Institutional ethnography: A methodology for exploring complex problems in healthcare systems.

Healthcare professionals experiencing barriers in the delivery of care are often unaware of factors within complex institutions that create and perpetuate those problems. Institutional ethnography in healthcare is a research methodology that starts from the perspective of a problem that clinicians or people receiving care experience and seeks to identify how those negative experiences are coordinated by institutional structures. This paper describes and advocates for the use of institutional ethnography as a powerful tool to investigate problems experienced by individuals or groups in the complex systems of healthcare design and delivery. It is a research methodology that has been adopted across settings in North America, although it has the potential to be utilized more broadly across other settings by clinicians and researchers. This echoes calls from other authors for its use across a wider range of healthcare disciplines and settings. Institutional ethnography is an underutilized research methodology that has potential to address a wide range of challenges experienced in contemporary healthcare. It offers healthcare clinicians the opportunity to better understand and resolve issues affecting their practice within complex healthcare systems.

Patient's experiences of suffering across the cancer trajectory: A qualitative systematic review protocol.

AIM: To identify, appraise and synthesize the available evidence from qualitative research exploring the suffering of patients with cancer during their illness trajectories. DESIGN: Protocol for a qualitative systematic review. DATA SOURCES: The database will include PubMed, CINAHL and Psych Info were searched in May 2020. METHODS: The review protocol has been registered in International Prospective Register for Systematic Review (CRD42020165405). This review will systematically search qualitative research studies in databases from 1982-May 2020, with predetermined search terms. Searches are limited to studies in English. Two reviewers will independently appraise the methodological quality of the selected studies using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Disagreements can be settled through discussion which includes a third reviewer, if necessary. This review will use the meta-aggregative approach to analyze and synthesize data. A summary of findings from selected studies will be presented. DISCUSSION: Suffering is a complex dimension that included physical psychological, existential and social dimensions. This review will enable nurses to gain an in-depth understanding of suffering that not only worsens at the end of life that can deliver comprehensive care. IMPACT: This review is designed to systematically identify and explore the suffering that patients with cancer experience during their illness trajectory. Often suffering is highlighted at the end of life phase. This review will synthesize the evidence of suffering from the beginning of the patient's diagnosis to the end of life. The results of this review provide evidence to support nursing developments in education and clinical practice so that understanding of cancer can be optimized. The findings of the proposed review will contribute as a basis for recommendations for future research regarding suffering.

Newly graduated nurses' socialisation resulting in limiting inquiry and one-sided use of knowledge sources-An ethnographic study.

AIM: To explore how the socialisation into the clinical setting and interaction between newly graduated nurses and experienced nurses influences the new graduates' use of knowledge sources. BACKGROUND: Newly graduated nurses' use of knowledge sources in decision-making has been subject to an increased interest in relation to evidence-based practice. Despite interventions to strengthen nurses' competencies required for making reflective clinical decisions within an evidence-based practice, studies highlight that new graduates only draw on knowledge from research, patients and other components within evidence-based practice to a limited extent. Research exploring new graduates' use of knowledge sources calls attention to the experienced nurses' decisive role as a valued knowledge source. The new graduates' process of socialisation and their interaction with the experienced nurse raises further questions. METHODS: Ethnography using participant-observation and individual semi-structured interviews of nine newly graduated nurses from a University Hospital in Denmark. Data were collected in 2014. The study adheres to COREQ. RESULTS: Two main structures were found: "Striving for acknowledgment" and "Unintentionally suppressed inquiry." CONCLUSIONS: New graduates are socialised into limiting their inquiry on clinical practice and unintentionally being restricted to using the experienced nurse as predominant knowledge source. Depending on how the experienced nurse responds to the role as predominant knowledge source, they could either limit or nurture the new graduates' inquiry into practice and thus the variety of knowledge sources used in clinical decision-making. Limited inquiry into the complexity of nursing practice indirectly excludes the use of a variety of knowledge sources, which are fundamental to an evidence-based practice. RELEVANCE: If clinical practice wishes to benefit from the newly graduated nurses' inquiring approach and skills within evidence-based practice, clinical practice will have to greet the nurses with a supportive culture where questioning practice is seen as a strength rather than a sign of insecurity and incompetence.

Nurses' intentions to respond to requests for legal assisted-dying: A Q-methodological study.

AIMS: To explore the intentions of nurses to respond to requests for legal assisted-dying. BACKGROUND: As more Western nations legalize assisted-dying, requests for access will increase across clinical domains. Understanding the intentions of nurses to respond to such requests is important for the construction of relevant policy and practice guidelines. DESIGN: Mixed-methods. DATA SOURCES: A total of 45 Australian nurses from aged, palliative, intensive, or cancer care settings surveyed in November 2018. METHOD: Q-methodology studying nurses' evaluations of 49 possible responses to a request for a hastened death. Data consisted of rank-ordered statements analysed by factor analysis with varimax rotation. FINDINGS: Four distinct types of intentions to respond to requests for assisted-dying: a) refer and support; b) object to or deflect the request; c) engage and explore the request; or d) assess needs and provide information. CONCLUSION: The findings underscore the complexity of intentionality in assisted-dying nursing practice and differences from other forms of end-of-life care, particularly regarding patient advocacy and conscientious objection. This study enables further research to explore determinants of these intentions. It can also assist the development of professional guidance by linking policy and clinical intentions. IMPACT: Identified a basic range of nurses' intentions to respond to requests for assisted-dying, as there was no evidence at present. Developed a fourfold typology of intentions to respond with most nurses intending to engage in practices that support the requestor and sometimes the request itself. A minority would object to discussing the request. The relatively low level of advocacy within the intended responses selected also is distinctly different from other end-of-life care research findings. This research could assist nursing associations in jurisdictions transitioning to legal assisted-dying to develop guidance ways nurses can frame their responses to requests.

Instruments measuring behavioural aspects of the nurse-patient relationship: A scoping review.

AIMS AND OBJECTIVES: To identify and map tools measuring behavioural aspects of the nurse-patient relationship. BACKGROUND: The behaviours nurses employ to develop relationships with patients form a key part of nursing practice. Systematically measuring these behaviours provides an objective means of assessing and evaluating how nurses establish and maintain relationships with patients in a variety of settings. Whilst tools exist to measure these behaviours, little is known about their aims/scope, structure, method of development and contexts of use. Such knowledge is crucial for understanding the nature of the literature, including in which contexts and for which patient groups existing tools are suited. DESIGN: Scoping review informed by Joanna Briggs Institute methodology. METHODS: A database search was undertaken using CINAHL, PsycINFO, Pubmed and Embase. Primary research articles, theses and methodological papers that developed, refined and/or administered tools measuring behavioural aspects of the nurse-patient relationship, in any setting and for any patient group, were included. Tools had to measure actual not hypothetical behaviour (e.g., perceptions regarding importance). Data from included studies and tools were mapped. Results are reported in accordance with PRISMA-ScR guidelines. RESULTS: One hundred and twenty-seven studies, containing 35 tools, were included. The literature was characterised by substantial variability, stemming from the continued refinement of tools (e.g., reduction to short forms) but also the development of new tools that appeared to duplicate existing work and the inconsistent use of tools across studies. CONCLUSIONS: The volume of tools available demonstrates the importance of measuring the nurse-patient relationship. However, the existing duplication and variability create challenges in choosing amongst the tools available and show that, as a concept, the nurse-patient relationship remains poorly understood. RELEVANCE TO CLINICAL PRACTICE: Research is required to synthesise, and assess the quality of, existing tools, enabling clinicians, leaders/managers, educators and researchers to administer appropriate tools to evaluate the nurse-patient relationship.

Hermeneutic Phenomenological Study of Military Nursing Officers.

BACKGROUND: Nurses working in military trauma teams often work in hostile and remote locations. They are faced with the burden of carrying out their duties while ensuring the safety of their patients and themselves in areas of conflict and humanitarian crisis. The stories and experiences of military nurses often go untold. In a phenomenological study, six Australian Defence Force Nursing Officers share their stories of working as members of military trauma teams. OBJECTIVES: The aim of this study was to gain an understanding of the lived experiences of nursing officers when working as a member of a military trauma team. METHODS: A hermeneutic phenomenological approach was used to conduct this research. In-depth interviews were conducted with six participants. RESULTS: The following themes were identified: telling their stories; the role-who we are and what we do; the environment-it is so different; training-will it ever fully prepare you; working in teams-there's no "I" in team; and leadership-will the real leader please stand up! DISCUSSION: This study has provided an insight into the experiences of six Australian military nurses working in trauma teams-experiences that were rarely given voice outside the military. Central to this experience is the need to have these stories told.

Anticipated advantages and disadvantages of a move to 100% single-room hospital in Australia: A case study.

OBJECTIVES: There is an international policy trend for building government hospitals with greater proportions of single-occupancy rooms. The study aim was to identify advantages and disadvantages for patients and nursing staff of a pending move to 100% single-room hospital, in anticipation of the challenges for nurse managers of a different ward environment. This paper presents these findings, summarizing potential advantages and disadvantages as well as comparison with findings from similar studies in England. METHODS: Mixed method case study design was undertaken in four wards of a large hospital with multi-bed rooms. Three components of a larger study are reported here: nurse surveys and interviews, patient interviews of their experiences of the current multi-bedroom environment and expectations of new single-room environment. Integration was achieved via data transformation where results of the nursing staff survey and interviews and patient interviews were coded as narrative allowing for quantitative and qualitative data to be merged. RESULTS: Four constructs were derived: physical environment; patient safety and comfort; staff safety; and importance of interaction. CONCLUSION: There are important factors that inform nurse managers when considering a move to an all single-room design. These factors are important for nurses' and patients' well-being. IMPLICATIONS FOR NURSING MANAGEMENT: This study identified for nurse managers key factors that should be considerd when contributing to the design of a 100% single-room hospital. Nurses' voices are critically important to inform the design for a safe and efficient ward environment.

Centrality of spirituality/religion in the culture of palliative care service in Indonesia: An ethnographic study.

Experiencing life-threatening illness could impact on an individual's spirituality or religious beliefs. In this paper, we report on a study which explored cultural elements that influence the provision of palliative care for people with cancer. A contemporary ethnographic approach was adopted. Observations and interviews were undertaken over 3 months with 48 participants, including palliative care staff, patients, and their families. An ethnographic data analysis framework was adopted to assist in the analysis of data at item, pattern, and structural levels. Religion was identified as central to everyday life, with all participants reporting being affiliated to particular religions and performing their religious practices in their daily lives. Patients' relatives acknowledged and addressed patients' needs for these practices. Staff provided spiritual care for the patients and their relatives in the form of religious discussion and conducting prayers together. An understanding that religious and spiritual practices are integral cultural elements and of fundamental importance to the holistic health of their patients is necessary if health-care professionals are to support patients and their families in end-of-life care.

Newly graduated nurses' use of knowledge sources in clinical decision-making: an ethnographic study.

AIMS AND OBJECTIVES: To explore which knowledge sources newly graduated nurses' use in clinical decision-making and why and how they are used. BACKGROUND: In spite of an increased educational focus on skills and competencies within evidence-based practice, newly graduated nurses' ability to use components within evidence-based practice with a conscious and reflective use of research evidence has been described as being poor. To understand why, it is relevant to explore which other knowledge sources are used. This may shed light on why research evidence is sparsely used and ultimately inform approaches to strengthen the knowledgebase used in clinical decision-making. DESIGN AND METHODS: Ethnographic study using participant-observation and individual semistructured interviews of nine Danish newly graduated nurses in medical and surgical hospital settings. RESULTS: Newly graduates use of knowledge sources was described within three main structures: 'other', 'oneself' and 'gut feeling'. Educational preparation, transition into clinical practice and the culture of the setting influenced the knowledge sources used. The sources ranged from overt easily articulated knowledge sources to covert sources that were difficult to articulate. The limited articulation of certain sources inhibited the critical reflection on the reasoning behind decisions. Reflection is a prerequisite for an evidence-based practice where decisions should be transparent in order to consider if other evidentiary sources could be used. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Although there is a complexity and variety to knowledge sources used, there is an imbalance with the experienced nurse playing a key role, functioning both as predominant source and a role model as to which sources are valued and used in clinical decision-making. If newly graduates are to be supported in an articulate and reflective use of a variety of sources, they have to be allocated to experienced nurses who model a reflective, articulate and balanced use of knowledge sources.

Umbrella review of the evidence: what factors influence the caring relationship between a nurse and patient?

AIMS: The aim of this study was to describe the nurse-patient relationships and to study how caring behaviours were described. The review question was: What factors influence the caring relationship between a nurse and patient? BACKGROUND: There is a growing perception that nurses fail to provide compassionate and competent care. Policy documents prescribe compassion as an essential aspect of care; however, the evidence drawn on remains unclear and without clear applications to practice. DESIGN: Umbrella review methodology, informed by the Joanna Briggs Institute guidelines, was employed and adapted to enable the inclusion of systematic reviews that were of sufficient methodological quality. DATA SOURCES: An extensive PsychInfo, Pubmed, CINAHL, Scopus, WoS and Embase search was conducted for literature published from January 2000-March 2014. Key words included 'nurse', 'patient' and 'relationship' in combination with index terms to find literature published from 2000 onward. REVIEW METHODS: Critical appraisal, data extraction and synthesis were carried out according to existing guidelines for undertaking umbrella reviews. RESULTS: Twelve reviews (representing over 290 studies) were included following critical appraisal. Forty-seven findings were extracted, resulting in 14 categories and six synthesized findings; 'Expectations of the relationships' 'Values', 'Knowledge and skills', 'Communication', 'Context and environment' and 'The impact of the relationship'. CONCLUSIONS: A substantial body of evidence demonstrates that both patients and nurses have expectations about the nature and importance of the caring relationship. Nurses should be mindful that their behaviours and attitudes need to align with what patients value about the relationship. Context shapes the relationship in positive and negative ways.

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.

Predatory journals and their practices present a conundrum for systematic reviewers and evidence synthesisers of health research: A qualitative descriptive study.

Predatory journals are a blemish on scholarly publishing and academia and the studies published within them are more likely to contain data that is false. The inclusion of studies from predatory journals in evidence syntheses is potentially problematic due to this propensity for false data to be included. To date, there has been little exploration of the opinions and experiences of evidence synthesisers when dealing with predatory journals in the conduct of their evidence synthesis. In this paper, the thoughts, opinions, and attitudes of evidence synthesisers towards predatory journals and the inclusion of studies published within these journals in evidence syntheses were sought. Focus groups were held with participants who were experienced evidence synthesisers from JBI (previously the Joanna Briggs Institute) collaboration. Utilising qualitative content analysis, two generic categories were identified: predatory journals within evidence synthesis, and predatory journals within academia. Our findings suggest that evidence synthesisers believe predatory journals are hard to identify and that there is no current consensus on the management of these studies if they have been included in an evidence synthesis. There is a critical need for further research, education, guidance, and development of clear processes to assist evidence synthesisers in the management of studies from predatory journals.

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).

BACKGROUND: Malnutrition, 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/DESIGN: A 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. DISCUSSION: Unplanned 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 REGISTRATION: ACTRN12611000020987.

How should we handle predatory journals in evidence synthesis? A descriptive survey-based cross-sectional study of evidence synthesis experts.

Synthesizers of evidence are increasingly likely to encounter studies published in predatory journals during the evidence synthesis process. The evidence synthesis discipline is uniquely positioned to encounter novel concerns associated with predatory journals. The objective of this research was to explore the attitudes, opinions, and experiences of experts in the synthesis of evidence regarding predatory journals. Employing a descriptive survey-based cross-sectional study design, these experts were asked a series of questions regarding predatory journals to explore these attitudes, opinions, and experiences. Two hundred and sixty four evidence synthesis experts responded to this survey. Most respondents agreed with the definition of a predatory journal (86%), however several (19%) responded that this definition was difficult to apply practically. Many respondents believed that studies published in predatory journals are still eligible for inclusion into an evidence synthesis project. However, this was only after the study had been determined to be 'high-quality' (39%) or if the results were validated (13%). While many respondents could identify common characteristics of these journals, there was still hesitancy regarding the appropriate methods to follow when considering including these studies into an evidence synthesis project.

Clinical nursing leaders', team members' and service managers' experiences of implementing evidence at a local level.

AIM: To describe the experiences of 14 clinical nursing leaders introducing a knowledge translation (KT) project into one metropolitan acute care hospital in South Australia. The study also explored team members' and service managers' experiences. BACKGROUND: KT strategies assume that local (nursing) clinical leaders have the capacity and capability to champion innovation combining positional leadership roles (ward leader) with a project lead role. There is limited evidence to support these assumptions. METHOD: Semi-structured interviews of clinical nursing leaders and managers were undertaken at month 4 and 12 of the project. Data were also collected from the interdisciplinary team members (n = 28). RESULTS: Clinical nursing leaders identified risks and anxieties associated with taking on an additional leadership role, whereas managers acknowledged the multiple pressures on the system and the need for local level innovation. Team members generally reported positive experiences. CONCLUSIONS: With support, clinical nursing leaders can effectively embrace KT project leadership roles that complement their positional leadership roles. Clinical nursing leaders' experiences differed from nursing and medical managers' experiences. IMPLICATIONS FOR NURSING MANAGEMENT: Managers need to be more attuned to the personal risks local leaders experience, providing support for leaders to experiment and innovate. Managers need to integrate local priorities with broader system wide agendas.

Women's experience of becoming caregivers to their ill partners: Gadamerian hermeneutics.

The recent morbidity trends in Australia indicate a steep rise in the number of individuals living with chronic illness who rely on the assistance of mostly women carers. Consequently, supporting and promoting carers' health should be a priority to sustain their health, and ensure their ability to provide care to a significant other. This interpretive hermeneutic study explored the lived experience of women during the transition of becoming carers to their male partners with various health conditions. Gadamerian hermeneutics were used to research participants' experiences allowing for interpretations that incorporated understandings of both worlds, those of the researcher and the participants. This negotiation of understandings made it possible to create mutual and new knowledge. The phenomenon 'entering transition' revealed itself as a precarious balance between a sense of loss and coping with the life changing situation. Yearning to preserve that equilibrium, the women did not wish to be considered as carers to their partners but expressed a need for maintaining the cohesiveness of their identity as part of a couple. One of the recommendations arising out of this study is that a different approach is needed to assist nurses and other health professionals to support this specific population of women carers in the community and in hospital settings.

Experiences and perspectives of suffering in cancer: A qualitative systematic review.

PURPOSE: Suffering refers to a situation in which a person's illness and condition threaten their integrity. The aim of this systematic review was to synthesize qualitative studies that explored suffering of persons with cancer. METHOD: A qualitative systematic review was conducted. Psych Info, PubMed, and CINAHL were searched for relevant studies. Methodological quality was independently assessed using the Critical Appraisal Checklist from Joanna Briggs Institute (JBI). A meta-aggregative approach was utilized to analyze and synthesize the data that focused on how persons with cancer perceive suffering across their illness trajectory. RESULTS: Twelve articles reporting the experiences of 230 participants were synthesized. Three synthesized findings were generated from the articles: suffering the loss of normality, suffering in relation to others and existential suffering. Suffering affects the person's normal activities of life and cause the loss of normality. Suffering in relation to others refers patients' suffering also impacts on and is impacted by those around them. The last synthesized finding refers to impact of suffering on patients' whole sense of being. In addition, feelings of hopelessness, and other mental anguish are inevitable responses that lead the patients to think about death. The overall methodological quality resulted in a ConQual rating of moderate for the synthesized findings. CONCLUSION: The persons' suffering not only affects themselves but also others, particularly close relatives. The suffering experienced is complex and goes well beyond the immediate impact of physical symptoms and treatment.

Factors affecting procurement of wound care products: a qualitative study of hospital managers and clinicians.

Objective To identify factors that influence procurement and disinvestment decisions for wound care products in the acute care setting. Methods A qualitative descriptive study was undertaken. Eighteen face-to-face semi-structured interviews were conducted with purposively sampled senior clinical and non-clinical managers from three Australian acute care hospitals with responsibility for consumables procurement and disinvestment decisions. Data were coded and analysed thematically. Results Three main themes (Systems and triggers, Evidence-free zone, Getting the governance right) with sub-themes were identified that reflect that: (1) procurement processes were often ad hoc and workarounds common. Disinvestment was poorly understood and opportunities were missed to reduce use of low value products ; (2) product selection was commonly based on clinician preference, contractual obligations and information from industry representatives; and (3) improved evidence-based governance and processes are needed to connect procurement and disinvestment decisions and to minimise the influences of clinician preference and industry representatives on product selection. Conclusions Systematic and evidence-based approaches are needed to strengthen procurement and disinvestment decisions related to consumables such as wound care products and to minimise the purchasing of low-value products Decision-making frameworks should consider cost and clinical effectiveness and enable the identification of opportunities to disinvest from low-value products. What is known about the topic? High volume-low unit cost healthcare consumables such as wound care products are a major component of healthcare expenditure. Disinvestment from low-value wound care products has potential to improve patient outcomes and optimise health resources. What does this paper add? Disinvestment was poorly understood and considered in isolation from procurement decisions. Procurement decisions were rarely informed by research evidence, with clinicians exercising considerable freedom to make purchasing decisions based on product preference and industry information. Frameworks and guidelines are needed to guide procurement and disinvestment decision-making for wound care products. What are the implications for practitioners? New models for procurement and disinvestment decision-making for wound care products could help to strengthen decision-making processes, facilitate evidence-based product choices and also prompt consideration of removal of low-value products.

Guidelines rarely used GRADE and applied methods inconsistently: A methodological study of Australian guidelines.

OBJECTIVES: The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach is accepted methodology to assess the certainty of the evidence included in systematic reviews and clinical practice guidelines. The GRADE approach is endorsed globally, in Australia, the National Health and Medical Research Council advocated for the use of the GRADE approach in 2011. The purpose of this methodological review was to assess how GRADE has been adopted for Australian practice guidelines. STUDY DESIGN AND SETTING: This methodological review searched of the National Health and Medical Research Council Clinical Practice Guidelines Portal from 2011 to 2018, in an effort to retrieve all practice guidelines available via this medium. RESULTS: 240 guidelines were retrieved authored by 51 different organizations. 15 guidelines followed GRADE methodology. Application of GRADE methods varied between guidelines, some misreported and altered aspects of the GRADE process. Guidelines that closely adhered to the guidance from the GRADE Working Group scored higher in domain 3 (rigor of development) of the Appraisal of Guidelines for Research and Evaluation II tool, indicating a positive linear relationship between GRADE adherence and rigor of development scores. CONCLUSION: The results of our project suggest that the use of GRADE in Australian guidelines is increasing, however, strategies to increase uptake and reporting within the guideline community need to be explored.

Should I include studies from "predatory" journals in a systematic review? Interim guidance for systematic reviewers.

ABSTRACT: A systematic review involves the identification, evaluation, and synthesis of the best-available evidence to provide an answer to a specific question. The "best-available evidence" is, in many cases, a peer-reviewed scientific article published in an academic journal that details the conduct and results of a scientific study. Any potential threat to the validity of these individual studies (and hence the resultant synthesis) must be evaluated and critiqued.In science, the number of predatory journals continue to rise. Studies published in predatory journals may be of lower quality and more likely to be impacted by fraud and error compared to studies published in traditional journals. This poses a threat to the validity of systematic reviews that include these studies and, therefore, the translation of evidence into guidance for policy and practice. Despite the challenges predatory journals present to systematic reviewers, there is currently little guidance regarding how they should be managed.In 2020, a subgroup of the JBI Scientific Committee was formed to investigate this issue. In this overview paper, we introduce predatory journals to systematic reviewers, outline the problems they present and their potential impact on systematic reviews, and provide some alternative strategies for consideration of studies from predatory journals in systematic reviews. Options for systematic reviewers could include excluding all studies from suspected predatory journals, applying additional strategies to forensically examine the results of studies published in suspected predatory journals, setting stringent search limits, and applying analytical techniques (such as subgroup or sensitivity analyses) to investigate the impact of suspected predatory journals in a synthesis.