of an educational programme about the guidelines. The objective was to evaluate changes in knowledge and practice following presentation of a lecture-based, educational programme about post-stroke rehabilitation guidelines. METHODS: The research design was a single group, pre-test-post-test design without a comparison group. A knowledge and referral practices questionnaire was developed specifically for this study. RESULTS: Lecture attendance was not associated with an increase in knowledge or referrals. However, we found that respondents who made more referrals at follow-up had a higher knowledge level at pre-test. Also, those who completed a follow-up assessment knew more about the guidelines at the initial assessment than did those who did not complete the follow-up assessment. In addition, doctors knew more about stroke rehabilitation than the non-doctors, both at the pre-test and follow-up. DISCUSSION AND CONCLUSIONS: Encouraging behaviour change among doctors and allied health professionals in referrals and clinical practice is a complicated process. Providing individual follow-up and lengthier contacts, assuring that care providers receive high-quality evidence that guidelines improve care, and consulting with key decision-makers about guideline implementation might enhance behaviour change.

Chicago↗
PubMed2001

Physician credentials and practices associated with childhood immunization rates: private practice pediatricians serving poor children in New York City.

Private practice physicians in New York City's poorest neighborhoods are typically foreign trained, have generally substandard clinical practices, and have been accused of rushing Medicaid patients through to turn a profit. However, they also represent a sizable share of physician capacity in medically underserved neighborhoods. This article documents the level of credentials, systems, and immunization-related procedures among these physicians. Furthermore, it assesses the relationship between such characteristics and childhood immunization rates. The analysis utilizes a cross-sectional comparison of immunization rates in 60 private practices that submitted 2,500 or more Medicaid claims for children. Immunization data were gathered from medical records for 2,948 randomly selected children under 3 years of age. Half of sampled physicians were board certified (55%), and half were accepted by the Medicaid Preferred Physicians and Children (PPAC) program (51.7%). Of physicians, 43% saw patients only on a walk-in basis, while only 17% scheduled the next appointment while the patient was still in the office. There were 75% of the physicians who reported usually immunizing at acute care visits. Immunization rates were higher among PPAC physicians compared to others (41% vs. 29% up to date for diphtheria and tetanus toxoids and pertussis [DTP]/Haemophilus influenzae type b [Hib], polio, and measles-mumps-rubella [MMR], P = .01), and board-certified physicians showed a trend toward better immunization rates (39% vs. 30%, P =.07). Physicians who reported usually immunizing at acute care visits also had higher rates than those who did not (38% vs. 27%, P = .05). Scheduling a date and time for the next immunization showed a trend toward association with immunization coverage (37% vs. 28%, P= .10). Private practice physicians who provide high volumes of care reimbursed by Medicaid have improved their credentials and affiliations over time, thereby expanding reimbursement options. Credentials and affiliations were at least as effective in distinguishing relatively high- and low-performing physicians, as were immunization-related practices, suggesting that they are useful markers for higher quality care. The relative success of the PPAC program should inform efforts to improve the capacity and quality of primary care for vulnerable children. Appointment and reminder systems that effectively manage the flow of children back into the office for immunizations and the vigilant use of acute care visits for immunizations go hand in hand. Opportunity exists for payers and plans to encourage and support these actions.

Certification↗
PubMed2000

Age, sex and practice variations in the use of statins in general practice in England and Wales.

BACKGROUND: Statins are highly effective in reducing the risk of sudden cardiac death and other acute coronary events in patients with pre-existing ischaemic heart disease or with raised blood cholesterol levels. However, relatively little is known about how statins are used in primary care. The objectives of this study were to investigate age, sex and inter-practice variations in the prescribing of statins. METHODS: This was an observational study of statin prescribing rates in 288 general practices in England and Wales that contributed data to the General Practice Research Database in 1996. RESULTS: In 1996, 0.7 per cent of men and 0.5 per cent of women received a prescription for a statin. In the subgroup of patients with a general practitioner (GP) diagnosis of ischaemic heart disease, 13.3 per cent of men and 8.2 per cent of women received a prescription for a statin in 1996. Below the age of 65 years, men with ischaemic heart disease were more likely to be prescribed a statin than were women. Patients aged 75 years and over with ischaemic heart disease were unlikely to be prescribed a statin irrespective of their sex. The percentage of patients prescribed statins in individual practices varied from 0.1 to 2.3 per cent in men and from 0 to 2.3 per cent in women. The recorded prevalence of ischaemic heart disease explained only 12 per cent of this variation in men and 7 per cent in women. CONCLUSIONS: There are large age, sex and inter-practice variations in the use of statins in primary care, which are poorly explained by measures of health need. Developing and implementing clinical guidelines to accompany the introduction of new drugs for the management of common chronic disorders should be seen as a priority for GPs, primary care groups and the National Institute of Clinical Excellence.

Adult↗
PubMedDate not supplied

Best practice guidelines: an invitation to reflect on Therapeutic Touch practice.

Best practice guidelines can support nurses in providing consistent, evidence-based quality care. This article describes the values and beliefs underlying a best practice guideline for client-centered care and the process used by the author to translate this guideline into reflective questions specific to Therapeutic Touch practice. Applying best practice guidelines in this way, to enhance reflection on a particular aspect of practice, can "bring them to life," facilitating implementation and allowing new possibilities to emerge for improving client care.

Attitude of Health Personnel↗
PubMedDate not supplied

Differences in physician referral practices and attitudes regarding hereditary breast cancer by clinical practice location.

PURPOSE: To compare physician referral practices and attitudes regarding hereditary breast cancer by clinical practice location. METHODS: A self-administered survey of 214 physicians in Ohio's tri-state region. RESULTS: Rural-practice physicians were less likely to have ever referred for an indication of hereditary breast cancer than urban- and suburban-practice physicians combined. Rural-practice physicians reported stronger barriers to referral, including distance, lack of awareness, lack of effective cancer risk reduction, and lack of patient interest. CONCLUSION: These findings demonstrate a need for increased clinical genetics outreach, physician education, and public awareness of genetic services for hereditary breast cancer in rural areas.

Attitude of Health Personnel↗