Creating room for evidence-based practice: Leader behavior in hospital wards.

The integration (routinizing and sustaining) of evidence-based practice (EBP) into hospital management is a key element for improving patient safety and ensuring better patient outcomes. Hospital managers and clinical leaders play crucial roles in this integration. Interactions between leaders and integration context influence the improvement's quality, but leader-based actions that are effective for improving nursing practice remain unclear. The relationship between leaders could also either hinder or enable this implementation process. The aim of this study was to generate a theory about patterns of leader behavior that leaders are engaged in when attempting to integrate EBP in a clinical setting. We used a classic grounded theory methodology to generate a substantive EBP theory. In this study, through participant observation, we observed 63 nurses (15 specialist, 39 registered, and 9 assistant nurses). From these, five ward leaders (two head nurses, one assistant head nurse, and two teaching nurses) participated in individual interviews, and 18 clinical nurses participated in four focus groups. "Creating room for EBP" emerged as a theory for explaining the way in which the leaders attempted to resolve their main concern: How to achieve EBP treatment and care with tight resources and without overextending the nurses. Creating room for EBP encompasses a process of interactions, including positioning for, executing, and interpreting responses to EBP.

Mothers' experiences learning and performing infant massage-A qualitative study.

AIMS AND OBJECTIVE: To explore the experience of learning infant massage among mothers who are having insecurity and stress in their transition to motherhood. BACKGROUND: Secure attachment is essential for healthy infant development. An interaction with the caregiver, characterised by sensitivity, engagement and adequate responding, is necessary for the development of attachment. However, transition to parenting can be a major challenge and create insecurity and stress for some mothers. This can interfere with mother's attachment and sensitivity to the baby's cues, which in turn can affect the mother-infant interaction. Mothers who struggled postpartum were invited to participate in a group called Mamma Mia, a programme where mothers learn infant massage as targeted measure for improving interaction between the mother and baby. To date, there is limited knowledge how mothers receiving this group programme experience infant massage. DESIGN AND METHOD: A qualitative and explorative approach was used, based on interviews with 12 mothers who had participated in Mamma Mia group facilitated by public health nurses at Well Child Clinics in Norway. We used qualitative content analysis with manifest and latent content to analyse the transcripts. RESULT: One main theme emerged: "A relief with an opportunity for emotional and physical connection with the baby" and four categories were identified to highlight the mothers' experiences through (a) appreciating the structure, (b) providing self-esteem and self-confidence, (c) connecting with the baby and (d) discovering the baby's presence. CONCLUSIONS: Mothers in this study in Norway enjoyed the experience of learning infant massage and felt closer to their babies as a result. RELEVANCE TO CLINICAL PRACTICE: Training of health professionals to provide infant massage to mothers in a Mamma Mia group or similar groups can be a low cost and efficient intervention in primary care.

Maternity groups in the postpartum period at well child clinics - mothers' experiences.

AIMS AND OBJECTIVES: To explore mothers' experiences as participants in maternity groups at well child clinics (WCCs). BACKGROUND: The level of psychological distress that new mothers have may be related to the quantity of social support they receive. Maternity groups to support new parents have a long tradition at WCCs in Norway, and most of the clinics have offered these groups. However, there is little knowledge about mothers' experiences of participating in these groups. DESIGN: Qualitative design. METHOD: Focus group interviews with mothers who had participated in maternity groups facilitated by public health nurses (PHNs) at WCCs. Interpretive description was used to analyse the transcripts from the interviews. RESULTS: Eight focus group interviews were conducted with a total of 30 mothers who had participated in maternity groups at WCCs in two counties in eastern Norway. The analysis resulted in one main category, 'The maternity group's salutogenic importance' and three subcategories, 'Networks that can last for many years', 'Fellowship with others in the same situation' and 'Become confident in mothering'. CONCLUSION: Mothers wanted fellowship and found it important to share experiences with other mothers. Maternity groups offered to parents are essential to meet parents' need to discuss experiences and challenges related to parenting. Maternity groups can also create a basis for establishing a social network for those who want it. RELEVANCE TO CLINICAL PRACTICE: Well child clinics should offer all mothers the opportunity to participate in groups to strengthen their social relations and their confidence in parenting. PHNs play an important role in facilitating groups for first-time parents. Group leadership can influence how mothers in a group connect and whether the parental role is affected.

Adolescents' experiences on coping with parental multiple sclerosis: a grounded theory study.

AIMS AND OBJECTIVES: To gain insight into what adolescents see as their main concern when having parents who suffer from multiple sclerosis, and develop concepts and theory that may explain how they cope with this concern. BACKGROUND: Health professionals have a special responsibility towards children of parents with chronic diseases, including multiple sclerosis. Few studies show the perspective of the adolescents themselves, and point out that further knowledge is needed. Previous research supports the need for intervention at a youth, parent and family level. DESIGN: Grounded theory. METHODS: We used grounded theory with a generative and constant comparative approach. Data were collected through fifteen individual semi-structured interviews with adolescents aged 12-18 years who had a parent diagnosed with multiple sclerosis. RESULTS: The adolescents' main concern was identified to be preserving control in an uncertain everyday life. This concern was resolved by 'balancing needs', implying the pattern of (1) reflecting, (2) adjusting, (3) taking responsibility and (4) seeking respite. These were used interchangeably in the adolescents' effort to solve their main concern. CONCLUSION: Openness within the family and outwards to the network, is essential for the well-being of the adolescents, and relies on knowledge about the disease, family functioning and support from health professionals. Thus, long-term intervention programs offering information and guidance should be offered. RELEVANCE TO CLINICAL PRACTICE: Understanding the impact of multiple sclerosis on the family from the perspective of the adolescents, gives a basis for health professionals when planning the best possible support for these adolescents. School nurses may play an active role in ensuring a high quality of this work.

Management Involvement--A Decisive Condition When Implementing Evidence-Based Practice.

BACKGROUND: Even though health professionals have a positive attitude toward evidence-based practice (EBP), they have limited skills when it comes to implementation of EBP. A postprofessional program in EPB has been offered at Bergen University College since 2004. To date, there is limited knowledge of how the graduates of the program implement and make use of the EBP principles in their working environment in different healthcare settings. AIM: The aim of the study was to explore the facilitators and strategies to successful implementation of the steps of EBP as experienced by health professionals who had completed a postgraduate program in EBP. METHODS: Grounded theory was used in gathering and analyzing data from single and focus group interviews of 20 health professionals who had attended a postprofessional program in EBP. Inclusion criteria also required current clinical practice. RESULTS: This study identified a specific set of activities used by health professionals when implementing EBP within their service organization. Creating an interest and understanding of EBP amongst their colleagues appeared to be a challenge, which they addressed by using the generated grounded theory of "tailoring principles." The dominant condition of this theory was management involvement. LINKING EVIDENCE TO ACTION: This study highlighted the importance of middle-range managers' coordinating and supporting role as a decisive component in the process of implementing EBP to clinical settings in Norway. Moreover, the dynamic complex process of "tailoring principles" also showed how the production of a clinical protocol became an outcome of implementation effectiveness as well as input for further intervention effectiveness. Tailoring the principle of EBP to the organizational and cultural context facilitated the implementation of EBP.

Nurses experience of using scientific knowledge in clinical practice: a grounded theory study.

BACKGROUND: Guidelines recommend the use of evidence-based practice in nursing. Nurses are expected to give patients care and treatment based on the best knowledge available. They may have knowledge and positive attitudes, but this does not mean that they are basing their work on evidence-based practice. Knowledge is still lacking about what is needed to successfully implement evidence-based practice. AIM: The aim of this study was to gain more knowledge about what nurses perceive as the most important challenge in implementing evidence-based practice and to explain how they act to face and overcome this challenge. METHOD: We used classical grounded theory methodology and collected data through four focus groups and one individual interview in different geographical locations in one large hospital trust in Norway. Fourteen registered clinical practice nurses participated. We analysed the data in accordance with grounded theory, using the constant comparative method. RESULTS: Contextual balancing of knowledge emerged as the core category and explains how the nurses dealt with their main concern, how to determine what types of knowledge they could trust. The nurses' main strategies were an inquiring approach, examining knowledge and maintaining control while taking care of patients. They combined their own experienced-based knowledge and the guidelines of evidence-based practice with a sense of control in the actual situation. CONCLUSION: The grounded theory contextual balancing of knowledge may help us to understand how nurses detect what types of knowledge they can trust in clinical practice. The nurses needed to rely on what they did, and they seemed to rely on their own experience rather than on research.

Parental groups during the child's first year: an interview study of parents' experiences.

AIMS AND OBJECTIVES: To highlight what was important to parents with respect to consultation groups at well-child clinics. BACKGROUND: Parents managing of their role as parents affect the child's health and are therefore an important priority for public health. Well-child clinics in Norway practise consultations in groups to support parents and to facilitate social network; however, few studies explore parents' perspective of this kind of groups. DESIGN: Grounded theory. METHODS: We used classical grounded theory with a generative and constant comparative approach. Data were collected through seven focus groups and two individual interviews with the parents of children aged 8-15 months. RESULTS: The parents were most concerned about how to achieve connection without accountability and how to obtain relevant health information. They managed this by 'multipositioning', encompassing the strategies of: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative and (4) expecting balanced health information. The use of these strategies explains how they resolved their challenges. CONCLUSION: Parental groups seem to be popular and have great potential to establish a social network; however, underestimating the need for structure and continuity in the groups might cause this opportunity to be missed. RELEVANCE TO CLINICAL PRACTICE: Understanding parents' perspectives will be useful when planning strategies to strengthen parental groups at well-child clinics and that the engaged organisers will account for this need to ensure public health work of high quality and effectiveness for parents.

Managing the first period at home with a newborn: a grounded theory study of mothers' experiences.

AIM: The article aims to present a theoretical account of mothers' first period at home with their newborn in Norway. BACKGROUND: Mothers' well-being affects their babies and is therefore an important priority for public health. Early discharge after childbirth is common in many countries. In Norway, this has been practised for 5-10 years but without any distinct agreement between maternity hospitals and the community health services and without documented follow-up care. Knowledge is lacking in how mothers deal with the first period at home with the baby. METHOD: Seven focus group discussions were conducted with 26 mothers who had babies 1.5-3 months old. The grounded theory method was used to gather and analyse data. RESULTS: The mothers were strongly concerned about preserving their control and integrity in the new situation. This main concern was resolved by the strategy of prioritizing newborn care. The strategy encompassed a process of developing competence as a mother, changing focus in relationships, stretching to the critical level and seeking recognition. These parallel processes were inter-related, sometimes mutually supportive and sometimes conflicting. When conflicts occurred, prioritizing newborn care guided mothers in finding solutions. Breaches of the implied conditions in health care tended to increase mothers' level of strain and uncertainty and to influence their efficacy in breastfeeding the baby. CONCLUSION: Being a mother to a newborn is a dynamic and extensive process. Succeeding in breastfeeding seems especially sensitive and essential in motherhood. The idea that giving birth is a simple and normal situation may obscure the importance of seamless health care and the need for professional support and information.

Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room.

BACKGROUND: Even though the use of perioperative checklists have resulted in significant reduction in postoperative mortality and morbidity, as well as improvements of important information communication, the utilization of checklists seems to vary, and perceived barriers are likely to influence compliance. In this grounded theory study we aimed to explore the challenges and strategies of performing the WHO's Safe Surgical Checklist as experienced by the nurses appointed as checklist coordinators. METHODS: Grounded theory was used in gathering and analyzing data from observations of the checklist used in the operating room, in conjunction with single and focus group interviews. A purposeful sample of 14 nurse-anesthetists and operating room nurses as surgical team members in a tertiary teaching hospital participated in the study. RESULTS: The nurses' main concern regarding checklist utilization was identified as "how to obtain professional and social acceptance within the team". The emergent grounded theory of "adjusting team involvement" consisted of three strategies; distancing, moderating and engaging team involvement. The use of these strategies explains how they resolved their challenges. Each strategy had corresponding conditions and consequences, determining checklist compliance, and how the checklist was used. CONCLUSION: Even though nurses seem to have a loyal attitude towards the WHO's checklist regarding their task work, they adjusted their surgical team involvement according to practical, social and professional conditions in their work environment. This might have resulted in the incomplete use of the checklist and therefore a low compliance rate. Findings also emphasized the importance of: a) management support when implementing WHO's Safe Surgical Checklist, and b) interprofessional education approach to local adaptation of the checklists use.

Learning strategies of public health nursing students: conquering operational space.

AIM: To develop understanding of how public health nursing students learn in clinical practice and explore the main concern for the students and how they acted to resolve this main concern. BACKGROUND: How professionals perform their work directly affects individuals, but knowledge is lacking in understanding how learning is connected to clinical practice in public health nursing and in other professions. DESIGN: Grounded theory. METHOD: Grounded theory was used in gathering and analysing data from 55 interviews and 108 weekly reports. The participants were 21 registered nurses who were public health nursing students. RESULTS: The grounded theory of conquering operational space explains how the students work to resolve their main concern. A social process with three identified phases, positioning, involving and integrating, was generated from analysing the data. Their subcategories and dimensions are related to the student role, relations with a supervisor, student activity and the consequences of each phase. Public health nursing students had to work towards gaining independence, often working against 'the system' and managing the tension by taking a risk. Many of them lost, changed and expanded their professional identity during practical placements. CONCLUSION: Public health nursing students' learning processes in clinical training are complex and dynamic and the theory of 'Conquering operational space' can assist supervisors in further developing their role in relation to guiding students in practice. Relationships are one key to opening or closing access to situations of learning and directly affect the students' achievement of mastering. RELEVANCE TO CLINICAL PRACTICE: The findings are pertinent to supervisors and educators as they prepare students for practice. Good relationships are elementary and supervisors can support students in conquering the field by letting students obtain operational space and gain independence. This may create a dialectical process that drives learning forward.

Evidence-based practice integration in hospital wards-The complexities and challenges in achieving evidence-based practice in clinical nursing.

AIM: Exploring the processes involved in two different strategies to integrate evidence-based practice into nursing practice. DESIGN: Classical grounded theory methodology was used. METHODS: Data were collected through 90 hr of observation and 4 focus groups among clinical nurses in two different hospital wards. RESULTS: We identified a multidimensional evidence-based practice integration framework that illuminates the complexities involved in the integration process. The dimensions were approaches to evidence-based practice, positions of evidence-based practice and levels of evidence-based practice. The interactions between the dimensions gave five combinations; an explicit evidence-based practice performed as a parallel to daily work at the systems level, an implicit evidence-based practice integrated into daily work at the systems level, an explicit evidence-based practice integrated into daily work at the individual level, an explicit evidence-based practice integrated into daily work at the systems level and an implicit evidence-based practice integrated into daily work at the individual level.

"Keeping on track"-Hospital nurses' struggles with maintaining workflow while seeking to integrate evidence-based practice into their daily work: A grounded theory study.

BACKGROUND: Evidence-based practice is considered a foundation for the provision of quality care and one way to integrate scientific knowledge into clinical problem-solving. Despite the extensive amount of research that has been conducted to evaluate evidence-based practice implementation and research utilization, these practices have not been sufficiently incorporated into nursing practice. Thus, additional research regarding the challenges clinical nurses face when integrating evidence-based practice into their daily work and the manner in which these challenges are approached is needed. OBJECTIVES: The aim of this study was to generate a theory about the general patterns of behaviour that are discovered when clinical nurses attempt to integrate evidence-based practice into their daily work. DESIGN: We used Glaser's classical grounded theory methodology to generate a substantive theory. SETTINGS: The study was conducted in two different medical wards in a large Norwegian hospital. In one ward, nurses and nursing assistants were developing and implementing new evidence-based procedures, and in the other ward, evidence-based huddle boards for risk assessment were being implemented. PARTICIPANTS: A total of 54 registered nurses and 9 assistant nurses were observed during their patient care and daily activities. Of these individuals, thirteen registered nurses and five assistant nurses participated in focus groups. These participants were selected through theoretical sampling. METHODS: Data were collected during 90h of observation and 4 focus groups conducted from 2014 to 2015. Each focus group session included four to five participants and lasted between 55 and 65min. Data collection and analysis were performed concurrently, and the data were analysed using the constant comparative method. RESULTS: "Keeping on track" emerged as an explanatory theory for the processes through which the nurses handled their main concern: the risk of losing the workflow. The following three strategies were used by nurses when attempting to integrate evidence-based practices into their daily work: "task juggling", "pausing for considering" and "struggling along with quality improvement". CONCLUSIONS: The "keeping on track" theory contributes to the body of knowledge regarding clinical nurses' experiences with evidence-based practice integration. The nurses endeavoured to minimize workflow interruptions to avoid decreasing the quality of patient care provided, and evidence-based practices were seen as a consideration that was outside of their ordinary work duties.

Midwifery students learning experiences in labor wards: a grounded theory.

BACKGROUND: The labor ward is an important and challenging learning area for midwifery students. It is there the students learn in authentic complex situations, in intimate situations, with potential risk for the life and health of mothers and their babies. OBJECTIVE: The aim of this study was to explore the main concern expressed by midwifery students in labor wards and how they handled this concern. DESIGN: A longitudinal study based on grounded theory methodology was used. The participants were 10 postgraduate midwifery students, from a University College in Norway. Data were gathered and analyzed throughout the 2-year postgraduate program, in the students first, third and fourth semesters. Every student was interviewed three times in a total of 15 single and three focus-group sessions. FINDINGS: The grounded theory of "building relationships" explains how students dealt with their main concern: "how to gain access to learning experiences". This theory consisted of three strategies; a) controlling vulnerability, b) cultivating trust and c) obtaining acceptance. CONCLUSION: Clarifying discussions involving midwives and students may facilitate the process of building relationships and contribute to confident learning. Students appreciate it when the midwives initiate discussions about acute situations and state that a novice may perceive labor and childbirth as more frightening than an experienced midwife would.

Importance of public health nurses precepting students in clinical practice: a qualitative study.

BACKGROUND: Preceptors' working environment, support and competence affect how they perform the preceptor role, are therefore important for developing students and can influence students' roles as students and future professionals. Previous research has focused on precepting student nurses and not so much on public health nurses or other postgraduate students. Knowledge in this field is therefore lacking. OBJECTIVE: The article aims to present a grounded theory of the role of public health nurses as student preceptors in Norway. DESIGN: We conducted 20 interviews with public health nurses in addition to a focus group with four participants. We used classical grounded theory method to gather and analyze data. FINDINGS: The preceptors were strongly concerned about invisibility and lack of recognition of the preceptor role. This main concern was resolved by the strategy of being obligated and included three patterns: optimistic, ambivalent and reluctant performance, all with differing motivation for being obligated. All stakeholders involved in clinical practice seem to contribute to making the preceptors' role invisible and thereby contribute to the lack of recognition, support and reward, which again seem to self-reinforce invisibility. CONCLUSION: The study highlights the obligation of public health nurses in precepting students and increases the understanding of the challenges of this role. Ensuring education of a high academic standard requires paying more attention to developing effective support for the people involved.