A qualitative evaluation of an adolescent cancer unit.

MULHALL A., KELLY D. & PEARCE S. (2004) European Journal of Cancer Care13, 16-22 A qualitative evaluation of an adolescent cancer unit The Expert Advisory Group on Cancer (1995) recommended that cancer centres in the UK should make provision for adolescents with cancer. However, although their number is growing, only a small number of specialist adolescent cancer units currently exist, and teenagers may often be treated in more general settings. To date, no formal evaluation of adolescent cancer units has taken place. This study adopted a qualitative approach to evaluate the first specialist adolescent oncology unit, which was established in the UK 10 years ago. The aim was to provide insight into: the culture of the unit; the experiences of patients and parents on the unit and the staff who worked there; and how the unit was valued by these groups. Semi-structured interviews were conducted with 10 teenagers with cancer, 10 parents and 14 professionals. Systematic non-participant observation of routine activities in the unit was undertaken also. Interview transcripts and observational data were analysed to identify key themes and categories. Six categories emerged from the data: (1) cancer and the cancer unit: although the word cancer had negative connotations, it provided a common supportive bond for adolescents and families on the unit; (2) what it feels like over time: key points in the adolescent cancer experience were emphasized as significant. These included diagnosis, end of treatment and recurrence of cancer; (3) physical structures and facilities: these were focused around the needs of adolescents with cancer and helped to provide a suitable environment of care; (4) the social context: approaches to care were relaxed in nature and suited the needs of adolescents and their families; (5) the family: there was an emphasis on maintaining normal routines whilst managing the impact of cancer on family relationships; and (6) specialism and expertise: the availability of an expert team of professionals with specialized insight into adolescents' needs was pivotal to creating an appropriate environment of care. In conclusion, the complex care and treatment needs of adolescents with cancer may best be met by specialist units.

Research information in nurses' clinical decision-making: what is useful?

AIM: To examine those sources of information which nurses find useful for reducing the uncertainty associated with their clinical decisions. BACKGROUND: Nursing research has concentrated almost exclusively on the concept of research implementation. Few, if any, papers examine the use of research knowledge in the context of clinical decision-making. There is a need to establish how useful nurses perceive information sources are, for reducing the uncertainties they face when making clinical decisions. DESIGN: Cross-case analysis involving qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England, United Kingdom. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 hours and 122 nurses were involved in the Q modelling exercise. RESULTS: Text-based and electronic sources of research-based information yielded only small amounts of utility for practising clinicians. Despite isolating four significantly different perspectives on what sources were useful for clinical decision-making, it was human sources of information for practice that were overwhelmingly perceived as the most useful in reducing the clinical uncertainties of nurse decision-makers. CONCLUSIONS: It is not research knowledge per se that carries little weight in the clinical decisions of nurses, but rather the medium through which it is delivered. Specifically, text-based and electronic resources are not viewed as useful by nurses engaged in making decisions in real time, in real practice, but those individuals who represent a trusted and clinically credible source are. More research needs to be carried out on the qualities of people regarded as clinically important information agents (specifically, those in clinical nurse specialist and associated roles) whose messages for practice appear so useful for clinicians.

The accessibility of research-based knowledge for nurses in United Kingdom acute care settings.

BACKGROUND: The successful dissemination of the results of the National Health Service (NHS) research and development strategy and the development of evidence based approaches to health care rely on clinicians having access to the best available evidence; evidence fit for the purpose of reducing the uncertainties associated with clinical decisions. AIM: To reveal the accessibility of those sources of information actually used by nurses, as well as those which they say they use. DESIGN: Mixed method case site, using interview, observational, Q sort and documentary audit data in medical, surgical and coronary care units (CCUs) in three acute hospitals. RESULTS: Three perspectives on accessibility were identified: (a) the humanist--in which human sources of information were the most accessible; (b) local information for local needs--in which locally produced resources were seen as the most accessible and (c) moving towards technology--in which information technology begins to be seen as accessible. Nurses' experience in a clinical specialty is positively associated with a perception that human sources such as clinical nurse specialists, link nurses, doctors and experienced clinical colleagues are more accessible than text based sources. Clinical specialization is associated with different approaches to accessing research knowledge. Coronary care unit nurses were more likely to perceive local guidelines, protocols and on-line databases as more accessible than their counterparts in general medical and surgical wards. Only a third of text-based resources available to nurses on the wards had any explicit research base. These, and the remainder were out of date (mean age of textbooks 11 years), and authorship hard to ascertain. CONCLUSION: A strategy to increase the use of research evidence by nurses should harness the influence of clinical nurse specialists, link nurses and those engaged in practice development. These roles could act as 'conduits' through which research-based messages for practice, and information for clinical decision making, could flow. This role should be explored and enhanced.

The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections. Department of Health (England).

In 1998, the Department of Health (England) commissioned the first phase of national evidence-based guidelines for preventing healthcare associated infections. These focused on developing a set of standard principles for preventing infections in hospitals together with guidelines for preventing hospital-acquired infections (HAI) associated with the use of short-term indwelling ureteral catheters in acute care and with central venous catheters in acute care. These guidelines are systematically developed broad statements (principles) of good practice that all practitioners can use and which can be incorporated into local protocols. A nurse-led, multi-professional team composed of infection prevention practitioners, clinical microbiologists/retrovirologist, epidemiologists, and researchers developed the guidelines. A rigorous guideline development process was used to inform the systematic reviews, the clinical and critical appraisal of relevant evidence, and linking that evidence to evolving guidelines. Both general and specialist clinical practitioners were involved in all stages of developing these guidelines, as were representatives from relevant Royal Colleges, learned societies, other professional organisations and key stakeholders. The introduction to these guidelines describes a robust and validated guideline development model that can be used by others to develop future guidelines. This model is described in more detail in the associated technical reports that can be found on the project web site http://www.epic.tvu.ac.uk. Locating and appropriately using good quality evidence to inform guideline development in this field is challenging. Evidence from rigorously conducted experimental studies was frequently limited and consequently a range of other types of evidence were systematically retrieved and carefully appraised. The concluding discussion on implementation highlights potential issues for clinical governance and areas for future research and suggests issues that need to be addressed to allow practitioners to successfully incorporate these guidelines into routine clinical practice.

Bridging the research-practice gap: breaking new ground in health care.

Many theorists have discussed the existence of a gap between nursing research and practice. Consequently much time and effort has been expended in trying to devise strategies to bridge this divide. This article explores what the research-practice gap is and discusses five important reasons for it. The issue is then raised as to whether or not there is a gap between evidence and practice, despite the existence of the gap between research and practice. This is explored in relation to the potential conflict between the 'know how' knowledge important in practice and the 'know that' knowledge important in academia. Finally, the concept of practitioner-centred research is described as one strategy that would effectively obliterate the research-practice gap as it is currently conceived.

Nursing research and nursing practice: an exploration of two different cultures.

Despite increasing efforts by both the government and the professions to institute evidence-based practice, there still remains a significant research practice gap in UK nursing. This paper explores the two worlds of practice and research and the factors that may affect them. It suggests that academic researchers and practitioners often have different perspectives and are working under different imperatives. These different cultures need to be recognized and made more explicit. Consideration will be given as to what sort of evidence is required by practitioners to nurse effectively, how we should identify this evidence and the role which research plays. The disharmony between the worlds of research and practice extends the discussion to consider the ways in which research is produced and disseminated. The question is raised as to why researchers fail to identify the contingencies, adaptations and social biases that affect their work. Strategies that might facilitate a franker discussion of research and the way in which it is produced will be illustrated by examples of research work undertaken by the author.

Research based nursing practice--an evaluation of an educational programme.

Although research based practice is being increasingly extolled by both the government and the profession, no clear educational strategy exists as to how practitioners should be supported in achieving this goal. Furthermore, the effectiveness of educational interventions in fostering a positive attitude to research, or a change towards a greater prevalence of research based practice, remains unknown. However, research has indicated that practitioners are dissatisfied with their research skills and the opportunities to enhance them. This paper describes a series of nine workshops on research utilization which were undertaken in a range of Trusts throughout England. The primary purpose of the workshops was to help nurses, health visitors and midwives to:The workshops were evaluated by two methods--a written semi-structured questionnaire and a qualitative study focused on three sites which used pre-workshop telephone interviews and post-workshop focus groups. Overall the workshops were effective in reducing fear and lack of understanding of research, alleviating the problem of jargon, and increasing the skills of critical appraisal. Although the participants' attitude to research was not changed by attending the workshops--it was positive before the workshop and remained so-several personal and professional benefits were accrued. The implications of this evaluation for practice, education, and research are discussed.

Bridging the research-practice gap: exploring the research cultures of practitioners and managers.

To ensure effective utilization of research in nursing more evidence is needed which illuminates the way nurses think about research, the value which they put on it, and how they envisage that it may help or hinder them in their everyday work. This English study aimed to meet these objectives by describing the research culture of practising nurses, health visitors and midwives, and their managers. It rests on two assumptions. Firstly that the reasons why practitioners do, or do not, base their practice on research are complex, and secondly, that interventions to increase research utilization must be grounded in an appreciation of this complex 'whole'. Thus the study took a qualitative approach to exploring: what participants thought and felt about research; the current status of research based practice; and the opportunities and constraints to increasing research based practice. The results confirm the hypothesis that many factors, both individual and organizational affect research utilization. Furthermore, practitioners and managers hold differing perceptions regarding the nature of research, its role, and the opportunities and constraints which effect its dissemination and utilization. The implications of the results for education, policy and practice are discussed.

Reflections for action.

This is the second of three articles based on a major report launched by the Foundation of Nursing Studies last year-Reflection for Action-which looked at the dissemination and implementation of research in nursing. This article discusses two of the studies that made up the report.

Nursing research: our world not theirs?

From both a theoretical and a practical standpoint the research-practice gap in nursing is as wide as ever. This, despite an increasing literature on the subject and a gamut of practical initiatives aimed at bridging the divide. This paper explores the two worlds of practice and research and the factors contingent on them. It suggests that academic researchers and practitioners have different foci and are working under different imperatives. These different cultures need to be recognised and made more explicit within current writing. The discordance between the worlds of research and practice forms the basis for extending the discussion to consider the principal conduit of research, i.e. the written word. The question is raised as to why research is typically reported as a seamless account, bereft of any information beyond details of the research process as it is currently legitimised within nursing ideology. Finally consideration is given to strategies which might facilitate the 'outing' of both researchers and their research.

Prescriptive care? Guidelines and protocols.

The first of two articles on the development and implementation of guidelines and protocols describes a series of workshops on research utilisation. The authors also attempt to explain some of the confusing terminology in the area of prescriptive care. The second article, which will appear in the near future, will attempt to answer the questions arising from the workshops described here.

Anthropology, nursing and midwifery: a natural alliance?

Anthropology, and its supposed operationalisation within transcultural nursing, is becoming increasingly prominent in educational curricula in the U.K. This increase in interest is driven both by governmental pressure to provide more culturally appropriate care, and an intuitive notion that anthropology, nursing and other related professions such as midwifery have a common basis of mutually overlapping and re-enforcing theory and practice. This paper explores the question of whether there is a natural alliance between anthropology, and the applied aspects of health care disciplines such as nursing and midwifery, by examining some of the concepts underlying each discipline, and the ways in which these concepts are applied in practice. Anthropology is the study of culture, and it is suggested that a more complete understanding of this central concept is essential if it is to be utilised in the applied disciplines encompassed by the practice of nursing and midwifery.

Cultural discourse and the myth of stress in nursing and medicine.

Nursing has within the last 20 years firmly embraced the idea that practice should be based on substantive research. Yet many of the issues with which modern nursing is grappling encompass complex multifaceted aspects which are difficult to conceptualise or define. Stress is one such concept which has been increasingly invoked in both health care and lay discourses as an explanation for illness and general misfortune. A number of models of stress have been proposed which have to a greater, or lesser extent also been adopted by the lay public. In many respects nursing models of health and illness have more in common with lay, rather than biomedical, conceptualisations of illness aetiology. However, it is unclear to what extent nursing, lay and biomedical ideas about stress overlap. This paper attempts to explore some of these issues by describing the semantic origins of stress and the ways in which it is conceptualised and invoked in both the professional and lay discourse. The many approaches to stress research are explored and some of the constraints pertaining to them discussed. The question is also raised as to why certain discourses on stress have arisen within particular professional domains, and why the nursing contribution to stress research has been marginalised. An ideological component to the stress discourse is identified, and the importance of nursing and other professional disciplines recognising this, and also those macro-level factors which may affect health and illness, is stressed.

The cultural context of death: what nurses need to know.

This paper introduces some of the historical work of sociologists and anthropologists on death and dying and discusses its relevance to nursing practice. Contemporary issues are highlighted as well as the importance of examining these contributions critically.

Nursing research: what difference does it make?

There is currently strong pressure for nursing to base its education and practice upon rigorous research. A strong research foundation is perceived as integral both to the formation of a distinct discipline, and also to the establishment of the profession. The broader implications of this initiative have, however, received little attention in the literature. This paper discusses the current status and organization of nursing research in the United Kingdom in the light of the history of its development alongside other research endeavours. The differing agendas of policy makers, practitioners and researchers are examined to ask the question 'Does research inform either policy or practice?' This issue is explored through a consideration of the constraints which may impinge upon the successful initiation and conduct of research in nursing, and its utilization to improve health care.

Transcultural nursing. Anthropology: a model for nursing.

The links between anthropology and nursing are not as tenuous as they may at first appear. Social anthropology provides a relevant framework for understanding transcultural nursing and can help to explain some of the drawbacks of using transcultural ideas to care for patients from different cultures.