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PubMed2000

Utilizing research in practice and generating evidence from practice.

This paper gives an overview of evidence-based practice in health promotion, with reference mainly to the National Health Service (NHS) context within the UK, but with wider international relevance. It starts by looking at the tensions raised at the interface of the two activities of research and health promotion. It goes on to explore two aspects of evidence-based practice: incorporating research evidence into health promotion activity and developing robustly evaluated practice in such a way as to feed the developing research agenda. Each of these two aspects is explored using a specific example, from within the UK. Finally, the paper goes on to make eight recommendations that taken together would help create an iterative process contributing to the development of health promotion theory and practice.

Evidence-Based Medicine↗
PubMed2000

Using evidence-based practice for managing clinical outcomes in advanced practice nursing.

Preparation of advanced practice nurses to assume leadership positions for clinical decision making requires that traditional ways of solving clinical problems be augmented with information from relevant, research-derived evidence. In this article, the authors describe how one graduate program prepares advanced practice nurses to use the best scientific evidence with clinical expertise to influence patient outcomes. The assignments that students complete in their program provide examples of evidence-based practice that apply quality improvement principles and science-based nursing interventions to create best practices.

Education, Nursing, Graduate↗
PubMed2004

"The mirror" and "the village": a new method for teaching practice-based learning and improvement and systems-based practice.

PURPOSE: Practice-based learning and improvement (PBLI) and systems-based practice (SBP) may be conceptually difficult for both residents and faculty. Methods for introducing these concepts are needed if PBLI and SBP are to be incorporated into education and practice. METHOD: In 2001, PBLI and SBP were introduced at Johns Hopkins Bayview Medical Center in Baltimore, Maryland, using the metaphors "the mirror" and "the village." PBLI was likened to residents' holding up a mirror to document, assess, and improve their practice. Specific tools for residents (e.g., weekly morbidity and mortality morning reports, continuity clinic chart self-audits, and resident learning portfolios) became the mirrors. SBP was introduced through specific training activities (e.g., multidisciplinary patient care rounds, nursing evaluations, and quality assessment-systems improvement exercises) using the metaphor of the village made famous by Hillary Clinton in the phrase: "It takes a village to raise a child." Residents completed a questionnaire in which they rated these initiatives' impact on their training. RESULTS: The majority of residents who participated in specific activities agreed that quality assessment-systems improvement exercises (92.9%), multidisciplinary rounds (92.1%), morbidity and mortality morning reports (86.8%), clinic chart self-audits (76.4%), and nursing evaluations (52.8%) helped to improve their proficiency in specific aspects of PBLI and SBP. Residents' retrospective self-assessments of their PBLI abilities demonstrated significant improvement after the introduction of specific training activities. CONCLUSIONS: PBLI and SBP can be introduced effectively in residency training by incorporating specific activities that use the metaphors of the mirror and the village.

Baltimore↗
PubMed1995

Differences in professional practice model outcomes: the impact of practice setting.

Over the past several years, involvement strategies such as professional practice models and shared governance strategies have been implemented in a variety of nursing practice settings. This article reviews the results of a secondary analysis of an evaluation of a professional practice model at a large academic medical center. This review compares critical care and general acute care nurses in terms of their perceptions of and satisfaction with work in a professional practice environment and identifies and contrasts significant predictors of general job satisfaction and turnover intent within the two groups. Implications of differences in outcomes in different settings are explored.

Humans↗
PubMed2000

Tel-eNurse Practice: a practice model for role expansion.

RNs are expanding their role in the continuum of care, incorporating telecommunication into their practice to provide efficient and effective patient care. However, role expansion requires the definition and articulation of nursing practice and related outcomes. The Tel-eNurse Practice Model is a theoretical framework nurses can use to define and guide the complex process of care in the telephone encounter. Application of the model gives nurse administrators a way to identify competencies and develop standards of practice and quality and outcomes measurement tools.

Decision Making↗
PubMed2002

Tel-eNursing practice: setting standards for practice across the continuum of care.

What was thought to be a quick and limited quality performance improvement (QPI) project between a few departments providing telephone nursing services became an involved organization-wide QPI project to standardize telephone practice. Initially, telephone nursing practice, expanded roles of nurses, and extent of healthcare professionals using the telephone to provide care from afar were not well understood. Lack of standardization and quality and risk management issues were identified. The Good Samaritan Community Healthcare QPI plan of action provided the roadmap to standardize telephone practice across the organization. Many leadership challenges occurred along the road to QPI for telephone practice, as caution signs were acknowledged, hills were climbed, and corners maneuvered.

Humans↗
PubMed1979

The physician assistant in rural primary care practices: physician assistant activities and physician supervision at satellite and non-satellite practice sites.

Nineteen practice sites in Iowa were studied to determine the differences in the types of physician (MD) supervision the physician assistant (PA) received at work at satellite (separate from the major practice site of the supervising MD) and non-satellite practice sites. The MDs supervised PA functions in 12.9 per cent of the patients seen by the PAs at non-satellite and 15.9 per cent of patients they saw at satellite practice sites. All patients with presenting manifestations that suggested life-threatening conditions were seen by MDs at satellite and non-satellite sites. The MD spent 9.2 minutes per patient at satellite clinics, compared to 4.4 minutes per patient at non-satellite clinics. PAs working at satellite sites appeared to receive as much supervision as PAs working at non-satellite clinics.

Clinical Competence↗
PubMed1997

The advanced practice nurse's role in differentiated practice: Martha's story.

The changing health care environment and increasing patient acuity necessitate a coordinated effort among all health care disciplines to assure the best patient outcomes. The advanced practice nurse in the role of case manager is well qualified to serve as the leader of this team. Within the framework of differentiated practice, advanced practice nurses work in tandem with associate and primary nurses to ensure positive quality, financial, and satisfaction outcomes. Clinical expertise and knowledge of systems allow the advanced practice nurse to assist the patient through complex systems to achieve these ends.

Case Management↗
PubMed2006

A practical application of practice-based learning: development of an algorithm for empiric antibiotic coverage in ventilator-associated pneumonia.

BACKGROUND: Development of practice-based learning (PBL) is one of the core competencies required for resident education by the Accreditation Council for Graduate Medical Education, and specialty organizations including the American College of Surgeons have formed task forces to understand and disseminate information on this important concept. However, translating this concept into daily practice may be difficult. Our goal was to describe the successful application of PBL to patient care improvement with development of an algorithm for the empiric therapy of ventilator-associated pneumonia (VAP). METHODS: The algorithm development occurred in two phases. In phase 1, the microbiology and timing of VAP as diagnosed by bronchoalveolar lavage was reviewed over a 2-year period to allow for recognition of patterns of infection. In phase 2, based on these data, an algorithm for empiric antibiotic coverage that would ensure that the large majority of patients with VAP received adequate initial empiric therapy was developed and put into practice. The period of algorithm use was then examined to determine rate of adequate coverage and outcome. RESULTS: : In Phase 1, from January 1, 2000 to December 31 2001, 110 patients were diagnosed with VAP. Analysis of microbiology revealed a sharp increase in the recovery of nosocomial pathogens on postinjury day 7 (19% < day 7 versus 47% > or = day 7, p = 0.003). Adequate initial antibiotic coverage was seen in 74%. In Phase 2, an algorithm employing ampicillin- sulbactam for coverage of community- acquired pathogens before day 7 and cefipime for nosocomial coverage > or =day 7 was then employed from January 1, 2002 to December 31, 2003. Evaluation of 186 VAP cases during this interval revealed a similar distribution of nosocomial cases (13% < day 7 versus 64% > or = day 7, p < 0.0001). Empiric antibiotic therapy was adequate in 82% of cases or =day 7: overall accuracy improved to 83% (p = 0.05). Mortality from phase 1 to phase 2 trended toward a decrease (21% versus 13%, p = 0.1). CONCLUSIONS: Application of the concept of PBL allowed for identification of local patterns of infection and development of an institution specific treatment algorithm that resulted in >80% adequate initial empiric coverage for VAP with a trend toward decreased mortality. PBL allows for alteration in practice based on local patterns and outcomes and has the potential to improve patient care.

Algorithms↗
PubMed2005

Epilepsy--success in clinical practice: translating trials to practice.

Success in clinical practice results from the combination of a clinician's experience, an understanding of patient preferences and factors that influence patient perceptions, and careful interpretation of data from clinical trials. However, successful clinical trials fulfil rigid methodological requirements in order to provide a basis from which to evaluate the place of a drug within a therapeutic strategy. Their translation into practice is therefore complicated by an intrinsic tension between the requirements for scientific methods that minimize error, and the need for clinically relevant data. In practice, the clinician has the flexibility to individualize epilepsy management to maximize benefits and minimize adverse effects of antiepileptic drug (AED) therapy. AED adverse effects and psychiatric comorbidity, in particular depression, have a profound impact on subjective health status; systematic screening for these confounding variables can guide clinical management and optimize quality of life. In addition, patient preferences can be acknowledged in any management plan. To achieve success in clinical practice, we need to remember that the information gleaned from clinical trials provides only part of the picture and needs to be augmented by our clinical experience, patient assessment (including routine screening for adverse effects and depression) and patient preference.

Anticonvulsants↗
PubMed1994

Description of the clinical practice of advanced practice nurses in family-centered early intervention in two rural settings.

The purpose of this study was to describe the scope of clinical practice of advanced practice nurses who were involved in a project designed to increase access of families with at-risk and disabled young children, newborn to 3 years of age, to early intervention services in rural Washington State. The findings from this study are based on the retrospective review of records of clients seen by the advanced practice nurses. Nursing diagnoses and nursing interventions were assigned to chart recordings. The most frequently occurring nursing diagnoses assigned to parents were Altered Parenting, Altered Family Processes, Fear, Noncompliance, and Knowledge Deficit. The most frequently occurring nursing diagnoses assigned to children were Impaired Physical Mobility, Impaired Verban Communication, Altered Nutrition: Less than Body Requirements, Sensory-Perceptual Alteration, and Altered Thought Processes. Categories of nursing intervention recorded most frequently were Monitoring, Planning and Information. Discussion of findings addresses the roles and reimbursement of advanced practice nurses who provide family-centered early intervention services in rural communities.

Child, Preschool↗
PubMed1996

Practical reasons and reasonable practice: the case of euthanasia in The Netherlands.

Since the early 1970s the issue of euthanasia has been intensely debated in The Netherlands. Through these debates knowledge about medical practices involving the end of life was no longer confined to medical or legal quarters, but became public to a large extent. Following public opinion changes, the legal reaction to euthanasia changed. By prosecuting test cases the public prosecutors allowed the Dutch Supreme Court to formulate specific conditions in which euthanasia would go unpunished. The political debate about changing the criminal law, which still holds that euthanasia is a serious crime, developed at a much slower pace. Several extensive empirical studies were undertaken to gain valid knowledge about the medical practices. This article is concerned with a presentation of the various debates and the changes that took place in the fields of criminal law, politics, and medicine. The main conclusion is the hypothesis that a more open climate for medical practices concerning the end of life allows society to better control these practices.

Attitude↗
PubMed2001

Molecular pathology of solid tumours: some practical suggestions for translating research into clinical practice.

"Molecular pathology" can be broadly defined as the use of genetic data, in addition to the standard pathological parameters, to optimise diagnosis and to indicate treatment and prognosis. The benefit to be gained from the exploitation of molecular techniques to provide additional information to aid patient management is potentially vast. Currently, molecular pathology is rarely used in clinical practice, although it is anticipated that it will eventually become a part of routine practice. However, incorporating molecular techniques into routine practice will not be straightforward because there are several issues to be resolved. Following on from a symposium held at the Royal College of Pathologists to discuss some of these issues, the establishment of a committee of molecular pathology is proposed to plan and coordinate the introduction of molecular pathology into routine clinical practice.

Congresses as Topic↗
PubMed2005

Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs.

AIM: To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage. METHODS: Two focus groups were held at the outset of an evaluation of Treat and Refer (T&R) protocols: one with staff based at an ambulance station who were to implement the new service (intervention station), and the other with staff from a neighbouring station who would be continuing their normal practice during the study (control station). A third session was held with staff from the intervention station following training and 3 months' experience of protocol usage. RESULTS: Before the introduction of the T&R protocols, crews reported experience, intuition, training, time of call during shift, patient preference, and home situation as influencing their decisions concerning conveyance. Crews were positive about changing practice but foresaw difficulties with advising patients who wanted to go to hospital, and with referral to other agencies. Following experience of T&R protocol use, crews felt they had needed more training than had been provided. Some felt their practice and job satisfaction had improved. Problems with referral and with persuading some patients that they did not need to go to hospital were discussed. There was consensus that the initiative should be introduced across the service. CONCLUSIONS: With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.

Ambulances↗
PubMed2005

Public health advocacy to change corporate practices: implications for health education practice and research.

Corporate practices, such as advertising, public relations, lobbying, litigation, and sponsoring scientific research, have a significant impact on the health of the people in the United States. Recently, health professionals and advocates have created a new scope of practice that aims to modify corporate practices that harm health. This article describes how corporate policies influence health and reviews recent health campaigns aimed at changing corporate behavior in six industries selected for their central role in the U.S. economy and their influence on major causes of mortality and morbidity. These are the alcohol, automobile, food, gun, pharmaceutical, and tobacco industries. The article defines corporate disease promotion and illustrates the range of public health activities that have emerged to counter such corporate behaviors. It analyzes the role of health professionals, government, and advocacy groups in these campaigns and assesses the implications of this domain for health education practice and research.

Consumer Advocacy↗
PubMed2006

Impoverishment of practice: analysis of effects of economic discourses in home care case management practice.

Home care is a health sector under increasing pressure. Demand is often said to be outstripping capacity, with constant change and retrenchment distinguishing features of the current context. This paper takes a reading of the current conditions of home care using data gathered during a field study of home care case management practices conducted in 2004. As economic discourses become increasingly influential in determining responses to client situations, case managers (and their managers) find themselves with limited capacity to exercise control over their practices. A growing gap between professionally influenced discourses--those presumably intended to guide practice--and organizational priorities creates a dissonance for case managers as the political-ethical dimensions of their practices are displaced by budget "realities." For front-line workers, such displacement cannot be sustained in their face-to-face encounters with clients, leading to a growing sense of frustration and powerlessness among these highly skilled practitioners.

Anthropology, Cultural↗
PubMedDate not supplied

A practical guide to assessing nursing students in clinical practice.

Preregistration student nurses and qualified nurses undertaking clinical programmes of study spend a substantial proportion of their courses in practice settings where they are contributing to patient care. Much of the accountability for assessing the clinical competence of learners lies with the nursing team with whom a student is working. Assessment is a significant responsibility and one which many professionals find complex, and hence challenging and time consuming (Rowntree, 1987). Making effective use of the time available for assessment is an important component of student learning, and is essential in order to determine competence to practice. This article seeks to offer practical guidance on how to tackle the assessment of nursing students in clinical practice so that the process is both rigorous and manageable.

Clinical Competence↗
PubMedDate not supplied

One key to practice growth: improving other practice encounters.

Practice growth is related to more than the encounter between the patient and physician. Those other practice contacts and exposures involving the staff, the bill, and the medical office environment can impact a medical group practice's growth. At CMC, initiatives taken by its leadership to address these encounter points have contributed to the reduction of patient dissatisfaction. These initiatives have also contributed to other efforts, including accreditation of CMC by the Joint Commission on the Accreditation of Health Care Organizations. Most importantly, these steps have led to a real change in CMC's community image. The results from a recently compiled patient satisfaction survey, while hardly scientific, showed high patient satisfaction with all major elements of the practice, including the physicians, the staff, the patient bills, and the medical office environment.

Academic Medical Centers↗