Practice change in long-term care facilities in Ontario: views of managers and staff.

Little is known about how the use of data and feedback influences change in long-term care, and that was the focus of this study. Semistructured interviews were conducted with 126 frontline staff and managers from 19 randomly selected Ontario long-term care facilities. Content analysis revealed that staff members use data for problem identification and solution finding, justifying change, and monitoring change. Frontline providers primarily provided resident-based examples of data and feedback processes, whereas managers mainly described organization-based examples. Few participants discussed how information from mandated databases and related feedback processes could be used to inform change. Knowledge gained from this study will help organizations better understand the perspectives of different team members about data and feedback, thereby informing interventions that will enhance resident outcomes and quality service delivery in long-term care.

Development of an evaluation tool for a clinical practice guideline on nursing assessment and device selection for vascular access.

This study developed and tested a chart audit tool to assess the implementation of evidence-based recommendations for vascular access nursing assessment and device selection. Chart audits of 71 patients were conducted in a home healthcare agency and a community hospital prior to guideline implementation. Observations of initial infusion therapy and chart audit documentation of 31 patients were also compared. Results from observations indicated that nurses provided care consistent with the recommendations, but findings from chart audits indicated that assessment and decisionmaking were poorly documented. Studies that use only precomparison and postcomparison by chart audit may miss changes in nursing practice.

A new role for advanced practice nurses in Canada: bridging the gap in health services for rural older adults.

This article is a report on the evaluation of a new nursing initiative in rural western Canada-the gerontological advanced practice nurse (GAPN) project. Using a qualitative approach in the i initial evaluative phase, the authors determined how the GAPN evolved, functioning primarily in a clinical nurse specialist role, and identified the successes and challenges of the project. The initial findings indicated health benefits to rural older adults. The project's success was attributed to strong support from key players, and attempts to address perceived gaps in rural health service. Challenges in developing the GAPN role included limited planning time, and lack of a clear definition about the role and responsibilities of the GAPN. The introduction of a GAPN, especially in underserved rural communities, has the potential to provide essential health care services to older adults, and to make major contributions to changing gerontology practice.

Challenges in home care practice: a decision-making perspective.

A qualitative approach using an ethnographic design was used to investigate the nature of clinical decision making in home care practice from home care nurses' perspective. In-depth interviews were conducted with experienced home care nurses (N = 16) in addition to observations of nurses during meetings and client visits. The findings indicate that the decision-making challenges involved in home care practice consisted of the following 4 major categories: (a) challenges that arise in the development of client-centered care plans, (b) challenges that arise from the home care practice environment, (c) challenges related to developing confidence in clinical decision making, and (d) challenges in ethical decision making. Education and practice recommendations for enhancing clinical decision making are also discussed.

Thinking processes used by nurses in clinical decision making.

Clinical decision making forms the basis of expert clinical practice. The purpose of this study was to investigate and document the thinking processes used by nurses in clinical decision making situations so the processes could guide educational practice. Clinical data was analyzed to reveal that clinical decision making is complex and requires a variety of thinking processes. Medical and surgical nurses used different thinking processes, showing the importance of context in clinical decision making. The nursing exemplars and working vocabulary developed in this study to describe the thinking processes used in clinical decision making can be used in nursing education.