Using Clinical Narratives in Program and Curriculum Evaluation.

Background: Using personal experience stories as teaching tools, clinical narratives are an effective means for sharing the art of nursing practice and provide insight into nurses' critical thinking and clinical proficiency. Using clinical narratives to assess curriculum effectiveness provides important insights into changed practice and learning beyond the classroom. Aim: This article provides an example of using clinical narratives in the evaluation of the Department of Veterans Health Affairs Office of Nursing Services (ONS) Evidence Based Practice Curriculum (EBPC). Methods: As part of a larger mixed-method evaluation of the EBPC, clinical narrative methods were employed to describe one incident where participants (n=3) applied at least two of three evidence based practice components (best available evidence; clinical expertise; patient preference). Results: Examination of clinical narratives demonstrated successful application of key components of evidence based practice and an integration into individual nursing practice beyond data obtained from other evaluation methods. Conclusions: Incorporating rich clinical narratives into a rigorous mixed-method program evaluation protocol provides insights beyond information uptake, satisfaction, efficacy, or competency assessment scores.

Evaluating an Evidence-Based Practice Curriculum for Nurses Entering Clinical Practice in the Veterans Health Administration.

Introduction: The Veterans Health Administration (VHA) registered nurse (RN) Transition to Practice (TTP) program is a 1-year comprehensive, standardized curriculum taught for entry-level nurses to assist them in transitioning to VA-trained, competent, professional RNs. The TTP program includes revised modules on Evidence-Based Practice (EBP) clinical decision making. The revised curriculum emphasizes EBP as a problem-solving approach to clinical decision making rather than a project-based approach to implement practice changes. The goal of this quality improvement project was to evaluate the content, delivery, and outcomes of a revised Evidence-Based Practice Curriculum (EBPC) for use in the VHA RN TTP program. Methods: Focus groups were conducted with TTP coordinators, who teach the program and facility EBP content experts from 32 VHA Medical Centers. All attended a three-day face-to-face training at a central location. Qualitative data were managed and analyzed with a rapid assessment process. Discussion: Leaders within and outside of organizations are commonly believed to affect the success of implementing and sustaining any program or initiative through their influence on organizational climate, leadership processes, and leadership alignment across multiple levels of leadership. Our findings were in line with other research showing that leaders should prioritize EBP and fuel it with resources to create sustainable change. Conclusions: In conclusion, the EBPC was reviewed very favorably by all who planned to use it in their facilities in teaching the content to practicing registered nurses. Future evaluation will focus on the degree to which faculty use the program, how they use the modules, and what feedback nurses provide after exposure to EBPC.

Identity, ideology and inequality: methodologies in medical anthropology, Guatemala 1950-1995.

This paper sketches the history of medical anthropology in Guatemala, focusing on how investigations carried out during the 1950s served as methodological and ideological foundations for subsequent work. Problematic examples from the literature and from the author's experience are used to provide insight into the nature of the anthropologist's role in applied research and development. For example, medical anthropologists are often hired to help navigate the gulf between the ideological identities of indigenous peoples and those of biomedical researchers and international development specialists. Instead of recognizing the inherently ethical nature of this work and acting accordingly, many anthropologists have adopted a detached, "scientific" and impossibly value-free perspective. This paper proposes a transformation of this role into one that (1) maintains an independent and critical relationship to mainstream science, (2) elaborates and advocates the indigenous agenda, and (3) adopts an explicitly value-filled ideology, methodology and theoretical framework.

Integrated local health systems in Central America.

This paper describes a few Central American experiences related to the development of integrated, participatory health care systems. Theory and analytic method center on the tensions inherent in the dichotomies of professional/popular, center/periphery and biomedical/traditional. Using a framework rooted in the World Health Organization's 1978 call for 'health for all' based on community-oriented primary care, this paper concludes that the underlying conditions necessary for truly integrated local health systems have not yet developed. Except for the cases of Costa Rica during 1978-1982 and Nicaragua during 1979-1990, the political will to create and support such systems has not existed. Perhaps more importantly, the cultural milieu in which Central Americans interact with their society fosters an individualistic, commercial, and paternalistic citizen/society relationship rather than the cooperative, community-oriented and democratic spirit needed for successful development of integrated local health systems. Nevertheless, there are a number of positive examples from which we can learn, and a growing tradition of citizen participation which may lead toward appropriate, sustainable, and truly integrated local health systems.

Herbal knowledge on Nicaragua's Atlantic Coast: consensus within diversity.

This article examines knowledge of medicinal plants, both among the people of Nicaragua's Atlantic Coast and among the scientific community. Data collected during an 809-household, five-community survey in 1990 and a ten-community botanical collection in 1991 are used to estimate the distribution of medicinal plant knowledge among the region's six ethnic groups. The list of 162 plants identified during this project is compared with other research results to provide the reader with a framework for understanding the distribution of medicinal plant knowledge. While a few plants are widely thought to have medicinal properties, the majority of identifications come from only one or two informants, demonstrating a pattern of consensus within diversity. Discussion focuses on the impact of methodology on the gathering of data, on the distribution and durability of medicinal plant knowledge, and on the proprietary nature of such knowledge.

Ethnomedical interactions: health and identity on Nicaragua's Atlantic coast.

This paper describes contemporary and historical interactions of medical belief and practice among the six ethnic groups of Nicaragua's Atlantic Coast--Mestizo, Creole, Miskitu, Sumu, Garifuna and Rama. The expansion of preventive medicine and primary care under the Sandanista-led government during the 1980s is presented, along with brief descriptions of counter-revolutionary attacks on the health care system. Traditional uses of medicinal plants and various forms of spiritual healing are then juxtaposed with the sporadic introduction of European and North American biomedicine throughout history. Next, the results of a health care survey carried out in 1990 are used to: (1) demonstrate the widespread use of the official health care system; and (2) show that traditional practices--use of herbal medicine, visits to spiritual healers, and home birth--are more prevalent among specific ethnic and socioeconomic strata of Nicaraguan Atlantic Coast society. Finally, I use these descriptions and survey results to argue for an understanding of health care behavior based on personal identity. I argue that a number of identities--ethnic, historical, political, socioeconomic and spatial (village, city, region or nation)--both situate and influence health care behavior, and thus mediate between the psychological and spiritual realms of illness and healing. Each individual chooses, variably and often subconsciously, to identify with any of a number these 'imagined communities' as he or she makes health care choices. These identity-influenced decisions are then manifested as specific health-related behaviors, forming the real-world data on which this argument is premised.

Health care behavior on Nicaragua's Atlantic Coast.

Survey methods are used to investigate health behavior in five communities on Nicaragua's Atlantic Coast. Eighteen health behaviors classified as 'biomedical' or 'traditional' are analyzed according to the ethnicity and educational level of the respondent. Household location (urban vs rural) and material wealth are also analyzed as predictors of health care behavior. Traditional behaviors are found to vary considerably among the six ethnic groups and among the various socioeconomic groupings. Biomedical behaviors are not found to be clearly related to ethnicity, wealth, or education.