Using Qualitative Research to Inform Development of Professional Guidelines: A Case Study of the Society of Critical Care Medicine Family-Centered Care Guidelines.

OBJECTIVES: To explore the importance, challenges, and opportunities using qualitative research to enhance development of clinical practice guidelines, using recent guidelines for family-centered care in the ICU as an example. METHODS: In developing the Society of Critical Care Medicine guidelines for family-centered care in the neonatal ICU, PICU, and adult ICU, we developed an innovative adaptation of the Grading of Recommendations, Assessments, Development and Evaluations approach to explicitly incorporate qualitative research. Using Grading of Recommendations, Assessments, Development and Evaluations and the Council of Medical Specialty Societies principles, we conducted a systematic review of qualitative research to establish family-centered domains and outcomes. Thematic analyses were undertaken on study findings and used to support Population, Intervention, Comparison, Outcome question development. RESULTS: We identified and employed three approaches using qualitative research in these guidelines. First, previously published qualitative research was used to identify important domains for the Population, Intervention, Comparison, Outcome questions. Second, this qualitative research was used to identify and prioritize key outcomes to be evaluated. Finally, we used qualitative methods, member checking with patients and families, to validate the process and outcome of the guideline development. CONCLUSIONS: In this, a novel report, we provide direction for standardizing the use of qualitative evidence in future guidelines. Recommendations are made to incorporate qualitative literature review and appraisal, include qualitative methodologists in guideline taskforce teams, and develop training for evaluation of qualitative research into guideline development procedures. Effective methods of involving patients and families as members of guideline development represent opportunities for future work.

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

OBJECTIVE: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. METHODS: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. RESULTS: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. CONCLUSIONS: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Assessing RN-to-RN peer review on clinical units.

AIM: The primary purpose of this study was to measure informal registered nurse (RN)-to-RN peer review (defined as collegial communication about the quality of nursing care) at the work-unit level. METHODS: Survey design with cluster sampling of 28 hospital or ambulatory care units (n = 541 respondents). Results were compared with existing patient safety and satisfaction data. A chi-squared test was used to compare responses against nurse characteristics. RESULTS: Nurses agreed that RN-to-RN peer review takes place on their units, but no correlation with patient safety and satisfaction data was found. Misunderstandings about the meaning of peer review were evident. Open-ended comments revealed barriers to peer review: fear of retribution, language barriers and lack of professionalism. CONCLUSIONS: Nurses need clarification of peer review. Issues with common language in a professional environment need to be addressed and nurses can learn collaboration from each other's cultures. IMPLICATIONS FOR NURSING MANAGEMENT: Managers should support RN-to-RN peer review on clinical units. Methods used here may be useful to assess current departmental nurse peer review.

Multi-institutional study of barriers to research utilisation and evidence-based practice among hospital nurses.

AIMS: The study aims were to explore the relationships between perceived barriers to research use and the implementation of evidence-based practice among hospital nurses and to investigate the barriers as predictors of implementation of evidence-based practice. BACKGROUND: Evidence-based practice is critical in improving healthcare quality. Although barriers to research use have been extensively studied, little is known about the relationships between the barriers and the implementation of evidence-based practice in nursing. DESIGN: Cross-sectional study. METHOD: Data were collected between December 2006-January 2007 for this cross-sectional study using computerised Evidence-Based Practice Questionnaire and BARRIERS surveys. A convenience sample (n=1301) of nurses from four hospitals in southern California, USA, participated. Hierarchical multiple regression analyses were performed for each of the three dependent variables: practice, attitude and knowledge/skills associated with evidence-based practice. BARRIERS subscales were used as predictor variables. RESULTS: The perceived barriers to research use predicted only 2·7, 2·4 and 4·5% of practice, attitude and knowledge/skills associated with evidence-based practice. Conclusions. It was unexpected that the barriers to research use predicted such small fractions of practice, attitude and knowledge/skills associated with evidence-based practice. The barriers appear to have minimal influence over the implementation of evidence-based practice for most hospital nurses. RELEVANCE TO CLINICAL PRACTICE: In implementing evidence-based practice, the focus on barriers to research use among general nursing staff may be misplaced. Further studies are needed to identify the predictors of evidence-based practice and to identify the subset of nurses who are most amenable to adopting evidence-based practice.

Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center.

AIM: This paper is a report of a study to describe nurses' practices, knowledge, and attitudes related to evidence-based nursing, and the relation of perceived barriers to and facilitators of evidence-based practice. BACKGROUND: Evidence-based practice has been recognized by the healthcare community as the gold standard for the provision of safe and compassionate healthcare. Barriers and facilitators for the adoption of evidence-based practice in nursing have been identified by researchers. Healthcare organizations have been challenged to foster an environment conducive to providing care based on evidence and not steeped in ritualized practice. METHODS: A descriptive, cross-sectional research study was conducted in 2006-2007 with a convenience sample of 458 nurses at an academic medical center in California (response rate 44.68%). Two reliable and valid questionnaires were electronically formatted and administered using a secured website. Relationships between responses to the two instruments were examined and results compared with previously published data. RESULTS: Organizational barriers (lack of time and lack of nursing autonomy) were the top perceived barriers. Facilitators were learning opportunities, culture building, and availability and simplicity of resources. Statistically significant correlations were found between barriers and practice, knowledge and attitudes related to evidence-based practice. CONCLUSION: Similar barriers to the adoption of evidence-based practice have been identified internationally. Educators must work with managers to address organizational barriers and proactively support evidence-based practice.

Regional evidence-based practice fellowship program: impact on evidence-based practice implementation and barriers.

This quasi-experimental, pre- and posttest study evaluated the impact of a 9-month collaborative regional evidence-based practice (EBP) fellowship program on practice, attitude, knowledge, and perceived barriers associated with implementation of EBP. Three annual cohorts (N=142) of nurses attending a fellowship program from 2008 to 2010 participated in this study. Paired t tests showed statistically significant increases in practice (+.82; p<.001) and knowledge/skills (+.78; p<.001) associated with EBP, but showed no change in attitude (+.16; p=.198). All four Barriers subscales showed statistically significant decreases (-.10 to -.31; p=.036 to <.001). Hierarchical multiple regression analyses showed that the barriers explained 6.8%, 8.9% and 13.9% of variances in practice, attitude and knowledge/skills, respectively. The collaborative regional fellowship program improved the practice and knowledge/skills associated with EBP. The barriers were significant predictors of the EBP implementation among the targeted group of nurses participating in the fellowship program.