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PACEsetterS First Quarter 2006
A health care publication supporting The Joanna Briggs Institute Practical Application of Clinical Evidence System Volume 3 No. 1
Most respected ma’am:
volunteering in Nepal
T
Paediatrics in Sweden:
it’s all about teamwork
Blazing the evidence-based trail in Indiana
Getting beyond the next minute
The Englishman who climbed up a hill
ISSN: 1449 - 7700
New guidelines for care of drug-misusing
women and their neonates
2
•
PACEsetterS
A health care publication supporting The Joanna Briggs Institute Practical Application of Clinical Evidence System
First Quarter 2006
Volume 3 No. 1
Distribution to JBI members in:
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First Quarter, 2006 - Volume 3, No.1 Republic of Emirates
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PACEsetterS is a quarterly magazine relating China
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Briggs Institute in conjunction with its Canada New Zealand Singapore United States of
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System (PACES) program.
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Executive Publisher
Professor Alan Pearson
Managing Editor
Anthea Court
email: anthea.court@adelaide.edu.au
Editor
Nic Rowan
email: nicola.rowan@adelaide.edu.au
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Nic Rowan
email: nicola.rowan@adelaide.edu.au
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28
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ISSN: 1449 - 7700 part thereof, may be reproduced without permission of JBI.
3
content •
32 Main Story:
Most respected ma’am:
volunteering in Nepal
Editorial:
04 PACES around the world
Profiles: First
06 Blazing the evidence-based trail in Quarter
Indiana - Lisa Hopp
46 The Englishman who climbed up a hill 2006
- Ian Bullock
Features:
10 Changing clinician behaviour in
stroke care - Sandy Middleton
12 Digger’s mate: Andrew Gilbert and
one very big veteran database
14 Magnetism in Oklahoma - Carole Kenner
18 Using evidence in the nurse practitioner
role: Wendy Cross and Southern Health
20 20 Paediatrics in Sweden: it’s all about
teamwork - Christine Jolinger
26 Hand washing: still defying the evidence
- Chris Baggoley
28 Getting beyond the next minute
- Donna Ciliska
32 Most respected ma’am:
volunteering in Nepal
38 Start at the very beginning:
Donna Waters on teaching evidence-
based practice
42 Building evidence-informed practice
capacity: now and the future
- Roger Dunston
50 New guidelines for care of drug-
misusing women and their neonates
- Anne Bartu
52 Joanna Briggs Institute International
50 Convention 2005: inaugural excitement
Information:
PICTURE: INF, Chris Dixon
40 JBI web site maintains rank as one
of best - David Grant
56 JBI World News
Front cover
62 The expanding JBI collaboration
Events:
Nepal.
60 The Conference Line
4
editorial •
Dropping your pebble of knowledge
As I write this I am reminded of the critical you." May I encourage you to do something
role of health professionals and good health with your experience so that other’s may
information play in our modern world. We benefit from what you have learned about
are now experiencing an increasing number applying research evidence to your practice –
of H5N1 bird flu virus infections in Asia and sharing both what works well and what
Turkey. We are told of the continuing need perhaps doesn’t work so well.
for good and immediate health care in
We are fortunate in this issue to have a
Pakistan following the earthquake in October
closer look at some of the issues mentioned
last year and we see strengthening of the
above, particularly with our cover story set in
health sector in affected countries in the
Nepal as we talk to Jill Benson and Susan
aftermath of the devastating tsunamis a year
Selby about their experiences working there.
ago. Globally we are still dealing with
Anthea Court
diseases like cholera, tuberculosis, We also take a look at evidence-based
Associate Director, Evidence Transfer and Utilisation
meningitis, measles, malaria, typhoid and practice around the world including interviews
HIV/AIDS to name with some of the delegates, from over 20
just a few. nations, who attended our successful
The aim of the Joanna
International Convention, Pebbles of
Briggs Institute through The aim of the Joanna
Knowledge: making evidence meaningful in
Briggs Institute
its PACES program is to through its PACES November last year. We talk to Christine
provide a tool for health program is to provide Jolinger from Sweden about paediatric
professions to integrate a tool for health intensive care and discuss some of the
good research evidence professions across origins of evidence based practice in Canada
into their practice. the globe to integrate with McMaster University’s Donna Ciliska,
good research We also speak to Lisa Hopp, Director of the
evidence into their Joanna Briggs collaborating centre in
practice. The editorial team at PACEsetterS Indiana, and Dr Carole Kenner from our
would love to speak to you about how you Oklahoma Centre among many other
are doing this in your setting with a view to interesting health professionals.
sharing this valuable information with others.
I trust that regardless of whether you are a
Aldous Huxley, author of Brave New World, clinician, manager, educator, student or
once said, "Experience is not what happens consumer of healthcare that you will find this
to you; it's what you do with what happens to issue of interest and use to you.
Have your say
Be controversial. Break new ground. State your case.
We are looking forward to learning more about you.
Make your voice heard on using
evidence in health care by contributing please contact me about how /we use evidence in practice
to our upcoming Opinions and Letters I would like to know more about the Joanna Briggs Institute
section. Please contact me by:
Letters up to 250 words and opinions pieces or essays up to 1000
email – my email address is........................................................
words will only be published if a name and address, telephone
number and email address are supplied, but authors can request not telephone – my number is ..........................................................
to have their name published.
mailing me an information package to ........................................
The Editor reserves the right to publish or reject any letter, opinion
....................................................................................................
piece or essay presented to the Opinions and Letters section.
....................................................................................................
Forward your letters and opinion pieces to
....................................................................................................
The Editor, PACEsetterS, Joanna Briggs Institute.
Name: ....................................................................................................
Email: nicola.rowan@adelaide.edu.au
Organisation (if applicable): ....................................................................
Facsimile: +61 8 303 4881
................................................................................................................
Mail: Margaret Graham Building, Royal Adelaide Hospital, North
Terrace, Adelaide, South Australia, 5000, Australia. I am/am not a current member of JBI
www.rah.sa.gov.au/nurse
Royal Adelaide Hospital
is seeking Registered Nurses
to join our dynamic nursing team
Who we are postgraduate education and undertakes research in
nursing practice. Royal Adelaide Hospital encourages
Royal Adelaide Hospital (RAH) is one of three tertiary nurses to undertake courses relevant to their area of
adult referral hospitals serving South Australia’s practice and provide support through paid study leave
population of 1.4 million. It is the central teaching or fee subsidies.
hospital (650 beds) in association with The University of
Adelaide. The Joanna Briggs Institute (JBI) is an initiative of Royal
Adelaide Hospital, and The University of Adelaide, with
It is the largest trauma centre for the State supported by support from the Department of Health (SA). The
on-site cardiothoracic, neurosurgical and orthopaedic Institute is based at Royal Adelaide Hospital and is
services as well as specialist burns, spinal injuries and linked to Centres for Evidence Based Health Care across
hyperbaric medicine units. The new purpose built five continents.
Intensive Care Unit and Burns Unit provides state-of-
Employees are paid in accordance with the relevant
the-art services.
South Australian Award and are currently entitled to:
The RAH Retrieval Service is a long standing world
• Generous salary sacrifice arrangements
leader in the specialty of retrieval medicine and modes
of transport include Ambulance, the State Rescue • Superannuation
Helicopters, the Royal Flying Doctor Service Aircraft, • Long service leave
LEAR jet and commercial aircraft. (12 weeks after 10 years of continuous service)
RAH currently consists of three campuses (North • Paid Maternity Leave
Terrace, Hampstead Rehabilitation Centre & Glenside • Uniforms, where relevant
Campus Mental Health Service) that provide more than
1138 beds for inpatients as well as associated outpatient Where we are
outreach and community services. RAH provides a
specific range of tertiary referral services to the people of Adelaide in South Australia is a cosmopolitan city that
South Australia and the nearby states and territories, provides the cultural advantages of city life without
and a broad range of clinical services to people who rely such drawbacks as long distance commuting or traffic
on RAH as their regional or local hospital. congestion. Adelaide enjoys a delightful Mediterranean
climate and is boarded by beautiful beaches and world-
Nursing at RAH renowned wineries. Excellent education and recreational
facilities are available at very affordable rates. The
Royal Adelaide Hospital Nursing Service offers a Outback, Flinders Ranges, Kangaroo Island and
challenging, diverse and rewarding career with ample numerous other holiday destinations are only a few
opportunities for professional advancement. Over 2000 hours drive from Adelaide. Royal Adelaide Hospital
nurses work across the Royal Adelaide Hospital enjoys a city centre location adjacent to The University
campuses and are a mixture of registered and enrolled and the Botanic Gardens; numerous cafes, restaurants,
nurses. art galleries, museums and shopping are within walking
The Nursing Service uses a fully computerised clinical distance.
information system - Excelcare - which generates the
nursing care plan, enables patient outcome Contact us
measurement and determines hours per patient per day For further information about Nursing at Royal
which interface with the rostering system - ProAct - to Adelaide Hospital and the vacancies available, please
provide costing data and assist staffing modelling. visit our website www.rah.sa.gov.au/nurse or contact:
The hospital’s Staff Development Department co- Nursing and Patient Care Services
ordinates a wide range of courses, study days and Royal Adelaide Hospital
workshops. The hospital offers a comprehensive North Terrace
orientation program for new staff that includes one and Adelaide SA 5000
a half supernumerary days. AUSTRALIA
The Nursing Service is enhanced by our collaboration Telephone: +61 8 8222 5125
with The University of Adelaide’s Department of Facsimile: +61 8 8222 5588
Clinical Nursing which provides undergraduate and Email: rahnurse@mail.rah.sa.gov.au
6
profile •
Blazing
the evidence-based
trail in Indiana STORY: Nic Rowan
PICTURE: courtesy of Cave Country Adventures - Gary Berdeaux
Searching for evidence upon which to base
contemporary clinical practice is rather like the oddly-
named sport of spelunking, or cave exploring. It
requires meticulous attention to detail and
examination of the quality of maps and signposts left
by other, earlier explorers. It is also not for the faint
of heart.
II t is poetic, therefore, that the visionary Lisa
Hopp resides in the same State of the
USA as the spectacular Wyandotte Caves,
with all their twists, turns and unexpected
rewards. Lisa is at the leading edge of
nursing in that State, and has now been
appointed director of the recently established
Northwest Indiana Centre for Evidence-
Based Nursing Practice (NWICEBNP). Lisa
will be required to lead the way forward, a
task to which she is eminently suited.
It was in September 2004 that the
Collaborating Centre became a reality, after
Lisa’s visit to the University of Nottingham
Centre for Evidence-based Nursing and
Midwifery in England confirmed that Purdue
University Calumet, with its strong clinical
practice relationships and academic record,
was well placed to apply.
7
profile •
‘But’, she says of her new role, ‘this really fits.
I have a joint appointment with the hospital
that is figured into my full time equivalent
workload, and my scholarly activity can come
out of the same work. Before, my scholarly
activity was very separate. The clinical work
was different from most of what I was
At the same time Lisa, like so many other teaching, so it was a struggle with these very
academics, was struggling to maintain a parallel activities, rather than activities that
balance between teaching load, clinical were coming together.’
contact and scholarly activities. She began to
One of the first activities that the new
wonder if establishing a Collaborating Centre
Collaborating Centre undertook was hosting
in Indiana might be a way of bringing
train-the-trainer for the northern hemisphere.
PICTURE: Nic Rowan together and intertwining these three strands,
Led by JBI’s executive director Professor
not just for her but for the benefit of other
Alan Pearson, and the education and
faculty and students as well.
utilisation manager Tiffany Conroy-Hiller, the
‘The nature of our comprehensive university,’ training developed participant skills in leading
she explains, ‘is that our primary function is local evidence-based practice activity. ‘We
to teach, and not conduct research, even valued the systematic review training’, says
though to advance means that we need to Lisa. ‘It really opened our eyes; even though
have a good record of scholarly activity. But we have been teaching this and we thought
it’s difficult if you have a full teaching load to we knew it well, it solidified that
then have a very active program of research, understanding.’ The training also allowed
The Centre has been established within the so this is a way of managing both things.’ Purdue staff to strengthen their ties with staff
School of Nursing at Purdue University from the other Collaborating Centres,
Reflecting on her work before the
Calumet, where Lisa is Associate Professor of including two in the USA.
Collaborating Centre was established, Lisa
Nursing. Currently, the School has links with
says that while she managed to successfully Purdue University Calumet has long offered
Community Healthcare System and also with
compete for federal research money related nursing education at both the undergraduate
Methodist Hospitals of Northwest Indiana.
to her interest in respiratory muscle function, and graduate levels. The Calumet campus,
Staff of the School first became aware of the she found that it was difficult to conduct the with a student body of 9,000, is one of five
activities of the Joanna Briggs Institute when research. ‘In order to be successful, you Purdue University campuses. For many
directing students toward literature need to have staff, you need to be able to years, the Calumet campus led the way in
supporting evidence-based practice in hire them and pay them. You need graduate graduate nursing education and has helped
nursing. They found that there was little that students who are willing to help.’ She found educate advance practice nurses across the
was specifically useful for nurses. ‘I became that quality graduates were hard to attract northern part of the state. For many years,
frustrated with the resources that were because they could earn more by just they were the only program in the Purdue
available for the kind of questions we were working a couple of shifts a week. What she system to produce nurse practitioners and
dealing with,’ says Lisa, ‘so we started has increasingly found is that while clinical nurse specialists. They used distance
referring students to the Joanna Briggs expectations for scholarly productivity rise, learning technologies to extend graduate
Institute site, recognising that it was much the same human and financial resource education to parts of the state with many
more nursing relevant.’ constraints remain. unmet healthcare needs.
8
profile •
In the first semester the students identify the
problem, negotiate that problem with their
clinical setting and then begin the planning
for the evidence-based practice project. Then
they write up a plan. In second semester
they finalise that plan and begin the
intervention, and in the third semester they
complete the intervention and evaluate it.
‘Usually, because they’re learning about
In the USA, the masters degree has evolved
evidence-based practice, they’re doing other
to focus more on practice than building
work besides this in the clinical setting, so by
primary
the end of that sequence they’ve usually
researchers. It
done a lot of work that they wouldn’t
while expectations for makes sense that
otherwise have been able to’ says Lisa.
scholarly productivity rise, curricula have
the same human and shifted towards ‘It’s very authentic to them. It makes the
evidence-based innovation of research much more pragmatic,
financial resource practice. Purdue much more concrete. I did some video
constraints remain Calumet’s clinical interviews with some of our very recent
nurse specialist graduates and presented some of what we’re
programs have had a heavy emphasis on doing with this program at one of our national
evidence-based practice. Five or six years conferences. One graduate is a wound
ago, the faculty overhauled the entire specialist and another is a director, and both
curriculum, and in the process recognised of them felt like they wouldn’t be able to do
that an evidence-based practice project their jobs as they know them without it. The
would bring that curriculum together. wound specialist does lots of patient care
Lisa says, ‘While we had to blaze trails and development of other nurses, and has a
‘In the past, we had the didactic component,
through university system issues, we were very direct influence. She has three or four of
that may or may not have related to what the
able to supply under-served areas with evidence-based practice projects going on
students were doing clinically, and we
advanced practice nurses. Now we’re using simultaneously. The project prepared her to
recognised that wasn’t right. We taught them
those same technologies to extend our go and do what she needed to do.’
to guide practice with theory and research
programs to nurses’ workplace so they
but we tried to do that by having them write Graduates are taking what they have learned
need not leave the hospital to get
papers about it. When we’d ask them to talk out into the practice setting when they finish
educated. We’re doing everything we can
about that in their reflection logs, the result their study, and using it in more sophisticated
to make our programs easily accessible to
was not very rich. Now we build their ways, reflects Lisa. The school is currently
busy adult learners.’
evidence-based practice skills in the didactic conducting an evaluation for their accrediting
Lisa has concerns about the future of nursing courses and they develop, implement and bodies, and Lisa says that one of the
research in the USA, and in particular is evaluate an evidence implementation project changes they have made is to start running
worried that primary nursing research in their clinical courses. This has been a focus groups. What they have found is that
capacity could be diluted with a new degree powerful way to bring the theory, research there is a significant difference between the
called the doctorate of nursing practice or and practice together.’ family nurse practitioners (FNP) and the
DNP. This new doctorate does not prepare clinical nurse specialists (CNS).
For instance, Lisa says, ‘We’ve had a few
graduates for research. Rather, it has been
wound specialists come through the program ‘FNP practice is very focused on individual
proposed as a practice-based degree.
and work on pressure ulcer prevalence. They patients. I think they look at their practice
Lisa fears that fewer nurses will pursue the use that first term to identify the problem. In more from an evidence-based medicine
research-based doctoral degrees. ‘Our the didactic portion they’ll do a phenomenon perspective. They tend to use clinical
masters degrees are already focused on exploration, then they’ll do a concept map of practice guidelines, algorithms and other
clinical practice rather than research. This that and try to explore everything around the decision aids to help them deliver care that
new degree simply extends the intent of our phenomenon, and then they’ll narrow it down physicians provided in the past. I think it may
current masters programs. I am very to a clinical problem and formulate their be harder to sort out the pseudo evidence-
concerned that students will opt not to clinical questions around that. It can be a bases sources because of the vastness of
pursue research careers for the familiarity mind-blowing experience for them to start what they are trying to learn, the number of
and attraction of practice.’ thinking that large and then that small again!’ patient problems that they deal with.
9
profile •
Lisa is very aware
that there can be a
our service mission, our difference between
teaching mission, and our rhetoric and reality
scholarly mission can all when it comes to
be coming from that evidence-based
same place healthcare. She
explains:
‘Everybody’s talking
about it. Whether or not they’re doing it is a
whole other question. One of our staff had
gone through systematic review training, felt
PICTURE: courtesy of Cave Country Adventures - Gary Berdeaux
much better about what she understood
about evidence based practice, and had
been invited to do some work on it in a text
A huge advantage of the changes to her book. They asked her to review any piece
role, Lisa has found, is that when she is of research that she wanted to pick, and
working with the evidence-based practice were going to call that evidence-based
team at the hospital, she is often working on practice approach.
the same projects as her students. Her work
‘They just didn’t know any better. And I fear
at the hospital allows her to have a clinical
a lot of that’s what’s happening. You’ll see
role very much like the nurses she is
articles published particularly in clinical
preparing, which she finds invaluable. The
journals, that say this is an evidence-based
divide between her scholarly work and her
practice “fill in the blanks” approach, and
teaching has significantly reduced. Another
basically it’s a convenience sample of the
advantage of the participating in the
literature. There’s a whole lot of mislabelling
Collaboration is the increased international
going on.’
‘It’s such a different approach. They might contact, which is reflected in the broader
say: “I need to take care of this patient’s strategies of the university. Back in Indiana and the Wyandotte Caves,
condition, let me go and find the latest clinical the Scouting rule book warns would-be
Of her healthcare environment, Lisa says, ‘I
practice guidelines,” if they find it, they use it spelunkers that ‘cave exploring can be
think we have to come to terms with how
to guide their care of a particular patient. It’s hazardous when the proper skills,
much health care in the USA costs. I don’t in
very different from how a clinical nurse equipment and judgement are not used’.
the foreseeable future imagine a national
specialist may struggle with, for instance, This warning does not translate to Lisa in
health care service. Clinton got as close as
pressure ulcer prevention, where if you only her new role. She is inordinately well skilled
probably anybody’s going to get for a while. I
looked at “What am I to do?” you would only and equipped to handle the challenges of
just don’t see that happening.
be one quarter of the way along, because her new role. ‘I’m very excited about what
then there’s all the change management ‘I’m glad my parents are able to take care of our centre can do, being a hub of lots of
strategies of influencing other nurses and their own needs because I don’t know how different kinds of activity,’ she says. ‘It
systems including implementation, utilisation I’d begin to help them. It requires a great brings three of our missions together really
and evaluation of the ulcer management deal of labour, and you’re forever sorting well. Our service mission, our teaching
strategies that we normally think of in our things out. At the same time, we don’t wait mission, and our scholarly mission can all
practice. I know not everybody would agree for any of our health care; if we need an be coming from that same place, and it just
but that perspective, that difference, keeps elective procedure we go out and get it. So, wouldn’t have happened without these
smacking us in the face.’ the quality of care is pretty good.’ international friends.’
10
feature •
Changing clinician behaviour
in stroke care
STORY: Nic Rowan
PICTURE: courtesy of ACU/Fiora Sacco
In March 2005 Sandy Middleton was appointed
Professor of Nursing at the Australian Catholic
University's North Sydney campus. She was also
recently awarded a three-year AUS$400 000
National Health and Medical Research Council
(NH&MRC) grant, to conduct a clustered randomised
control trial of acute stroke management in New
South Wales. This grant will fund the Quality in Acute
Stroke Care Project.
ays Sandy, ‘Stroke is the third leading
S cause of global morbidity and mortality
after cancer and cardiovascular
disease. Our grant will determine the impact
of a standardised, multidisciplinary team
building intervention to monitor and manage
three complications following stroke known to
result in poor patient outcomes, namely fever,
blood sugar and swallowing dysfunction.
11
feature •
Still, it is early days, she says. ‘We’re still
recruiting and seeking ethical clearance at
some hospitals. To date, we have four sites
up and running with a further four coming on
board in early January. New South Wales
has many new
stroke units as a
they will see that result of government
patients are going to funding occurring
under the umbrella
have better outcomes,
of The Greater
so they will implement Metropolitan Clinical
the changes Taskforce (GMCT).’
GMCT initiatives
such as these are a result of
recommendations for improvements to the
public health system, arrived at in
consultation with consumers and managers.
Its principles are transparency, clinician and
‘Optimal management of these three clinical consumer involvement, and population
issues is pivotal for favourable patient based services founded on equity of access Sandy’s project addresses the evidence-
outcomes. All three have been identified in and equity of outcome. based practice gap in many ways. She says,
the National Clinical Guidelines for Acute ‘I think there is a gap between what we
Stroke patients who go to hospital and are
Stroke Management recently released by the know to be best practice and what actually
admitted to a stroke unit do better than
National Stroke Foundation as priority care gets practiced. There are lots of barriers, but
stroke patients who are not admitted to a
issues for inpatient stroke management. we have to embed change in the clinical
stroke unit, Sandy says. Such units have
practice that’s actually happening at the
‘These physiological parameters have been been set up in the metropolitan area and
time, and it’s difficult.
shown to have an effect on patient now are appearing in rural areas.
outcomes. Acute stroke therapy these days ‘This trial I’m doing is not going to be
While Sandy’s project is significant for
is very much aimed at trying to minimise the straightforward. It is going to be difficult
stroke victims, it is also important in another
amount of brain damage; we know that because we want clinicians to change their
way. It will be the first research project to
following stroke if your blood sugar is raised behaviour. But I’m also hoping that because
use the Towards a Safer Culture (TASC)
and you have a fever, you can extend your it’s so clinically relevant they will be engaged
data, routinely collected clinical information,
infarct with a detrimental effect on patient by it. They will see that patients are going to
for research purposes.
functional outcomes. Similarly, swallowing have better outcomes, so they will implement
dysfunction can lead to aspiration pneumonia The TASC initiative, set up by the Clinical the changes.’
and even death.’ Excellence Commission and the Royal
Sandy will also complete a process analysis
Australasian College of Physicians is a
The funding Sandy has received is to as part of the project, to discover what did
clinical pathway and quality improvement
undertake the trial in stroke patients in and didn’t work. She believes that more of
tool that is used from the time of the patient’s
hospitals in New South Wales. ‘So far about this kind of activity is required, to help
admission to the Emergency Department
twenty hospitals have given us the green address the evidence-based practice gap in
and then continued in other wards
light. As this is a clustered randomised unpacking whether a particular process
throughout the hospital. Under the TASC
controlled trial we will be randomising Stroke facilitated change or not.
initiative, patient information is collected
Units to either the intervention or control
routinely for a variety of clinical conditions, of ‘I think we need to come at evidence-based
group. This work hasn’t been done
which stroke is just one. practice from different areas’, she says. ‘We
elsewhere in the world. It will be
have such a plethora of approaches. Have
groundbreaking. ‘The project is multidisciplinary; it’s a
we got evidence-based researchers? Have
fantastic project, she says. ‘We’ve got many
‘This will be an evidence-based suite of we got evidence-based lecturers? We have
people collaborating on it. One of the other
interventions,’ she explains, ‘based on the to have all of these in place to support our
lead investigators is Dr Chris Levi who is the
literature about what works and doesn’t work evidence-based clinicians.’
medical director of the National Stroke
in terms of knowledge transfer.
Foundation, and we have Professor Jeremy Projects such as Sandy’s, which touch on the
‘Our primary outcomes are patient outcomes, Grimshaw, the Director of Ottawa Health practice of many clinicians at many hospitals
such as death and dependency, but we also Research Institute in Canada, as well. all at once, can only help to drive the
have secondary outcomes about clinician Jeremy is an international expert on evidence-based practice movement forward.
behaviour change.’ knowledge transfer.’
feature •
12
13
feature •
conditions at the same time. And what’s the
The sum? What’s the evidence for better
outcomes when you manage them with five
affectionate different guidelines? We simply don’t know.’
Australian
nickname to doctors, on the care
Andrew is impressed by work coming out of
the USA at present. ‘There’s a nice paper
'Digger', used that’s being delivered to
that’s just come out from Mary Tinetti
to refer to their veteran patients. They
[‘Potential pitfalls of disease-specific
army also offer evidence-based
guidelines for patients with multiple
information to sit alongside
personnel, is that feedback. Practitioners
conditions’, NEJM Dec 30, 2004], talking
attributed to can be provided with lists of
about the fact that if you actually follow those
the number guidelines, the person would be spending
STORY: Nic Rowan PICTURE: Nic Rowan
their veteran patients with
about two and a half days a week running
of ex-gold diggers in early army specific diseases such as
around getting various allied health services
units, and to the trench digging diabetes, and can be
and managing complex medication regimes.’
activities of those soldiers during shown current patterns of
medication use and Clearly, says Andrew, that doesn’t happen.
World War I. However, the term management for those Practitioners make a choice about what
might also be used to refer to patients. This can highlight they’re going to do. ‘But where’s the
Andrew Gilbert and a team that is for the practitioner where evidence to back up those choices?’ he asks.
systematically digging down there might be a need to ‘Where does patient preference come into it?
through a massive database review, or areas where Patient preference is not considered very
relating to Australian veterans. there is under-treatment, for often when we put these disease
example cardiovascular risk management guidelines together.’
associated with diabetes.
Andrew believes that the most exciting work
P rofessor Andrew Gilbert is Director of
the Quality Use of Medicines and
Pharmacy Research Centre in the
University of South Australia. He is
responsible for a project called Veterans’
‘It’s been extremely well received,’ says
Andrew. ‘In fact, it has the potential to be a
major advance in practice management in
general practice, if in the future this sort of
for him and his team will be in recognising
the limits of current evidence-based work
and working out how to get evidence to
support practice in these more difficult and
information is available on the desktop for complex areas.
MATES (Medicines Advice and Therapeutic
doctors. The current age profile of the
Education Service), which is a partnership ‘That’s where it’s going. One of the big
veteran population is pretty much where the
with the Department of Veterans’ Affairs. worries in America is that a lot of the
Australian population is going to be in twenty
practice incentives and the payments to
About 330 000 veterans in Australia regularly or thirty years’ time, with the baby boomer
health practitioners are based on
receive medicines or treatment through bulge going through.’
practitioners following guidelines, which
Department of Veterans’ Affairs programs.
Andrew feels that one of the major might not be the best for the patient at the
Those treatments include medical, allied
challenges lies in understanding the limits of end of the day.’ Andrew is concerned that
health and hospital services, and the
the evidence. ‘What we’ve got now is a Australian health care might follow suit,
Department has the only linked database in
whole range of evidence-based guidelines working to guidelines as a requirement for
the Australian health system that tracks all of
for practice around specific diseases or practitioners to be registered with health
those services together.
conditions, like management of arthritis, management organisations.
‘This originated from a payment perspective’, where we know the place of physiotherapy
‘The benefits of polytreatment must be
Andrew says, ‘but it also enables us to look alongside anti-inflammatories and pain relief
weighed against the effects of
at individual veterans, see what services and so on. We’ve got beautiful disease
polypharmacy,’ argues Andrew. As the
they’re getting, what medicines they’re based guidelines for diabetes, hypertension,
database grows the team’s mission will grow
getting, whether they’re in hospital or not and heart failure, all of the big conditions.’
alongside it, working toward a future where
so on. Also, it enables us to identify their
The difficulty, however, is that members of hopefully healthcare and disease
individual healthcare practitioners.’
the veteran population typically have more management guidelines are realistic,
The team is working with that database to than one concurrent disease. ‘They applicable to these complex patients, and
provide feedback information, thus far mainly commonly have four or five chronic take into account the needs of the patient.
14
feature •
Magnetism in
Oklahoma STORY: Nic Rowan
PICTURE: courtesy of University of Illinois
15
feature •
Magnet status, explains Dr Kenner, refers to
Dr Carole Kenner is a busy woman. As well as being
a program that rewards health care systems
Dean and Professor at the College of Nursing, that promote positive work environments and
University of Oklahoma Health Services Centre, she are patient focused with good outcomes. The
is Director of the year-old Evidence Based Practice magnetism is reflected in the forces that
Centre of Oklahoma, one of three JBI Collaborating attract health professionals to a hospital and
Centres in the USA. The Collaborating Centre retain them, but is also the culture that
supports scientific evidence to ground
represents a partnership between three institutions:
interventions. It is present in hospitals that
the University of Oklahoma Health Sciences Centre tend to have a very good workplace
College of Nursing, Integris Health Centre and the environment for all health professionals and
Veterans Administration Medical Centre. the patients and families they serve.
The award program is managed by the
American Nursing Credentialing Centre, the
credentialing arm of the American Nursing
Association. It arose from a study about why
‘ The reason that we were very interested in
Oklahoma getting involved with the Joanna
Briggs Institute’, says Dr Kenner, ‘is
some American hospitals were managing to
retain staff while others struggled in the
1980s. Key findings were staff autonomy,
recognising that many of our hospitals are management involvement, administrative
beginning to really value evidence-based support and sufficient funding. Since the
practice. It’s more than just lip service; they development of the program, organisations
recognise that it’s important in the United across the USA including hospitals, nurses
States for achieving magnet status and associations and education providers have
improving health outcomes.’ been accredited.
16
feature •
Of the future of the Evidence Based Practice
Centre of Oklahoma, Dr Kenner opines that
the focus will probably be on evidence-based
practice training more than on conducting
systematic reviews.
As evidenced by the four presentations from
the Centre at the JBI International
Convention, Oklahoma has already had a
sound beginning
with the JBI. Dr
Magnet status, explains Mary Allen-Carey
Dr Kenner identifies Dr Kenner, refers to a presented
‘Implementation of
the faculty shortage program that rewards
Evidence Based
and limited clinical health care systems that Case Management
settings as a promote positive work Protocol for the
challenge for now
environments and are Depressed
and the future. ‘The
Dr Kenner says, ‘Nursing and patient
average age of
patient focused with good Community Client’,
outcomes, and patient and family satisfaction
faculty in the United outcomes. Dr Renee Leasure
are key components, but a part of being presented ‘CHAIN: A
States is about 56,
designated as a magnet centre means that resource to enhance
so couple that with the growing numbers of
you also have to have a commitment to access to HIV/AIDS Evidence Based
people that need nursing care and the fact
doing research and to look at research Resources’, Ms Shari Clifton from Library
that clinical sites are very difficult to obtain
utilisation in your setting as well as being Services presented ‘Health Information
because of the shortage, and we can’t
able to demonstrate that you have evidence- Literacy: An Essential Component for
increase our enrolments in the States in the
based guidelines to guide as much of the Evidence Based Practice’, and Ms Susan
nursing programs. We have three to five
care as possible.’ Jones from clinical partner Integris presented
times more qualified applicants than we can
‘Reducing Ventilator Associated Pneumonia
The college has a case management take, because we don’t have the practice
Rates Through Multi-Institutional Evidence
practice service directed by Margo sites or practice partners, so that’s been
Based Practice Changes’.
MacRobert, MS, RN, with a client base of very difficult.’
about 1,800 primarily elderly, chronically ill Dr Kenner is also interested in rolling out the
Dr Kenner feels that because of some of the
clients. The service provides nursing case JBI ACTUARI (Analysis of Cost, Technology
standards in the USA, it’s a little easier to do
management and care based on evidence- and Utilisation Assessment and Review
evidence-based work in the clinical facilities
based protocols that have already been Instrument) package. She hopes that
because accrediting bodies are requiring it.
developed, and others that are currently Oklahoma can create a niche for costing out
Institute of Medicine studies on patient safety
being worked on. Dr Kenner considers this a evidence-based guidelines and practice.
and errors, especially medication errors, she
unique opportunity for the students, and
says, are forcing hospital delivery systems to Although worldwide methods of review for
reflects that this is reinforced through
look more closely at scientific evidence to economic data are considered to be at a
masters students being required to
support how they are carrying out care. developmental stage, many of the elements
undertake evidence-based projects.
While she says that’s not quite as true on the of the review process have been debated
‘All of those things to me are why Oklahoma academic side, she does suggest that the and scrutinised for some time. While that
makes a good case that you can blend academic partners have more flexible debate will continue, there is a need to
clinical practice with research and education schedules to help conduct some of the provide tools for reviewers working in this
components, if you are committed to evidence-based practice projects and to area. JBI ACTUARI is one initiative that
evidence-based practice’, she says. develop guidelines. attempts to meet this need.
17
feature •
The software reflects the developmental
stage of economic evidence review
methodology and it is intended that
subsequent versions of the software will be
upgraded as the methodology develops.
Perhaps the most significant benefit of the
software development is that reviews of
Dr Kenner is particularly interested in this
economic evidence can be conducted in
field because she has been involved in the
parallel with reviews of clinical effectiveness,
development of the Council of International
feasibility, appropriateness and
Neonatal Nurses, and the World Health
meaningfulness. The beta version of the
Organisation emphasised that she must
module will shortly be available for testing.
examine economic indicators. She has
‘Nursing has typically not looked at economic begun to learn about gross domestic index,
indicators as much as other disciplines have purchasing parity, direct and indirect foreign
had to do,’ Dr Kenner says. ‘Medicine has investments and how those play out in
had to because of the way that morbidity and mortality rates. It is a whole The work of the Joanna Briggs Institute is
reimbursement of services occurs. That’s new area for her, but one that she embraces. under-recognised in the USA, says Dr
probably pushed them a little sooner than it Dr Kenner is also excited about the Kenner. She hopes to increase its profile,
has for us. We need to look at nursing care possibility of doing economic work at a local and, indeed, she is an ideal ambassador,
economic value and cost versus benefit of level with small projects, and then filled with enthusiasm and vision, a magnet
clinical treatment plans.’ extrapolating this out at a global level. of her own making.
Are you interested in promoting best practice?
The Joanna Briggs Institute is committed to providing the best
available evidence for clinicians worldwide. CONNECT facilitates
this process by inviting Health Professionals to collaborate with JBI
in the research and development of interventions for the
international health care community. •
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phone: +61 8 8303 4880 www.joannabriggs.edu.au
18
feature •
Using
evidence in
the nurse
practitioner
role: Wendy
Cross and
Southern Health, in
Victoria, Australia,
provides care to more
than 750,000 Melbourne
people. As such it is
extremely well placed to
promote and enact
evidence-based
research and practice.
Professor Wendy Cross
is Southern Health’s
director of nursing
education and research,
and in this role she
fosters research and
evidence-based
education and practice
in the 4,500 plus nurses
currently employed by
Southern Health.
STORY: Nic Rowan
19
feature •
‘It is an interesting place to be at the
moment,’ says Wendy, ‘and I think we are
able to be interesting because we’re able to
call in different people with different
expertise. We are about to appoint a chair of
nursing, a new appointment in conjunction
with Deakin University. That will be a pivotal
position. While it’s embedded with just one
university we do very much want to maintain
strong relationships with other universities,
because we have their graduate students
To identify opportunities for coming through the door, and there are
interdisciplinary collaboration and opportunities for joint research and the
postgraduate education, senior associated grants.’
medical staff, the director of post
Opportunities for new clinical practice
graduate medical education and
guidelines are identified by nurse
Wendy have set up a strategic
practitioners. They then review and appraise
planning workshop hoping to link
the evidence, look for any practice guidelines
with all health professionals to develop these
that already exist, and translate the evidence
relationships and create a long term plan for
for use by Southern Health’s emergency
P
rojects at present include research in interdisciplinary work.
departments. The guidelines are
neonatal intensive care about
Senior medical staff are certainly interested contextualised through a multidisciplinary
keeping low birth weight babies
in developing closer relationships. As they advisory committee, which includes
warm; attempts to identify and utilise the
struggle with the undersupply of medical pharmacists, physicians, radiologists, nurses
evidence in acute confusional states; and
officers, they are recognising the benefits of and relevant allied health professionals. After
reviewing the use of seclusion practices and
developing after-hours nurse practitioner approval by the therapeutics committee, the
‘as required’ medications in the acute setting.
roles, particularly in Southern Health guidelines can be used by Southern Health
‘So there is quite a bit of activity happening,’ emergency departments, in collaboration ED nurse practitioners. Guidelines are also
Wendy says, before adding that this is an with on-call medical staff. One of Southern reviewed by the Department of Human
adjunct to routine evidence-based practice Health’s strengths is its size, and a staff Services and are then made available to
activities such as falls prevention, pressure population of ten thousand translates into other practitioners. Southern Health ED
ulcer management, wound care, indwelling economies of scale that allow for trials that nurse practitioners are currently finishing
catheter management, and continence might not be feasible in a smaller setting. around 30 clinical practice guidelines.
management activities that require a
‘I guess from a nursing point of view, I’d like Evaluation is built into the process. The
coordinated approach. To assist in that
to have a more coordinated approach, and guidelines are evaluated every six months for
approach, Southern Health has recently
I’ve been stimulated at the Joanna Briggs currency and acceptability. The evidence so
appointed a practice improvement
Institute International Convention into far is that the acceptability of the guidelines is
coordinator who is a nurse.
creating what I think I will call “SHARING: occurring so much that the director of the
‘She’s trying to pull together some of these Southern Health Applied Research in emergency department is very keen to
things’, says Wendy. ‘She works closely with Nursing Group”. I think if we can harness all extend the program, particularly to mental
me because most of these things have a of the activities of nursing research to health nurses in the ED who are currently not
large education component to them. I’m also accomplish some of the understanding of involved. Southern Health is keen to develop
helping her to identify methodologies around evidence-based nursing and the application the role of the nurse practitioner into other
various activities. We’d also like to look at of that to practice, that will be quite useful.’ areas such as paediatrics, women’s health
integrated care pathways. Southern Health management are likely to and mental health.
be receptive, suggests Wendy, adding that
‘Whilst we talk about it a lot, we haven’t One of Wendy’s roles is to nurture and
‘there’s a lot of good will around those sorts
really got to that point yet. We need a lot support the nurse practitioners in developing
of things.’
more buy-in. Having said that, nursing clinical practice guidelines, even though the
education and research at Southern Health One of the spin-offs from developing the practitioners do not report to her. Because of
is now liaising much more closely with the nurse practitioner role has been the this she is free to act as advocate for them
Monash Institute of Health Services increased self-efficacy. As nurses are to other managers if required. But what she
Research and also much more closely with enabled in their practice, their ability to read, is really an advocate of is a coordinated
our large Simulation Centre.’ understand and utilise research improves. approach to evidence-based practice.
20
feature •
Paediatrics in Sweden:
it’s all
about
teamwork
21
feature •
STORY: Christine Jolinger and David Grant
PICTURES: courtesy of Christine Jolinger
Christine says that she didn’t choose to go to
Paediatric intensive care clinician Sweden for any reason other than ‘it just
Christine Jolinger talks to PACEsetterS happened to be the first au-pair job abroad
about working in Sweden, where that I came across’, and she has always felt
at home in Stockholm. She adds that,
rhetoric meets reality. ‘Sweden is a beautiful country, covering a
large area. It is relatively under-populated
D
espite popular misconceptions,
and it has everything from flat countryside to
Sweden is not all ABBA music,
mountainous regions.
sparkling snow, Volvo cars and the
Muppets’ Swedish Chef. ‘Although at first glance the Swedish culture
isn’t dissimilar to British culture, there are a
There also exists a dynamic education and
number of things here in Sweden that make
research environment that includes the
a huge difference to my way of life.
Karolinska Institute, a large medical training
and research centre. Within this Institute is ‘Almost all Swedish youth are well educated.
the Astrid Lindgren’s Children’s Hospital, with Everybody is encouraged to participate in
a total of 180 beds. The hospital is aptly further education and all are entitled to a
named after Sweden’s much-loved author of place. If extra resources are required, they
Pippi Longstocking, the rebel girl with are expected to be provided. Most people
attitude who stole the hearts of children the nowadays have a three year college degree,
world over. Located in the Swedish capital, and more and more people are adding on a
Stockholm, the university hospital is also three year university degree. A specialised
home to researcher Britt-Marie Ygge. nurse today has a minimum of seven years
further education.’
Originally from the north-east of England,
Christine Jolinger moved to Sweden’s capital The Swedes have been very successful at
to work as an au-pair and twenty five years promoting equal opportunity for women, says
later she is still in Stockholm, but as a senior Christine. ‘There is still a lot of work to be
paediatric intensive care nurse within the done in this area, but compared to some
children’s hospital. other countries, a lot has been achieved.’
22
feature •
PICTURES: courtesy of Christine Jolinger
After working for two years as an au-pair and
experiencing a steep language learning Working in the ICU environment often means
curve, Christine moved into healthcare work, engaging with the latest treatments
training and then qualifying as a registered combined with the latest technology. ‘We
nurse and finishing off her education with an gather the latest information from all kinds of
extra year specialising in intensive care. places. Conventions, research, articles and
training courses’, says Christine.
‘I have spent most of
my qualified nursing ‘I was in Denmark yesterday and it was just
career working with
there comes a magic
like walking into our unit – same diagnoses,
children,’ she says.
moment when you same treatments, and the same machines.
Earlier experiences suddenly realise that you Visits to other units assist us in gathering
include five years are not afraid of the Christine says that
information. A good example is our transport
working on a pre- and unknown. You trust your one of the
module. One of our doctors first saw it in use
post-transplant unit ability to improvise highlights of her
whilst delivering a patient to an English
specialising in bone hospital, and yesterday, when I was in
work at the hospital
marrow, renal and Denmark with it, the same module created a
is the fact that her role is very multi-
hepatic diseases, before moving to children’s lot of interest. It’s a small world.’
dimensional. It spans PICU, the recovery
intensive care nursing.
room, giving lectures and staff training, Christine has done a great deal of traveling
‘Moving into paediatrics gave me a chance working in the hyperbaric oxygen unit and in her work. ‘I’ve been sent to Ireland,
to use my auxiliary experience. After working transporting ICU patients throughout England, France, Canada, and Pakistan, and
with critically ill children on the wards, Sweden. ‘Connected to our department, we I recently spent a month in China. At the
working in the intensive care unit seemed have PICU (9 beds), ECMO (extracorporeal moment we have a nurse training exchange
natural. membrane oxygenation; 3 beds), LIVA (long- program with China; the Chinese nurses stay
term intensive care; 4-5 beds), and recovery on our ward for 3 – 6 months and we get to
‘I had enjoyed working on the children’s
room (12 beds)’ she says. visit them, observing and giving lectures. It’s
transplant unit immensely, so working in
a wonderful experience.
PICU (the paediatric intensive care unit) ‘The thing I enjoy most has got to be never
meant I got to use my experience from there knowing how the day is going to turn out. I ‘We’re helping them to further develop
and at the same time learn more about haven’t always enjoyed that; it’s something nursing as a profession. While they have all
critically ill children. I have always regarded that comes with experience. Most people the technology, they’re still growing their
my placements as training courses, and the who work in ICU will probably agree with me nursing skills. Traveling to Asia has given me
reason I have stayed in PICU is simply when I say that there comes a magic a deeper understanding of what nursing is
because there is always something new to moment when you suddenly realise that you as a profession. Learning what nursing is,
learn. I never get bored; there are so many are not afraid of the unknown. You trust your and how to develop it, is I think, the major
different diagnoses.’ ability to improvise.’ and most important thing we all learn.’
23
feature •
‘We’ve always transported cardiac patients,
and have recently started our own transport
service. The Paediatric Emergency Transport
Sweden has an international reputation for
Service is a specialised service designed to
striving to provide equal access to health
transport critically ill children to our intensive
services for all its citizens. Christine says,
care unit, and to provide a skilled paediatric
‘Adults pay a small fee when seeking
intensive care team to assist in the treatment
treatment from a general practitioner, but
of children both before and during the
hospital care is basically free. Children will
transfer. I particularly enjoy working in the
pay nothing from July 2006, an initiative of
The flip side of Christine’s work is the transport team. We transport ICU patients by
the Swedish Government.
challenges, including mastering of all the plane, helicopter or ambulance all over
machines used in the ICU. ‘Often you don’t ‘As healthcare is almost free, private Sweden,’ she says.
get more than minutes to prepare an healthcare is something people turn to for
‘As treatments become more advanced and
enormous amount of technical equipment for procedures like cosmetic surgery. There are
refined, the need to transport children to a
one specific diagnosis. For example, infusion always complaints about waiting times for
PICU is becoming more apparent. We have
pumps, respirators, monitors, dialysis particular operations but basically health
expanded our own transport service, so that
machines and so on. care is there for those that need it.’
as well as delivering patients for treatment
‘Meeting everybody’s needs can be very While care is virtually free, gaining elsewhere, we now collect patients, both
challenging. Different ages, ranging from geographic access to it can be a different stable and unstable, that require treatment
newborn 600 grams to 18 years of age, many matter. ‘Because of the size of the country by us.’
different diagnoses and families from all versus population, availability can be
Moving patients inside the hospital is low risk
walks of life; sometimes we don’t get it right. restricted. Getting a critically ill child from
compared to transporting them between
one part of the country to a PICU in another
‘I’m always haunted by the worry that we will hospitals, says Christine. ‘We have a large
can be a problem and not always possible.’
make mistakes. No matter how many times ECMO unit on our ward, so we have had a
we are praised by mums and dads, one Sweden is a large country, so only having 3 lot of experience in traveling with critically ill
mistake and … ‘ Christine trails off. ‘Parents PICUs can present problems. In an attempt patients. Outside the hospital the transport
of children in ICU can be very unforgiving. to provide equal healthcare for children, team is on their own, dealing with problems
Right from our first day in nursing school it is certain specialties have been centralised, for as they arise. Planning on all levels
drummed into us: you cannot make a instance paediatric cardiac surgery. Children becomes crucial. Rules and regulations have
mistake. But they forget to tell us that from large areas of Sweden are flown to to be taken into consideration; not all
everybody makes mistakes.’ Lund, a city in the south. equipment can be taken onto an aircraft.
24
feature •
Christine Jolinger
‘There was no model; it had to be
researched properly because flying with
medical equipment means everything has to
be approved by the governing body, which is
‘To develop the nursing profession nurses
both expensive and time consuming.’
have worked hard at defining exactly what
The relationship between universities and nurses do. That leads to research in
The areas Christine has chosen to specialise
hospitals is strong in Sweden. ‘The hospital evidence-based nursing as distinct from
in are transport, trauma and dialysis. ‘Apart
I work for is connected to Karolinska evidence-based healthcare.’ She also
from focusing on improving patient care
Institute, a large medical training and reflects that, ‘In some countries nurses are
within these areas, I also have teaching
research centre. A lot of research at the trying to define nursing as a distinct
responsibilities’, she says.
hospital leads from the Institute and we see profession because they don’t want to be
medical and nursing students on a daily perceived as a doctor’s assistant. In our Research in a paediatric intensive care unit
basis. It leads to an open climate when it society where there is equality between presents its own special problems.
comes to further education and gives more individuals, we take it for granted so this is ‘Research obstacles within children’s
incentive to pursue research projects.’ not a problem. Any doctor who regarded me healthcare are always going to be divided
as a doctor’s assistant in our unit would be into two main areas’, says Christine. ‘They
Christine believes that evidence-based
frowned on. are lack of patients, and ethics.
healthcare has ‘exploded’ in Sweden. ‘In our
unit, I think it is fair to say that we identify ‘On our unit, we have always worked very ‘As far as the lack of patients is concerned,
more with evidence-based care rather than hard at documenting all aspects of PICU we often simply don’t have the numbers to
evidence-based nursing, as we are strongly patient care. We use research, and interpret do the relevant research, so we find
encouraged to work as a team, intensive and evaluate our own practice. Ongoing ourselves one step behind adult patient
care nurses and medical practitioners education of our PICU team has always research. Compared with the adult
together. We work as a team while delivering been a high priority. We are all encouraged population there are always less children in
care, so we tend to develop our practice as to choose a specialty area, then expected to ICU. In Sweden we have a population of
a team, but we still have some specific focus on improving patient care and around nine million people and only three
nursing projects. professional development in that area.’ PICUs, with a total of maybe 30 beds in all.’
25
feature •
PICTURES: courtesy of Christine Jolinger
there are problems Ethics also presents
translating research as an issue as far as
findings to children, when research in children
is concerned. Parents
originally developed for of very sick children
adults may not be willing to
allow those children
‘My latest project was done together with
to participate in research into, for instance,
This, coupled with the span of patient ages one of our anaesthetists – we have just
differing methods of paediatric intubation, or
from premature to 18, and different finished developing guidelines for PRISMA
trials of different pain-killers.
diagnoses, reduces possible cohort groups renal dialysis for PICU patients from 2 kg
significantly. ‘To carry out any serious Christine says that ‘Many medicines and upwards. The specific evidence-based
research, you have to have patients that can techniques are trialed on fit 18 to 22 year old nursing projects we have on the ward at the
be compared to each other and this is where males but there are not many kids in that moment are quite traditional nursing
our problem lies. For example, a patient queue. There are problems translating subjects, projects often used to establish
weighing three kilograms can’t often be put research findings to children, when originally nursing guidelines. A lot of work is being
in the same study as a patient weighing fifty developed for adults.’ done around the subject of pain, sedation
kilograms.’ and nutrition.’
The Swedish Nursing Society [Svensk
Differences in diagnosis also present a Sjuksköterskeförening] promotes In 1995, Sweden joined the European Union.
problem. ‘If we have six patients in the development of nurses by the development Christine believes that this opened an
unit, we are almost guaranteed that they of clinical guidelines that allow nurses to opportunity for Sweden to demonstrate best
will be six different ages and have six provide care based on scientific methods practice in healthcare to developing
different diagnoses. and proven experience, but Christine European Union countries.
believes this organisation is not well utilised.
‘One thing that always has surprised me is Sweden is working hard on two things:
the number of diagnoses we have to deal She says that this might be because of incorporating evidence-based practice into
with. It makes research a problem. What limited interest in specific nursing research in multidisciplinary healthcare systems,and
usually happens is that extensive literature Sweden. ’I would say Swedish nurses are providing equal access to health services for
studies from adult patient care are carried interested in interdisciplinary research. This all citizens. After all, this is the country that
out and interpreted before we try them. That probably has to do with Swedish society as a produced Astrid Lindgrun’s Pippi
usually means the outcome is anticipated whole. On our ward, developing patient care Longstocking, the very forward-thinking
before the research is actually carried out.’ guidelines as a group is an ongoing process. heroine of children the world over, .
26
feature •
Hand washing: still defying the evidence
27
feature •
Over the course of the next twenty years
Semmelweis became alienated from the
increasingly hostile medical community in
Vienna, and was only vindicated when the
germ theory of disease became accepted
after his death.
But even though the evidence is now well
accepted, the battle to achieve utilisation
goes on. A 2003 systematic review published
in the Lancet found that simple hand
washing with soap in the community could
reduce the incidence of diarrhoea by 42-47
per cent, and save a million lives.
PICTURE: Nic Rowan
In a continuation of this 150 year-old fight to
implement effective hand washing in
healthcare settings, the World Health
Organisation October 2005 draft guidelines
on hand hygiene in health care state that,
‘Currently, hand hygiene is considered the
most important measure for
preventing the spread of
In his closing address at the Joanna Briggs Institute 2005 pathogens in health-care
International Convention, Professor Chris Baggoley, Chair of settings’.
the National Institute of Clinical Studies and Chief Medical Healthcare organisations
Officer of South Australia, used the basic task of hand worldwide have tried virtually
washing as an exemplar of the difficulties associated with every conceivable strategy to
achieving evidence utilisation. STORY: Nic Rowan achieve employee compliance
with hand washing guidelines. ‘It
beggars belief that we are still
studying hand washing’, Professor Baggoley
said. ‘Continuous quality improvement is still
a hybrid approach. The difficulty is in getting
spread. It’s not like hybrid corn or disease. It
doesn’t naturally “take off” when it reaches a
P
He made this discovery after a colleague
rofessor Baggoley presented a
died from a wound inflicted by a medical certain momentum. Safety and quality
sobering statistic: 7 to 10 per cent of
instrument while conducting an autopsy; the initiatives don’t spread like this, even
hospitalised patients acquire an
man’s symptoms were similar to those of between wards in the same hospital.’
infection, with the rate increasing in
women who died of puerperal fever.
proportion to length of stay. He cited a recent Professor Baggoley said that no single
Semmelweis later extended his experiments
study showing that doctors estimate that they strategy has been shown to effectively
to include the washing of all instruments
wash their hands around 73 per cent of the increase hand washing rates among health
coming into contact with women in labour,
time, but the actual unobtrusively observed professionals, and that a multi-faceted
and infection in these patients was almost
rate may be as low as 10 per cent. Reasons approach is required. He said that systems,
eliminated.
for this include habit, not believing the synopses, and systematic reviews must
evidence, underestimating or not observing Despite strong and replicated evidence, result in clinical guidelines that health
resultant complications, and overestimating however, Semmelweis’ findings were not professionals and patients are aware of and
performance. embraced by healthcare workers, in part accept; are applicable; are within their
because he was reluctant to share his abilities; and are acted on, agreed to and
Yet compelling evidence has existed for over
results. This reluctance was hardly adhered to.
150 year that hand washing is a critical
surprising; the environment of the day was
health care worker activity. Back in 1847, Dr Failure of this process was exemplified by a
not politically receptive, and his findings
Ignaz Semmelweis achieved a decrease in recent Scottish campaign, which injected
contradicted current medical thought.
the mortality of maternity patients in the UK£15 million into hand washing strategies,
Vienna General Hospital from puerperal fever Some doctors complained that it would take including the provision of alcohol hand
(also known as childbed fever) from 18.27 far too much time to wash their hands washes at every frontline bed in Scotland.
per cent to under 1.27 per cent, simply by between attending patients, and others An unintended and rather alarming
forcing staff to wash their hands in believed that the findings had a superstitious consequence was that patients started
chlorinated lime when moving between or religious origin. They were disturbed that drinking the hand wash, necessitating
cadavers and these patients. the source of fever was always the dead. adding a foul taste to the brew.
28
feature •
Getting beyond
the next minute
Donna Ciliska is a busy, multi-
talented woman to say the least.
Not only is she a professor at
McMaster University’s School of
Nursing in Ontario, but she has
an appointment with the
Hamilton Public Health
Services. As well as that she is
lead editor of Evidence-Based
Nursing, and co-director of the
Canadian Centre for Evidence-
Based Nursing. Her research
interests include community
health, obesity, eating disorders
and research dissemination.
STORY: Nic Rowan
PICTURE: Nic Rowan
29
feature •
She explains, ‘We’ve done a lot about
guideline development, and that can have
an impact on frontline staff, but most
organisations are understaffed; there aren’t
enough nurses. Evidence-based practice is
definitely not a priority when you have to do
35 dressings and give medications to 40
people. You don’t have time to go away and
think about, “What are the clinical issues
here, and how do I find the best evidence
for them?”
‘At some level most organisations have
somebody who is already doing this, so it’s
beginning to happen, but it really hasn’t yet
had an impact on the way staff think.
There’s a big gap’, she says, and adds that,
‘As an educator, you look to the next
generation. We want to see our students
getting it in the curriculum across Canada,
for it to become a standard curriculum.
There’s some expectation from the
accreditation bodies that evidence-based
nursing and evidence-based practice is part
of the curriculum, so I think we’ll be moving
toward that.’
Even at McMaster University’s School of
Nursing, says Donna, where faculty
members are very aware of evidence-based
P rofessor Ciliska travelled to Adelaide
in South Australia to present the
inaugural Joanna Briggs Oration at
the JBI international Convention last
November, and while there she spoke to
practice and evidence-based nursing, there
is still a need for faculty development. In
order to help the students to increase their
skills, faculty first need to improve on their
own skills.
PACEsetterS about evidence-based practice
Other problems exist. There is still confusion
in Canada.
‘Some of the leaders of evidence-based about what evidence-based practice really is,
‘Canada was one of the beginning countries nursing are in Canada’, says Donna. ‘Some according to Donna. ‘Some of the research
for evidence-based practice’, she says. ‘In of the people have moved to a slightly says that the frontline staff believe that
fact evidence-based medicine originated at different terminology, such as knowledge evidence-based practice means we’re talking
McMaster University, and then one of the translation and knowledge utilisation; there about doing a research project, actually
originators moved to Oxford and it has are several centres for that as well as the collecting new information for analysis.
grown from there. It has been a way of evidence-based nursing centre.
‘But on the other hand, if we continue to
thinking which we’ve been exposed to for
‘I think we are maintaining some lead in develop practice guidelines, maybe they can
quite a long time, and it’s had some impact
terms of the research that goes on about practice in an evidence-based way without
on spread to the rest of the world.’
how knowledge translation happens, how ever knowing about it. Hopefully we’ll get to
McMaster University continues to support a evidence-based practice gets taught and that with the new generations of nurses. But
wide range of evidence-based practice and how to impact on knowledge utilisation and in the short term, a solution is to continue
evidence-based medicine groups, including evidence-based policy making at the with working with guidelines that are
the Evidence Based Practice Center, the government level as well as at the clinical evidence-based, having staff practice those
Effective Public Health Practice Project and level’, she says. Despite this, Donna worries guidelines, and then they’re practicing in an
the Health Information Research Unit. that impact on frontline staff is small. evidence based way.’
30
feature •
There is some government support in
Canada, says Donna. There is support for
guideline development for nurses, and
CAD$1 500 per nurse per year is available
‘Yet another is a qualitative study of people
for continuing education; however this is
who are nominated as knowledge brokers.
currently under-utilised.
The knowledge broker idea is someone who
‘There’s money, in Ontario, for organisations has the clinical experience and the ability to
to become best practice champions’, she understand and translate the research, who
says, ‘where they look at how practice can actually work within an organisation to
guidelines can best be refined for their own be the person who helps with knowledge
organisation and context. There’s money for translation and evidenced practice. We’re
individuals within organisations to have their trying to go back a step now, doing a
time freed up to be a best practice qualitative study of people who are
champion. Doris Grinspun and the nominated as knowledge brokers, what they
Registered Nurses’ Association of Ontario actually do and what the various facilitators
have had a big impact on pushing it forward.’ are in their practice.’
Of her current work, Donna says ‘I have The Canadian industrial climate is something
done a number of systematic reviews, and I that Donna believes has a big impact on
keep doing those. I enjoy it. It’s always great uptake of evidence-based nursing practice.
to get a huge body of literature synthesised
into three or four recommendations.
‘To me one of the main barriers about why
evidence isn’t practiced is the issue about Ontario
‘But in the last five years, there’s been a shift
because of the number of systematic
hiring of part time people who don’t get
benefits and who don’t get continuing torrent of
reviews we’ve done that haven’t been
particularly well utilised. We’ve moved to
education.
‘It’s been about 15 years now since cost
government
asking “How do you get research into
practice? How do you impact on the policy
cutting happened in healthcare in Canada,
where hospitals particularly, and community
support
level, the managers and the frontline staff to agencies, felt that they could save money by STORY: Nic Rowan
actually use the research?”’ employing part time people. A major step PICTURE: courtesy of Elena Tennant
forward will be for
Donna’s team have done a number of
nurses to have
The Canadian province
studies on this. ‘One was with top level chief
full times jobs of Ontario is home to one
executive officers of organisations, trying to
get them to look at use of evidence, and
with benefits.’ third of the population of
another was in public health across Canada, The goal is to
Canada, and is bordered
testing out three different strategies in achieve 70 per cent by the beautiful Great
terms of intensities of interventions to of nurses working Lakes and provinces
get people to change their full time. ‘Nurses who Quebec and Manitoba.
practice in public health. need full time income
tend to work in multiple
O
jobs; they can be ne of the most multicultural societies
working part time in three on earth, Ontario boasts stunning
different organisations scenery including the Canadian side
with three different of the Niagara Falls. Named the Horseshoe
philosophies, and some Falls in Canada, they drop a massive 52
are more evidence-based metres into a riverbed that is even deeper than
than others. They might the falls are high. Equally as impressive,
even be in three different however, is a government that takes evidence-
clinical areas. based practice very seriously.
‘If we could get 70 per cent of Sue Matthews, Provincial Chief Nursing Officer
the nurses in the workforce of the Nursing Secretariat of the Ontario
employed full time, and they could Ministry of Health and Long Term Care, was
get beyond “What do I need to do in passionate enough to attend the Joanna
the next minute?” we could go a long Briggs Institute International Convention in
way to promoting evidence based practice Adelaide, South Australia, along with evidence-
in nursing.' based practice leaders from Ontario.
31
feature •
‘We have many initiatives that support
providers to be evidence based,’ she says.
Indeed, she lists an impressive range of
activities. ‘We have the Ontario Health
Technology Assessment Committee that
looks at new technologies and the evidence
that supports (or does not support) their
implementation, and we provide funding to
the Registered Nurses Association of
Ontario (RNAO) to develop best practice
guidelines for both clinical nursing practice
and nursing leadership.
‘We have funded the implementation of
eight best practice coordinators for Long
Term Care in seven regions of Ontario.
Their role is to help organisations and
individuals to implement best practices in
their organisations.
‘We also provided seed funding for Queen's
University to develop as a Joanna Briggs
Collaborating Centre [Queen’s Joanna
Briggs Collaboration], and we fund the
University of Ottawa and RNAO in a
partnership to evaluate clinical best practice
guidelines. We also fund the Nursing Health
Services Research unit at the University of
Toronto and McMaster University. They work
closely with us to develop research that is of
Horseshoe Falls, Canada
The Nursing Secretariat that Sue leads was interest to the health system.’
created in December 1999. It provides
This work drives policy. Sue says, ‘We work
strategic advice on health, the health care
closely with the researchers in the
system and public policy issues from a
development of research agendas, and in
nursing perspective. It also supports and
the dissemination of research. My office has
Sue has worked as a staff nurse, nurse monitors the implementation of the Nursing
a knowledge translation specialist that works
educator, manager, and director of inpatient Strategy for Ontario, and informs the
with the researchers and with us to help
programs, and Chief of Nursing and government and external stakeholders on
ensure that research informs policy.’ The
Professional Practice. She holds a Masters the status of the implementation of Nursing
Ontario government keep abreast of
of Health Science, Nursing, and has Task Force recommendations, and advises
initiatives and research results through our
completed a Doctorate in Public Health at on directions, activities, and strategies that
close relationship with the research
Charles Sturt University in Australia. She is impact nursing. It provides policy and
community, and through roles like the
also a Fellow of the Wharton School of administrative support to the Joint Provincial
knowledge translation specialist.’
Business in Philadelphia. Nursing Committee and its working groups. It
develops and implements recruitment and Sue also supports the drive to increase
Rounding out this impressive resume is the
retention initiatives for the profession of numbers of full-time nurses working in Ontario,
Registered Nurses Association of Ontario
nursing in Ontario. suggesting that increasing the percentage of
Leadership Award in Nursing Administration
full time nurses increases continuity of care for
for 2002, and York Region's ‘In Celebration Sue says, ‘The Ontario government
patients, clients, or residents and increases
of Women’ Award for 2003. She has long supports evidence-based practice. Its
the satisfaction of nurses.
been involved in provincial activities and has benefits include better heath care and
held positions as Treasurer of the outcomes for Ontarians, improved The work of the Ontario government
Association of Nurse Executives of the effectiveness and efficiency, and increased continues to grow and strengthen evidence-
Greater Toronto Area, and both Treasurer accountability. The government have set based practice in the province, but,
and President Elect for the Nursing accountability as one of their top priorities, importantly, is also informed by it, in a
Leadership Network of Ontario. She founded and evidence-based practice is important to wonderful example of the best use of
the Professional Practice Network of Ontario. show and maintain accountability. evidence for all.
feature •
32
33
feature •
Most respected ma’am:
volunteering in Nepal
STORY: Nic Rowan
PICTURE: INF, Chris Dixon
Nepal is a country of breathtaking beauty, of
overwhelming tragedy and of hope. It is home to
Mount Everest, to the mythical city of Kathmandu,
and to massive health problems.
In the 12th poorest country in the world tuberculosis
is rife, and almost 40 per cent of the population
smoke. Rural people may have limited or no access
to health care unless visited by medical camps.
Health care workers are in very short supply, and are
seduced by better working and living conditions in
other countries. Civil war has torn the land for ten
years. Nepalis are often undernourished, anaemic,
and have low resistance to disease, and women often
experience difficult pregnancies.
T
T
wo Australian general practitioners
from the Department of General
Practice at the University of Adelaide
travelled to Nepal in 2005 to work in very
different ways, one in a hospital and the
other in a medical camp.
Jill Benson went to Dharan on the plains of
eastern Nepal to fill in for a friend for a
month at the BP Koirala Institute of Health
Services and University. On her return to her
home in Australia she suffered an acute
stress reaction.
Susan Selby travelled through International
Nepal Fellowship (INF), a Christian mission
involved in health and development work
with Nepal’s government, non-government
organisations and local communities. Susan
worked in a medical camp in the western
Lumbini region for six days, and plans to
return to Nepal to participate in another
medical camp this year. She is also
undertaking research into the relationship
between international volunteering
placements and grief and loss issues on re-
entry to the volunteer’s home country.
34
feature •
The list of medical health problems
significant to Nepal is long: malaria,
tuberculosis, encephalitis, tetanus, snakebite,
typhoid, cholera, amoebic abscesses,
gunshot wounds, leprosy, aplastic anaemia,
poisoning and malnutrition. Jill learned,
sometimes on the run, to deal with medical
problems she had never encountered, let
alone treated, in suburban Australia.
Another significant problem Jill encountered
was pharmaceutical. In Nepal, where
pharmaceutical
At the other end of the pharmaceutical
regulation is
For healthcare working in Nepal lends an virtually non-
scale is the sheer inaccessibility of some
practitioners from illuminating perspective to existent, a
medications. Jill is used to being able to
affluent countries, best practice prescription is not
prescribe medications such as Prozac for
working in Nepal lends depression, but it is prohibitively expensive
required for the
an illuminating in Nepal, so she was forced to fall back on
purchase of medication. This translates into
perspective to best practice. Practitioners tricyclic antidepressants that can have
polypharmacy on a grand scale and is
must assess what can be achieved within the unpleasant side effects. Not surprisingly,
complicated by Nepali reluctance and/or
significant financial, technological and patient compliance was poor. Depression
financial inability to take any medication on
cultural restraints imposed by local is common; a terrible suicide method that
an ongoing basis. Patients at the Dharan
conditions, which often means that they must she saw among Nepali women was
emergency department would routinely
painstakingly choose between treatments to ingestion of organophosphates.
reveal whole bags of medications they had
find the simplest and least expensive that will
brought with them, that interact in very Primary health care, too, was very different.
achieve an acceptable outcome for the
unproductive ways. She was not used to having to say ‘don’t
patient
beat your wife’. Another primary health care
Jill also noted a great deal of over-
Jill, working in one of Nepal’s largest hospitals issue was that most urban Nepali, unless
prescribing of ciprofloxacin. ‘Because it’s
as a consultant in the emergency and wealthy and able to buy it in bottles, must
such a useful drug’, she says, ‘ciprofloxacin
outpatient departments, found her practice boil all their drinking water. Perhaps as a
was used more than any other antibiotic in
profoundly impacted by the local context. consequence, they tend not to drink enough,
Nepal because of typhoid. And so people
complicating urinary tract infections, renal
‘In Australia’, she says, ‘if someone has a were given ciprofloxacin often with very
stones and diarrhoea, so this was another
headache and a fever and muscle aches and minimal symptoms and signs on the basis
message she was required to reinforce.
pains, they’ve got a virus, and you go “there that it might be typhoid. We spent a lot of
there, you’ve got a virus”. If someone comes time trying to educate the students and the If Jill wanted to give an injection, a family
into Dharan with a headache and fever and house officers about how to properly member of the patient had to go to the local
muscle aches and pains, there’s a whole list diagnose typhoid, so that they were giving pharmacy, buy a syringe, needle and the
of things that they might have, potentially antibiotics based on the proper diagnosis.’ medication, and then bring it to her to
very nasty, including malaria. You need to Still, she fears that ciprofloxacin resistance administer. If this could not be done, the
treat that as a very high risk set of will emerge as a real problem in Nepal in the medication could not be given. The same
symptoms; the difference is enormous.’ near future. applied to most medical products.
35
feature •
PICTURE: INF, Chris Dixon
If a patient required blood, a family member
had to be willing to go to the blood bank to
donate. No donation meant no transfusion.
Every pathology test she ordered was
carefully weighed: cost against benefit. She
learned not to order general screening tests
where one specific test would do. This
frugality has carried over to her practice in
Australia since her return, and she now has
little patience for health workers who
bemoan being accountable for the public
funds they spend. PICTURE: INF, Tim Frank
Says Jill, ‘There was
a certain amount of Primary health care, too,
money that we as was very different. She
the department of Jill has identified this lack of close social
family medicine had
was not used to having to
contact and the debriefing inherent in it, as a
and that the hospital
say ‘don’t beat your wife’. major reason for her psychological difficulties
had, and there was when she returned to Australia. Her head,
a process that you could go through, for she says, was full of images of Nepal; not
instance, if people needed a CAT scan, or Something else that struck Jill forcibly was necessarily distressing ones, but there
needed blood or something, but it was a the language difficulty. Most medical student nonetheless. She felt dissociated and had
process and there was a budget, and you teaching was in English, yet hardly any poor concentration. This reaction was very
couldn’t do it with just anyone. You had to Nepali patients speak this language. What different to her experiences of working in
make these awful decisions about who was this translated into was limited consultation other developing nations, but did gradually
going to get [treatment].’ with patients by treating health professionals, dissipate by itself.
and poor understanding of what was going
Family are critical to the care of inpatients, Susan has recognised the problems
on by those patients. Jill constantly reminded
and are expected to camp out around the associated with overseas work and re-entry
Nepali doctors to talk to and consult with
patient’s bed. They undertake all the patient’s as a result of her clinical work in general
their patients.
personal care and provide food. Nurses, who practice with missionaries re-entering
are in short supply, perform more complex Jill, who loves talking and laughing, says that Australia after placements in various
treatments and give out medications. If no she felt very isolated during her stay in capacities in developing countries, and is
family are available to advocate for the Nepal. Local people were unfailingly friendly researching this area. Re-entry adjustment is
patient, basic care may simply not occur. and helpful, but maintained a polite and an important issue for cross-cultural workers,
respectful distance. She was required to live with 40 per cent of aid workers developing a
The presence of family cannot always
in the guarded hospital grounds. psychological disorder either whilst away or
guarantee care, though. An unconscious
soon after return, she says.1
man who was intubated and ventilated after ‘I talked to the professor of psychiatry, but
a stroke was about to be transferred to otherwise the other professors didn’t chat to Susan also recognises that it is vital to
intensive care when the family admitted that me; it was the registrars and the house recognise re-entry adjustment, associated
they could not afford such expensive care. officers who chatted to me. And there’s only loss and grief issues and the need to provide
Staff stopped ventilating the man and the so much you can talk about when they’re support to deal with this to prevent further
family took him away, with his tracheal tube twenty years younger then you!’ she says. Jill morbidity.2 Fortunately, says Susan, Jill’s
still in place. A woman who had been was referred to as Most Respected Ma’am medical training allowed her to recognise the
savagely raped needed a blood transfusion. throughout her stay, and became used to issues; however it is important that members
Rape, which is not uncommon in Nepal, courtesies she is not afforded in her usual of the health care team are aware of this as
brings shame on the family and no one was life, such as everyone standing when she an increasing number of people return from
willing to give the blood. The woman died. entered a room. doing this type of work.1,2
36
feature •
While this picture
certainly seems You had to make these
bleak, the future
may not be. Jill says
awful decisions about
that, ‘Being at a
who was going to get This level of staffing
university teaching [treatment].’ might well have
hospital, where I been a luxury for
was, they were obviously very interested in Susan Selby. The team of ‘expats’ consisted
evidence-based healthcare; they had of four gynaecologists, two anaesthetists, a
scientific meetings, and the lectures that we scrub nurse, general practitioner, and two
gave needed to be based on evidence. I nurses who managed outpatients and the
prepared a lecture for instance on diarrhoea, post-operative area. An amazing 65 year old
and had to write exam questions using World Scottish midwife was the team leader and
Health Organisation dehydration guidelines also helped manage outpatients and the
about how to grade dehydration and the postoperative care. She had been in Nepal
recommendations for the different levels of for 30 years. They were complimented by a
dehydration; that level of evidence is very Nepali team who managed equipment set up
important for those sorts of those things. and sterilising, patient transfers, medication
Susan had to separate herself from the long-
dispensing and patient registration.
‘They are building up protocols for things like term outcome for many patients. ‘You just
early diagnosis of appendicitis and how to Susan’s team set up camp for a week and had to keep saying to yourself, if you hadn’t
diagnose fever, proper evidence-based saw as many patients as they possibly done the bit you could do, then nothing would
diagnosis of fever based on their culture, could. The camp focused on women’s have been done and that was even worse.
because the diagnosis of fever in Nepal is health problems, including sexually And therefore the bit you could do was
very different from the diagnosis here [in transmitted diseases, infertility, probably helpful. If you tried to take a longer
Australia]. Evidence-based medicine takes on complications of previously performed view of it all, it would become completely
a different definition in a different abortions, and complications of pregnancy overwhelming, and you couldn’t even do the
environment, because what’s evidence-based including huge uterine prolapses caused by bit you were able to, I would imagine.
here is not necessarily what’s evidence- inadequate access to appropriate care
‘We did six and a half days of it, and we saw
based for them.’ during labour and a return to heavy work in
seventy or eighty patients a day in
the fields after the birth.
Nursing and allied health professionals were outpatients where I was working, but you
in short supply. At the 700 bed hospital at Patients walked very long distances to get to couldn’t have kept that up for much longer.’
Dharan there was a physiotherapy the camp, and then slept on the ground
The team were careful to consult with the
department, a social worker, an occupational overnight until they could be seen. The team
local GP, who would be responsible for
therapist and soon to be a speech kept two operating tables constantly in use.
follow-up care after the camp ended. ‘I
pathologist. While the wards were staffed by
Like Jill, Susan also had to cope with thought the level of care was amazingly
nurses, the outpatient department was not.
distressing situations. ‘I had a lady come in good’, says Susan, ‘considering the fact that
The nurses were all women; men weren’t with a very low haemoglobin of six. She was the GP was there by himself. He was very
culturally permitted to do the job. Jill says of assisted in and she’d actually had an skilled. The main hospital was six hours
the relationship between medical and nursing abortion but had retained the products of away in a Land Rover, but he could cope
staff that while productive and positive, it was conception. Translation was a real problem; with most things that you would expect a
restrained. ‘There wasn’t a lot of friendly we finally got to understand that she’d had rural GP to cope with. And he was doing it by
exchange that went on; the nurses didn’t an abortion, and she’d been bleeding for two himself. I was full of admiration for him. He
tend to come on the morning teaching ward months. She went off to theatre and had a just didn’t have the backup that we take for
round at 8 o’clock. If you wanted things done curette, but then immediately went home granted here. He didn’t have any x-ray
you did them yourself, because there just because there was nowhere else to put her. reports, he could do only basic haemoglobin,
weren’t enough nurses. There’s a nursing We had no facilities for blood transfusions, white cell count and urinalysis, and had to
shortage in Nepal; they train good nurses so she just went home on a stretcher with a refer the rest.’ He was responsible for
and then they go somewhere else. It’s the bottle of iron tablets and that was the end of between two and five thousand patients,
same with doctors as well.’ that. Hopefully she was all right.’ Susan estimates.
37
feature •
‘We went with INF because they’ve been
doing camps for twelve years. We were
welcomed by the local GP and we
complimented what he was doing and
worked with the local hospital, but I would
imagine that if you went in and it wasn’t
under those circumstances, there could be
difficulties in
Evidence-based medicine relationships, and
perhaps access for
takes on a different other groups in
definition in a different future.’
environment
Despite the
enormous
difficulties they encountered, both women
are very clear about one thing, which is that
Pictured (from left) are Jill Benson and Susan Selby they feel privileged to have been offered
such hospitality by the Nepali people whom
they served.
Susan reflects that, ‘they were very kind to
‘They need basic things like safe water and us; they laughed with us, not at us. When I
sources of iron’, says Jill, who found it very first went, I didn’t wear the Nepali dress. I
difficult to buy fresh, safe meat in Nepal. ‘I had a long shirt because culturally you have
think there’s going to be a problem with drug to cover your bottom, but I still had my
resistance in the future, so they need trousers on under this long shirt, and the two
Both Jill and Susan are clear about the
pharmaceutical information. They need to health workers had a giggling, intense
problems that must be overcome if Nepal is
make the good drugs more accessible, conversation about me. I thought, “What are
to improve its health outcomes. For Jill, the
which is going to be very difficult for such a they talking about?” and they were trying to
first imperative is the workforce issue. ‘If you
poor country.’ work out if I was a man or a woman. But
look at Health for All by 2000 [the Alma-Ata
they still accepted me with all my
declaration made in 1978 at the International Susan’s concerns include physical access;
weaknesses and foibles. I felt like I didn’t
Conference on Primary Health Care in the her medical team travelled over very rough
deserve it; it was a drop in the ocean
USSR], workforce is one of the most roads that had to be cleared of landslides at
compared to our privileged lives.’
important things. And they’re trying to times before the group could continue on
address that. They’re increasing the number their way. ‘Some of these roads are Jill sums it up well. ‘It certainly makes me
of medical schools and increasing the unbelievable. And some of the people are so realise what a privileged life we have
number of graduates and generalists, but the poor that they can’t afford to come out. So medically, to be able to order what ever you
nursing and skilled health worker shortage is they live there for the whole of their lives and want to, the free or almost free medical care,
also something they talked about a lot.’ never see anywhere else. Unless you go to the almost free pharmaceuticals, the way
them, you don’t get at their health issues, these things are regulated, the continuity of
Susan adds that, ‘Western countries should
and that’s the bottom line.’ care that patients get, the high level of
be making it attractive for the locally trained
technology that’s so easily available, we are
people to stay in their country, and not Susan is aware that medical camps can
so privileged, and we don’t realise it.’
seducing them to our countries. Obviously cause problems as well as solving them.
someone who is trained and has the local ‘You haven’t usually got the option to follow At the time of going to press, Jill plans to
language is going to be much more up if you uncover problems that need to be return to Nepal, but this time she will travel
effective than someone like me who comes referred on. I think you have to do this with a companion. Susan returned to work
in and has no language. So somehow we [medical camps] in conjunction with some on another INF gynaecology camp at
need to be encouraging that, not sort of longer-term programmed plan, as INF Ghorahi in the west of Nepal in February.
discouraging it, and giving support to the do. If you go in and you don’t know what The work of the INF can be seen at
local Nepali healthcare workers.’ you’re doing it can be very tricky. www.inf.org/
1
People In Aid Information Note: Effective Debriefing. Contributors Lovell-Hawker D and Emmens B downloaded 16/12/05 Available at http://www.peopleinaid.org
2
Selby S, Jones A, Clark S, Burgess T and Beilby J. Re-entry adjustment of cross-cultural workers. Aus Fam Physician 2005; 34: 863-64.
38
feature •
Start at the very
beginning:
Donna Waters
on teaching
evidence-based
practice
STORY: Nic Rowan
PICTURE: Eric Lum
Donna Waters is manager for research and projects She set about investigating the phenomenon,
with the College of Nursing, in Sydney, which is a and explains, ‘I interviewed heads of schools
and deans of nursing faculties and colleges
national Australian body incorporating the New South in New South Wales, and looked at curricula
Wales College of Nursing. She has a particular and found the same thing. There isn’t a
interest in perceptions of evidence among consensus about what to teach regarding
undergraduate and postgraduate nurses. evidence-based practice, how to teach it,
what’s important to know, and what’s not
‘I
important to know.
think there’s a lot of variation in what
post-graduate students understand ‘Some institutions are teaching evidence-
evidence to be’, she says. based practice really well, and others less
so. Undergraduates complete their program
‘The students of the College have often been
and as beginning practitioners they are
in practice for a few years, and they’re
expected to conform to national standards of
undertaking professional development
competency, for example, which have
activities. They’re interested in keeping
evidence-based practice written all through
themselves professionally relevant, yet you
them, but what does it mean? And how are
get the impression when you’re teaching
we actually saying this is what we mean, this
them that some of them know what you’re
is what it means to prepare them to be
talking about in terms of evidence-based
evidence-based practitioners?’
practice and others don’t.
Donna emphasises that she does not
‘From an educator’s point of view there’s a
advocate that all curricula be identical.
whole level of variation in what clinicians
‘Undergraduate curricula are going to have
understand to be evidence for nursing. This
differences. They should reflect the specific
disturbed me enough for it to become my
excellence, context and flavour of that
PhD topic. Where is that variation coming
university, for example a rural university, but I
from, and why is it so?’
think that in terms of the definition of what
Donna looked at undergraduates as well, we expect of undergraduates and their
and found that there was the same degree of preparation for evidence-based practice, we
variation. She had expected that evidence- have not yet agreed upon how that can be
based practice would be part of educational achieved. There’s got to be a degree of
programs, and that undergraduates would all freedom in that, but I’m not sure that we’ve
have a reasonably similar notion of what it is, actually decided yet on the basics of what
but the opposite was true. they need to know.
39
feature •
‘It’s a first principle notion. A third year
graduating nurse will begin practice and
confront a huge sphere of people with
different levels of training about evidence-
based practice and research and different
opinions on whether they think it’s useful or
not useful. It’s not surprising that the
graduate may have problems if they don’t
have their own firm understanding.’
She also says that there are variations
between fields and specialty areas. ‘Clearly
there are some multidisciplinary groups or
‘I would like to see our universities come
teams in specialty areas who are really
together in terms of identifying what we’d
switched on and have a good evidence-
like to do about evidence-based practice.
based framework for what they do, but there
‘Most (but not all) undergraduate programs That sounds like I’m advocating some kind
are others that don’t. There are a whole lot of
will do something about searching in first of a standard program and I’m not; I fully
competing factors, and so it’s not surprising
year, and then there are various courses support the concept of variation and people
that it’s such a difficult concept for some
which address research or evidence. A teaching things in different ways, but it’s
people to come to terms with.
course might be principally about evidence- more basic than that. It’s deciding what they
based practice but it might be called “Making ‘And yet some people have an excellent need to know.
Clinical Decisions” for instance, and that’s pathway and manage to get there. But is that
Another problem that Donna has identified is
not very clear. What is that course about? It just circumstance? Is that just because they
educators themselves not modelling
may be about making decisions, but actually found the right people in the undergraduate
evidence-based practice. ‘I don’t believe that
it’s about using evidence, so the course title program and it clicked, then they went out
as educators (and I include myself), we’re
is not even clearly articulating what it is. into practice with a group of people who
very good at modelling behaviour about
were switched onto evidence-based practice
‘Some places leave discussing evidence- using evidence. I don’t think there are a lot of
and kept them engaged in it? What
based practice to the third year, based on the teachers who say that they know this is the
determines that? It’s haphazard.’
assumption that students don’t have enough best way to do something because it’s been
practical and clinical knowledge until then, Equally, some practitioners have a terrible researched or even where that research has
and that’s fair enough. Other places build it experience, says Donna. ‘Some of the come from, whether it’s good or bad. So the
up over the three years, and that’s good too. nurses I teach say, “As soon as you say the students are thinking “this just came out of
Some places don’t ever explicitly talk about word “research” I just switch off”. this woman’s head. She knows this because
evidence at all. They vertically integrate it she’s the teacher”. But it doesn’t always
‘There’s even confusion in the use of the
into everything, which is another approach, come out of your head. It comes from
words research and evidence; some people
but if you say to a nurse after that, “Did you somewhere.’
don’t grasp the notion that some evidence
learn anything about evidence-based
comes from research, but not all, and people Quite a few simple things like that could be
practice in you course?”, they say no.
use the terms interchangeably and in the done, she says. ‘There’s a lot of emphasis
‘It’s such a small part of the curriculum, and wrong circumstances, which is also confusing. placed on evidence implementation, and
for some, is not very important’, she says. ‘In that’s perfectly correct, but my bandwagon is
‘The way I think about it – which may be
some curricula it doesn’t even get looked at to say: let’s get it right from the beginning.
simplistic – is that if we as a profession can
or it might be in a subject in which it is
agree on what we need to do to prepare an ‘My plea is for educators to think about the
“implied” rather than made explicit’.
undergraduate for evidence-based practice, way evidence-based practice is brought to a
The problem, says Donna, is that and give them that first point or foundation nurse in the beginning, and don’t expect that
practitioners are increasingly expected to on which they can build, then it just might they’re going to just be able to engage with
implement evidence-based care, but their make them a little bit more resilient when this process, based on an assumption that
foundation understanding of evidence may they encounter differences when they get they know something about it, because often
be weak or missing. into practice. they will not.’
40
information •
JBI web site
maintains
rank as one
of best
One of the first ways that
many health care
professionals around the
world come into contact
with the Joanna Briggs
Institute is through our
extensive web site. STORY: Nic Rowan
PICTURE: Nic Rowan
It is a portal to a vast range of public
and member-only resources and
information, and yet, the same as
any website, it is also potentially a barrier to
those resources. Web sites in growing
organisations risk becoming clumsy, slow,
difficult or confusing to navigate, yet JBI has
avoided this trap.
Back in 2001, in an AACJ Clinical Issues journal
article entitled Evidence-based Nursing Web
Sites: Finding the best resources, Maja Morris,
Shannon Scott Findlay and Carole A Estabrooks
wrote that ‘An example of a well-designed and
highly useful Web site is the Joanna Briggs
Institute Web site.’ They went on to say that the
site was ‘well organised, frequently updated
(several times per week), and addressed a
diverse range of health professionals (ie,
nurses, health educators and physicians).’
It seems that those strengths have been
maintained. Four years later in 2005, Mary E
Duffy, in a 2005 Clinical Nurse Specialist
journal article entitled The Joanna Briggs
Institute, it’s contribution to evidence-based
practice, says that the site’s links page is ‘an
extremely popular port of call for Web visitors
because it is very well maintained and
frequently updated.’
41
information •
www.joannabriggs.edu.au The international nature of the Joanna Briggs
Institute web site and its visitors is something
else that David likes very much. ‘One of the
most pleasing and interesting aspects of the
work I do is the chance to liaise with users
across the globe. In any given week, I can
be working, for instance, with people in
China, the United States and Spain. It’s a
part of my job I thoroughly enjoy after having
spent some time travelling in my youth. I
suppose the awkward, rather than difficult
aspect of this is getting to know the cultural
She also says that, ‘Currently, the JBI Web
differences between nations. For example,
site ranks among the best international
Canadian nationals may have a different
internet resources for ‘high quality’, credible
outlook to people living in Asia.’
sources of evidence-based information
applicable to nurses in clinical practice. It is a The website itself is extremely popular and
place that all advanced practice nurses David has never been responsible for a
should get to know well.’ world wide publication with so many users.
‘We have never quite managed to get over In his free time, David looks after a popular
David Grant has maintained the web site
700 separate users per day on the site but community website, and he’s usually quite
since 2003. The softly-spoken Scot has seen
it’s a goal that is probably not that far away happy if he can get over thirty visitors per
many changes.
as the website’s popularity is consistently day, certainly a different scale to the JBI web
He says, ‘The site is database driven and growing. The current daily average for site. He explains: ‘Many internet service
this is something that keeps me on my toes. visitors is just under 700 people so, roughly, providers offer free web space for their
The handy thing about this is that future someone in the world is accessing the JBI customers with 10 Megabytes of space. This
changes are more easily implemented as, website every two minutes of every day. is usually plenty for a private site but the JBI
generally, the alteration to several pages website, not including databases, is over 350
‘This gives us a monthly total of around
needs only to be made in one place. The Megabytes in size. A large digital photograph
20,000 different users, and we usually
change is then carried through to the might take up half a megabyte and a page of
receive over three million hits per month.
appropriate pages elsewhere on the site. text might take up 50 Kilobytes or one
However, many of these statistics can vary
However, there is a lot of time consuming twentieth of a Megabyte.
according to things like student semesters
work that goes into this as far as initial set-up
and so on. December is always a much ‘The size of the site can mean that the odd
is concerned.’
quieter month because of the extensive error escapes my attention. Occasionally, I’ll
The constant updating of the site also keeps holiday period. get an email from a user who has discovered
him very busy. ‘I make several minor a broken link or a spelling error. These
‘A narrow majority of users are based in
changes every day and place notices on the suggestions are very welcome as they assist
Australia but we also receive a large
“What’s New?” section every time there is an me to offer the best possible service our
proportion of visits from users in Italy,
alteration of note, for example the release of website can provide.’
Norway, Saudi Arabia, Philippines and
a new Best Practice Information Sheet.’
Turkey. Interestingly, these are countries in David’s work at the Joanna Briggs Institute
The perpetual advance of technology also which we do not yet have Collaborating may be based in Australia, but his presence
means there’s always something new to Centres although we generate plenty of visits is felt around the world. He welcomes
master. It’s been a steep learning curve, but from countries with JBI Collaborating Centres comments via the website comment page or
one that David appreciates. too. to david.grant@adelaide.edu.au
42
feature •
Building
evidence-informed
practice capacity:
now and the future
STORY: Nic Rowan
PICTURE: Nic Rowan
43
feature •
Roger adds that whilst these two factors –
the demand from governments and the
curiosity of practitioners – should coalesce to
produce significant developments in
Dr Roger Dunston is head of the Division evidence-informed practice and research
of Allied Health, Royal North Shore and literacy across all groups of health
Ryde Health Service, Sydney, Australia, professionals, this is very far from what is
and is also the Director of Social Work at occurring on the ground.
the Royal North Shore Hospital. He is One of the most well developed themes in
passionate and articulate about the the literature, Roger comments, is about the
opportunities and challenges ahead for gap that exists between the findings of
contemporary research and the practice and
the evidence-based practice movement.
decision making of busy health
professionals. ‘Part of the challenge is, I
believe, the fact that we have two somewhat
R oger says that whilst there is a
strong emphasis from governments
and funding agencies on the
development of evidence-based practice (he
prefers the term ‘evidence-informed
parallel universes operating’, he says. ‘One
is a practice universe, the other is a research
universe. We’re learning much, but there is
still an immense amount of work that we
need to do to bring these two worlds
practice’), arguably the greatest potential for together. How do we systematically link
future developments lies in the inherent practitioners into the world of formal
curiosity of practitioners to understand and knowledge generation, and how do we link
improve the effectiveness of their practice. researchers into the frequently messy and
complex world of understanding and
He says, ‘What I experience, managing an
developing improved practice?’
allied health division, is health professionals
with an immense interest in looking at their Roger believes that there is now a
practice. They are wondering whether their widespread recognition that we need to
interventions are the best interventions, understand much more about these issues,
they’re curious about the outcomes that and also that this recognition has generated
they’re achieving, and are extremely the development of many significant
interested in finding ways to look at these initiatives and partnerships over the past five
questions and receive some systematic and or so years. ‘When you look at what has
ongoing feedback. It’s exciting that we’ve got developed, both nationally and
practitioners who are curious and wish to internationally, in the past few years, it really
engage with this process. is impressive,’ he comments.
‘I find it surprising when I hear comments ‘For example, within the United Kingdom
about practitioners resisting change and there has been what we could call an
innovation. Whilst I am sure this does occur, explosion of well funded evidence-informed
I suspect that more frequently we are simply initiatives, many developed as partnerships
not understanding well enough what is between front-line workers and researchers
required to enable and support change.’ based in university settings.
44
feature •
Roger identifies similar developments in
Australia, for example, the recent
establishment of the National Institute of
Clinical Studies (www.nicsl.com.au). NICS
was established by the Commonwealth
Government with a mandate to be
‘Australia's national agency for closing the
gaps between evidence and practice in
health care’.
Roger says of the work of the Joanna Briggs
Institute, ‘As I look at what is occurring
nationally and internationally, the work and
development of the JBI reflects all the
developmental trends I have discussed. It is
clearly a leading organisation in the
development of evidence-informed thinking
and practice. Its commitment to an expansive
approach to knowledge, in particular, its
strong engagement with knowledge derived
from qualitative research has been ground
breaking and a model for others. Like the
UK’s Evidence Network, JBI
has developed what in the
UK has been termed a
‘joined-up’ approach to
evidence linked to practice.
Just as we talk about the
importance of a continuum
of care, a process which
links all those involved in
providing care to patients
across the continuum, we also need to think
‘One of the most ambitious and productive of a continuum of knowledge which is
initiatives has been the establishment of a shaped and developed through active and
national ‘Evidence Network’. This project was equal partnerships between practitioners,
conceived and has been funded by the UK’s researchers and consumers.’
Economic and Social Research Council, or
With reference to the allied health
ESRC (www.evidencenetwork.org). The
Roger is passionate about the emerging professions in Australia, Roger, notes the
development of the Evidence Network has
discourse around qualitative research and important initiatives undertaken by, for
been important in a number of ways; it has
evidence, and comments that this expansive example, physiotherapists, with ‘PEDro’, the
recognised the need to take a far more
and inclusive approach to what constitutes physiotherapy evidence data base
expansive approach to what constitutes
useful and relevant knowledge – an (www.pedro.fhs.usyd.edu.au/index.html) and
‘knowledge’. For the Evidence Network,
approach that both includes and legitimises by Occupational Therapy with ‘OT Seeker’,
important and relevant knowledge is far more
knowledge derived from qualitative or the occupational therapy evidence data base
than knowledge derived from one form of
interpretive research – has been a critical (www.otseeker.com). ‘Both these initiatives
research design. Most importantly, it has
ideological and methodological step. have been modelled on the work of the
included knowledge derived from what we
international evidence-based practice
generically term ‘qualitative research’. It has He says, ‘There is an increasing opportunity
collaboration, the Cochrane Collaboration.
also given considerable emphasis to to expand the way that we think about the
Both PEDro and OT Seeker identify relevant
understanding how we can build more term ‘evidence’, to include a diverse range of
studies, critically appraise those studies and
productive linkages between busy types of knowledge and information, each
make the appraised findings freely available
practitioners and available and relevant with its strengths, each with its limitations.
via their web pages. Some members of the
knowledge (See the work of the Research This development, an expanded approach to
Occupational Therapy profession, a group
Unit for Research Utilisation at the University what constitutes useful, legitimate and
led by Annie McCluskey who is based at the
of St Andrews Scotland, a centre relevant knowledge, clearly makes the
University of Western Sydney, have also
commissioned by the ESRC to look evidence informed movement more relevant
undertaken research on local approaches to
specifically at research utilization - to many practitioners, managers and policy
increasing the utilisation of research by
www.st-andrews.ac.uk/~ruru/general_ makers within the health and community
occupational therapists.’
information.htm).’ service sectors.’
45
feature •
Roger believes that whilst there is no one
most effective approach for developing
evidence-informed practice across all
sectors of the health workforce, there are a
Roger and a number of colleagues are also number of factors that will enable or impede
running multi-professional evidence-informed the achievement of this outcome. ‘We are
literacy programs, and programs that build learning much about what supports and
critical appraisal skills. ‘Many practitioners what constrains the development of
are not familiar with this kind of discourse, evidence-informed practice capacity. What
and don’t feel confident engaging with will support and enable? Firstly, the
research literature. There is a fantastic article development of evidence-informed practice
written by Trisha Greenhalgh and published will not occur if
in the British Medical Journal (BMJ, 1997; already over- we need to be far more
315: 243-246 – 26 July), that talks about the stretched active in how we engage
‘science of trashing research papers’. The practitioners are
process of ‘trashing’ refers to practitioners expected to do this
with and include
developing the critical appraisal skills to work on the
consumers in the
determine whether a piece of research is periphery of their development of research
worth attending to or not – trashing it. We’re practice. Supporting and practice
attempting to build this kind of competency practitioners will
across all groups of health care staff. We are require a significant investment at all levels.
getting a tremendous response. Again, it’s In particular it will involve ensuring time and
tapping into practitioner curiosity.’ skilful support exists. Whilst Roger expresses this optimistic view,
he also comments on some political and
They are also running a similar process for ‘Secondly, we will need to establish far
policy directions that could, in his view,
social workers, to try to make visible the stronger and more productive partnerships
significantly diminish the ability of the public
world of evidence-informed practice. ‘We between health practitioners and researchers
health sector to achieve this expansive and
want to encourage social workers to start – between health service providers and
well-developed approach to evidence
formulating questions about their practice, knowledge providers.
informed practice. ‘One of my concerns is
and to then think about how they might take
‘Thirdly, our approach to what constitutes with the influence of neo-liberal or economic
those questions into conducting a new
useful and relevant knowledge – legitimate rationalist ideas on the development of
systematic review. We’ve linked a couple of
knowledge – must be expansive. Networks health care policy. Policy decisions are being
these groups into the Cochrane Collaboration
and organisations, such as the UK’s made that are likely over time to erode the
process, and that’s worked brilliantly.’
Evidence Network and the JBI are capacity of our public health services and
Roger comments that at a broader level – exemplars in this area. increasingly shift the focus of service
the level of state and national workforce provision and government and user-pays
‘Finally, I believe we need to be far more
planning – there is now a recognition of the dollars into the private sector.’
active in how we engage with and include
need to ensure all graduating health
consumers in the development of research This kind of policy thinking concerns Roger
professionals are knowledge based
and practice. Many of these directions are because he believes that a parallel system,
practitioners, that is, ‘they are constantly
well identified and discussed in a recent public and private, could easily become a
engaged in generating, appraising and
special supplement of the Journal of Health two tier system where the public sector
utilising knowledge in the development of
Services Research and Policy (Volume 10, becomes the ‘dumping’ ground for very
their practice. I find myself increasingly
number 3, supplement July 2005 - complex, chronic, long term patients that the
engaged in discussions about overall
www.rsmpress.co.uk/jhsrp.htm).’ private sector and user pays services will not
workforce development. We – a team, myself
address. ‘Unless we maintain the public
and colleagues from the University of In reflecting on what has changed in the past
sector as the place to be and support this
Technology, Sydney and Charles Sturt few years, Roger notes, ‘If you compare
with appropriate levels of investment, we’re
University - are in the process of developing where we were five years ago to where we
in danger of eroding our public sector
a research project which aims to define what are now, I think we’ve moved an immense
capacity and diversity, our expertise, our
we’re calling future professional amount. If we maintain this momentum, in
research capacity, our ability to teach and,
competencies. We’re attempting to define another five to ten years we will have built a
ultimately, our ability to recruit and retain
what the future health professional will need far greater evidence informed capacity
high quality and high performing
to know and do in relation to knowledge across our health workforce and, most
practitioners.’
generation and utilisation. In particular we importantly, become far more skilful in
are concerned to identify what practice and assisting busy health practitioners and Roger’s passion is extraordinarily infectious;
partnership models will support health managers to engage with and utilise the spend half an hour in his company and it is
professionals developing and sustaining high findings of diverse forms of knowledge in easy to believe that his vision can become
level competencies in the area of knowledge their clinical and policy decision making. reality. One can only imagine what he is
development and utilisation.’ Quite something to aim for!’ capable of achieving in another five years.
46
profile •
ll
up a hi
climbed
n who
glishma
The En
47
profile •
Ian is currently involved with the College’s
quality improvement program, and has a
broad remit to work in a number of key
areas, including development of clinical
guidelines and implementation tools. The
program also works with the British
healthcare commission in developing audit
and monitoring processes and the National
Patient Safety Agency, focusing on safety
awareness and safety culture.
The safety work and the audit work are
separate but still linked, he says. ‘It’s two fairly
separate streams that are headed up by a
colleague of mine, currently working in areas
around needle safety, hand washing and hand
hygiene. So whilst they’re often seen as two
separate things, the aim of the program is to
run projects in parallel, creating opportunities
On that basis, Ian has recently been working
for them to converge, providing powerful
on the National Defibrillator Programme
messages for our membership.
through the department of health in the
‘But the real interest that I have,’ he adds, United Kingdom, which places defibrillators
‘is guideline development and the into public places. The program is funded by
utilisation of evidence, and how evidence a very large lottery fund in the United
gets into practice.’ Kingdom (UK).
This interest in clinical guidelines came from The results have been remarkable. ‘We’ve
Ian’s practitioner background as a registered started to see that for patients suffering from
nurse in critical care. He became aware of critical episodes in the acute situation, in
STORY: Craig Lockwood and Nic Rowan the need for novice practitioners or clinicians training lay people and healthcare
to know what to do in emergency professionals defibrillation is delivered
situations, and how to utilise the quickly.’ His work with the Resuscitation
There once was an Englishman best evidence in that context. Council in the UK has, with colleagues, seen
who believed that placing He says, ‘An area of my own
the development of a one-day immediate life
support course, which most health care
cardiac defibrillators in British clinical expertise is in the field of
professionals in the acute sector of
public places would be a very resuscitation and emergency
healthcare in the UK now complete. ‘We’re
good idea. He and his medicine, so I started to get a real
starting to see improvement in survival
interest in the way we looked at
colleagues worked extremely using the evidence to impact on
figures in hospital from 15 to 20 per cent
hard and climbed up many hills patient outcomes, particularly in
some years ago, up to early to mid 40 per
to achieve this dream, and it terms of morbidity and mortality,
cent because of the innovation of accessible
defibrillation’, he says.
came true just in time for a but it’s expanded beyond that to
good friend of his to be deal with non-life threatening The location of defibrillators in public places
successfully defibrillated in one conditions in a different context. is based on footfall figures (the number of
I’ve really enjoyed that expansion, people walking by), collected through a
of those public places. because you can begin to see how number of traffic routes, in collaboration with
evidence can make a difference to ambulance NHS trusts in the UK, who kindly
patient outcomes, if the clinical practice provided the intelligence. The defibrillators
guideline is fully realised in the way it was have been located in the public domain,
always intended.’ where they are ready to hand and can have
T
he Englishman in question is Dr Ian
maximum impact on lifesaving.
Bullock, a senior research and Ian and his colleagues particularly noted
development fellow of the Royal reductions in mortality related to the use of This style of program was first demonstrated,
College of Nursing Institute, in Oxford. He defibrillation. ‘Defibrillation is one of the main Ian says, in Chicago airports in America. In
spoke to Craig Lockwood, principal research evidence sources in the field of resuscitation, that case, a two year study of defibrillators
officer of the Joanna Briggs Institute, when and time to defibrillation is absolutely critical. installed like fire extinguishers in glass cases
they each attended the Guidelines The figures say that every minute lost from showed that in every one of eighteen
International Network conference in Lyon, ‘down time’ equals about a 10 per cent witnessed cardiac arrests, someone tried to
France, in December 2005. reduction in patient mortality.’ use a defibrillator.
48
profile •
‘There have been some fairly high profile
events which have helped along the way.
The international explorer Sir Randolph
Fiennes, who had a cardiac arrest catching
an EasyJet flight out of Bristol airport, was
defibrillated by an attending airport worker
and then went on to have successful
bypass surgery, so he’s one of the public
faces behind the project.’ After he
recovered, Sir Randolph ran five marathons
in five days in different continents, raising
public awareness.
While strong celebrity endorsement has
helped, it largely occurred after the team
secured their second-stream funding from
the big lottery fund, in a collaboration
between the British Heart Foundation and
the department of health.
Celebrity support for this kind of project has
Ian Bullock
been evident in other countries as well. In
Specific personnel are trained to use the Australia, billionaire media magnate Kerry
machines. ‘We designed a four hour training Packer had a cardiac arrest and was
program for non-healthcare professionals. fortunate to be resuscitated in one of the few
Members of the public, people like cleaning ambulances of the day that carried a
staff, airport attending staff or train station defibrillator. Subsequently he made an offer,
‘Within that context is also revaluing the
staff who have volunteered for the training go in the state of Victoria, to pay AUS$2.5
basis of clinical judgement. So often
through the program and can then be million toward the cost of installing a
guideline development groups get worried in
acknowledged as the people who can handle portable defibrillator in every ambulance.
the absence of good evidence. I prefer to
the automated defibrillator equipment.’ The machines were fondly nicknamed
use that as a springboard; using formal or
“Packer Whackers”.
This will be important when the UK informal consensus methodology with
experiences a huge influx of visitors for the While the defibrillator work is interesting, whatever evidence we have to inform clinical
2012 Olympics, notes Ian. ‘We’ve got clinical Ian’s primary passion remains with judgement processes. I think that’s the first
experience now; we actually run the only guidelines. He believes that there are three key area.’
national defibrillation program in the world main challenges, and the first is in the nature
Ian draws an unusual analogy in describing
currently. I hope that doesn’t sound arrogant; of evidence, and the grading or quality of it.
his second key area. ‘Guidelines are often
it’s just a reality.’ So far, nearly 700
He explains, ‘I think, coming from a nursing like sausages; they’re produced in a factory
defibrillators have been placed at 110
background as somebody who prefers and unless somebody catches them when
locations across England, and more than
quantitative research, I have been very they come off the production line, and works
6,000 volunteers have been trained.
embedded within the whole context of out how they’re going to be digested in order
Government support has been critical, and qualitative research, and that’s a huge to create nurture and growth, that’s a big
celebrity endorsement has helped. ‘We’ve challenge for the guideline development field, problem. So much of my work in the last 18
been thrilled to see how the government to grasp and to quantify or to appropriately months has been around implementation
have really grasped the opportunity to use critically appraise qualitative evidence and to strategies and working out creative and
public funds to make a difference in this use that as a basis to inform clinical innovative ways to help clinicians and
context [to date, STG£2 million]. guideline recommendations. healthcare professionals use the guidance.’
49
profile •
PICTURE: Craig Lockwood
He believes that
a major challenge is to
recommendations
devise recommendations should be written
that are simple, in such a way that
straightforward, and will anybody can
make a difference to the way understand them,
practitioners think. so that rather
than being
interpretive, they
become adoptive. He believes that a major
challenge is to devise recommendations that
are simple, straightforward, and will make a
difference to the way practitioners think.
Ian and his colleagues have been working
The last challenge he hard on innovative guideline implementation
sees is developing strategies. ‘We’ve been developing web-
methodology. ‘I think based resources in such a way that there is
the methodology has an interactive element to the way that we are
come on over the last uploading the textual information of
few years, but you’ll find guidelines to an interactive web resource.
On a personal level, Ian is an extraordinarily
that you get a number The team have also engaged members
busy man, who travels often, much to the
of reviewers reviewing the same evidence within the Royal College of Nursing to write
envy of his three children. ‘Life is always a
and they will be using different outcome best practice accounts, or good practice
constant balancing act,’ he says, ‘and I think
measures within that context. I think if we stories, about how they’ve integrated the
that regardless of any success that you have
could standardise that, it would be a big, evidence and changed their practice, leading
in your professional life, family is a very
big gain.’ to improvement in patient care.
grounding opportunity, and my family are
Ian is also interested in the use of graded Added to this is the patient perspective. important to me. I try to balance the time
evidence to support guidelines. ‘I think that ‘We’ve got a patient voices element to that away from home with quality time at home,
historically within the UK we’ve tended to web resource as well, using the same sort of and generally that works pretty well. I’ve
back recommendations with the levels of methodology. We’ve described it as a living become better at saying no as I get older.’
evidence behind them. In fact,’ he adds, ‘one resource, so that it’s always developing.
It is fortunate for Ian’s friend who required
of the biggest guideline houses has just
‘We’re also intending to develop algorithms defibrillation that Ian had not said ‘no’ to
committed to removing any levels of
as wallpapers and screen savers; things like that particular project. Ian himself says that,
evidence behind the recommendation. I think
that are quirky but useful, and will presence ‘Developing national policy is one thing, but
that’s quite an important move because it de-
themselves in the consciousness of clinicians when you see its impact on the lives of
emphasises the hierarchy of evidence behind
within the clinical area. friends and people that you care about, it
the recommendation, avoiding the possible
brings home with great clarity the value in
interpretation that something which is high ‘The other aspect that we’re looking at is
using evidence to change current thinking
level is more important, which may clinically using some work around the
and develop practice. Something like this
be very, very wrong. It could simply be that ‘plan/do/study/act’ cycle, which is more
enables you to sense the impact not just on
there is a lack of good evidence behind a focussed on the context of healthcare,
broad population outcomes but on
really important clinical recommendation, bringing the multidisciplinary team together,
individual experience.’
highlighting future research agendas. So I’m identifying barriers to potential change and
glad to see that we’re moving through these systems and processes, and using clinical No doubt the other 67 people, who along
early birthing stages of clinical guidelines, guidelines within that group to change the with Ian’s friend have survived a cardiac
and now we’re beginning to get to the real way that people think, the systems behind arrest directly because of the defibrillator
nitty-gritty. the way that healthcare is delivered.’ program, would agree.
50
feature •
New guidelines
for care of
drug-misusing
women and their neonates
Anne Bartu reports on a project aimed at developing
guidelines for the management of drug dependency
during pregnancy, delivery, and the early
development years of the newborn. STORY: Anne Bartu PICTURE: Nic Rowan
P
regnant drug-using women make up
a special population with different
and specific treatment needs, often
with complex social, medical and obstetric
complications. The complexity of care The consequences of drug use during and
required demands an advanced level of after pregnancy are major public health
knowledge among care-givers. issues in many countries. The main drugs of
concern are heroin, amphetamines,
Yet many health professionals have been
cannabis, cocaine, and ecstasy, which are
inadequately prepared in their
often used in combination with other drugs
undergraduate and postgraduate studies to
such as alcohol, tobacco and Drug use has been
provide accurate information to pregnant
benzodiazepines, and multiple drug use is associated with a range
women regarding drug use and its potential
the norm. of serious health
maternal and neonatal effects. It is
reportedly not uncommon for women to It is widely believed that there is a general consequences for both mother and child,
receive conflicting and misleading under-identification of problem drug use by including spontaneous abortions, still births,
information that can undermine the women in maternity services. This may be infants withdrawing from exposure to the
relationship between the women and those the result of inadequate assessment, and/or mother’s drug use, and sudden infant death
who manage their care. Health professionals a reluctance on the part of the woman to syndrome. Those who inject drugs are at risk
need ready access to relevant, evidence admit to drug use which could reflect of contracting blood borne viruses such as
based up-to-date information that can be negatively on issues related to child hepatitis C and HIV. Infants may display
used to inform their practice. protection and custody. developmental and behavioural problems.
51
feature •
Other issues addressed included continuity of
care; screening and assessment; mental
health problems; withdrawal care
(detoxification during pregnancy); blood borne
viruses (hep C, hep B, HIV); breastfeeding;
Neonatal Abstinence Syndrome (NAS); pain
management and vaccinations.
In addition attention was given to drugs used
to treat opioid dependence. Methadone has
long been prescribed as a maintenance drug
Many drug users have social, economic, and
for drug dependent women in pregnancy and
other problems associated with their drug
its medical and social benefits have been
using lifestyle that contribute to poorer
well documented. Buprenorphine has
maternal and infant health. Pregnant women
recently been introduced as a prescribed
with drug and alcohol problems are at higher
opioid substitute, but is not yet approved for
risk of maternal and perinatal morbidity and
use in pregnancy in Australia. Naltrexone in
mortality than pregnant women who do not
the form of implants has been used but is not
misuse drugs. Infants born to parents where
recommended for use in pregnancy.
one or both are drug misusers are at high
risk of harm in the early development years The process involved production of trigger
and vulnerable to a range of psycho-social papers which reviewed the available
problems throughout life. evidence on the above topics and identified
gaps in the research. Discussant papers
In Australia, concern about the negative
which reviewed the adequacy of the trigger
consequences of drug misuse provoked
papers were also produced. The level of
strong support from all jurisdictions for the
evidence adopted for the reviews was a
development of national guidelines
modified version of the National Health and
to enable a comprehensive,
Medical Research Council which included
consistent approach to the care
“consensus” as a category. The papers were
and management of pregnant
discussed at a national summit convened of
drug-misusing women
experts from relevant disciplines. Following
antenatally, through delivery and
this, draft guidelines were produced which
postnatally, and extending to the care
have been circulated widely for comment.
of mother and child in the early
developmental years. While most In Perth, Western Australia, members of the
maternity hospitals have protocols for Joanna Briggs Institute are working towards
management, they have, in general, been developing a web-CT environment that will
developed in isolation to meet the needs of be one of the means of making the National
a particular institution and some were found Pregnancy Guidelines easily available to
to be in need of revision. Clinicians are clinicians. This will be of particular relevance
busy people and often don’t have time to to clinicians in rural and remote areas. It will
review protocols on a regular basis. also have sections in easy to read lay
language for parents and other interested
The national project was developed as a cost
parties. The National Guidelines should be
shared venture under the Ministerial Council
available in the near future, however a
on Drug Strategy (MCDS) Cost Shared
definitive date has not yet been set.
Many illicit-drug-using women have low self Funding Model. New South Wales Health and
Developing guidelines to guide clinical
esteem, and suffer from depression and South Australian Health were nominated as
practice is no guarantee that they will be
feelings of powerlessness. The chaotic, the lead agencies for the project. A Steering
implemented and adopted, but they are a
unregulated lifestyle of these women plus Committee consisting of key personnel from a
first step in the transfer of knowledge that
menstrual irregularities caused by use of range of relevant disciplines was convened to
has potential to improve care for and
some drugs results in unplanned oversee the project. The drugs reviewed for
outcomes for a very vulnerable population.
pregnancies. This has the potential to risk and management during pregnancy,
increase the incidence of psychological labour, birth, and in the postnatal period Anne Bartu is Professor(Adj) at the School of
morbidity, and negatively effect include alcohol, tobacco (including nicotine Nursing and Midwifery, Curtin University of
mother/baby interaction in the postnatal replacement therapy), opioids, cannabis, Technology, and the Drug and Alcohol Office
period and lead to infant developmental benzodiazepines, amphetamines and Perth, Western Australia. Member of the
and behavioural problems. cocaine. National Steering Committee.
52
feature •
Joanna Briggs Institute
International Convention 2005:
many pebbles of knowledge
STORY: Nic Rowan
PICTURES: Nic Rowan
The JBI International
Convention, themed
Pebbles of Knowledge:
making evidence
meaningful, attracted
delegates from 23 nations
around the world to enjoy
the beautiful city of
Adelaide from November
28th to 30th, 2005.
53
feature •
The Joanna Briggs Oration is a celebration
of the evidence-based healthcare movement
and its accomplishments, and an opportunity
to focus on visioning the future. The
inaugural oration was presented at the
convention by Professor Donna Ciliska, from
the School of Nursing, McMaster University,
Ontario, Canada.
Canada is one of the leading countries in the
world in terms of evidence-based practice,
and yet Professor Ciliska worries that the
impact on front-line staff is small. In her
oration, the professor laid out a challenge to
all those attending.
By the year 2010, she said, she hopes that
healthcare will have moved beyond the
research transfer gap toward 'thirty second
access to the best information available'.
She also called for a move toward using
T
research evidence, both quantitative and
he convention aimed to facilitate the
qualitative, in making decisions, and for
exchange of knowledge and
Keynote speakers ranged widely in their equitable access to evidence.
experience in evidence-based
perspectives and included Professor Jos
health, making evidence meaningful for Professor Ciliska called for research priorities
Kleijnen from England, Teresa Moreno-
multi-disciplinary health professionals and to include effective strategies to get evidence
Casbas from Spain, Dr Pikul Nantachaipan
consumers. into practice by practitioners, managers and
(paper presented by Assoc Professor
policy makers, and for effective strategies to
Plenary and concurrent sessions were Chaweewan Thongchai) from Thailand,
teach evidence-based healthcare to
designed to promote the international Associate Professor Margaret Harrison from
undergraduate, graduate and continuing
exchange of knowledge related to evidence- Canada, Dr Patricia McInerney from South
education students. She also suggested that
based healthcare; advance the science of Africa, and Sandra Robinson, Professor
economic evaluations are vital and should be
evidence review, transfer and utilisation; Chris Baggoley, Professor Robin Watts,
undertaken more often.
provide a forum for JBI Collaborating Centres, Professor Andrew Gilbert, Associate
International Networks and Members to Professor Sally Green and Julian Barton (all In closing the oration, Professor Ciliska
contribute to the Institute’s mission; and to from Australia). reminded the audience that 'within these
explore opportunities for international priorities, there is a lifetime of work for each
The best original paper award, which was
collaboration between consumers, medicine, of us'.
sponsored by the University of Adelaide’s
nursing and allied health.
Department of Clinical Nursing and selected This theme was echoed throughout the
Host city Adelaide, in South Australia, turned from all free papers presented at the convention, with a range of concurrent papers
on her best spring weather with balmy days convention, was awarded to Julie Reeves, presented on subjects such consumer
and mild evenings. The gala convention from the Mercy Hospital for Women in involvement in evidence-based practice;
dinner at the Hilton Hotel in the centre of the Victoria, Australia, for her paper entitled ‘a evidence translation, transfer and utilisation;
city was extremely well attended, with guests novel approach to introducing evidence- qualitative findings as evidence; education;
still dancing at midnight. Exhibitor stands based practice’. The paper outlined the reducing the gaps; nursing, multi-professional
were also well patronised, and the sparkling introduction of an innovative education and allied health issues; and evidence-based
gems at the Opals of Australia stand strategy in a gynaecology unit, using a healthcare in Europe, Australasia, Asia, Africa
particularly attracted overseas delegates. competition as an incentive. and the Americas.
54
feature •
The first JBI
convention was a
tremendous success.
Here’s what some
delegates had to say.
The convention was extremely well organised - good balance
between sessions, good speakers & some fun! You should feel very
proud you attracted people from 27 countries. This is difficult for
conferences on this side of the world but has made the convention a
truly international one.
I have benefited a lot by attending my first JBI convention. The
speakers were dynamic and very specific and it was interesting to mix
with people from different cultures.
An excellent meeting, which has inspired and motivated me to keep
At the close of the convention representatives exploring - I am keen to go home & share!
from the South African Centre for Evidence
Based Nursing and Midwifery: A Collaborating Choice was good - broad range of topics & good international
Centre of the Joanna Briggs Institute at the representation.
University of KwaZulu Natal, promoted the
2006 JBI Colloquium. Called Amagagasi Trade displays were great, generous & informative, papers were all of
Olwazi (Waves of Knowledge): the search for a good standard and teas and lunches were not rushed allowing time
evidence to confront contemporary threats to
to network and talk to colleagues.
global health, it will be held in Durban, South
Africa, from August 6th to 8th. The colloquium
is held in alternate years to the convention.
Really enjoyed the conference and have taken a lot away from it.
Papers are invited that address evidence It's very good and helpful to include consumer representatives in this
synthesis, transfer or utilisation in areas such
conference. The session by the motivational speaker was very
as: new disease threats, including MRSA,
inspiring.
drug resistant tuberculosis and malaria, avian
flu, SARS and HIV/AIDS; phenomena such
as climate change, natural disasters and An excellent three days. I thoroughly enjoyed all aspects of the
terrorism; and continuing global issues such convention.
as poverty and war.
Well organised and professionally assembled.
All enquiries about the 2006 colloquium in
Durban should be addressed to
jbi@adelaide.edu.au
Thank you - I have found the conference to be very beneficial. It was
great you had workshops on the third day - kept interest going.
The 2005 Joanna Briggs Institute
International Convention was supported by
The convention was a very timely, relevant event as we are becoming
its Gold Sponsor, the Australian
Government Department of Health and
more aware of the need for EBP.
Ageing; by Silver Sponsors the National
Institute of Clinical Studies (NICS), and Hall Loved the dinner on the first night. Great social event to get to know
and Prior Aged Care; and by Speaker some exciting people. Really liked 'motivational speaker'. Great break
Sponsor Pfizer Australia. up of topics. Thank you for a wonderful convention!
Amagagasi Olwazi
( W a v e s o f K n o w l e d g e ) :
5th Joanna Briggs
Colloquium
The search for evidence to
confront contemporary threats
to global health
Papers are invited that address
evidence synthesis, transfer or utilisation
in areas such as:
New disease threats: Phenomena:
• MRSA • Climate change
• Drug Resistant Tuberculosis • Natural disasters
• Drug Resistant Malaria • Terrorism
• Avian Flu
Continuing global issues:
• SARS
• Poverty
• HIV / AIDS
• War
Hosted by The South African Centre for
Evidence Based Nursing and Midwifery
Registrations of interest via
email: jbi@adelaide.edu.au
or visit
www.joannabriggs.edu.au/events
6th - 8th August 2006
Durban, South Africa
www.joannabriggs.edu.au
56
information •
JBI World News
3rd International Conference of Evidence-
Based Health Care Teachers and
Developers: Building bridges between
research and teaching
PICTURE: Tiffany Conroy-Hiller
Over 100 delegates from all over the world converged web based and available 24 hours a day, it
on the beautiful Italian resort town of Taormina in [PACES] will help all of us in our endeavours
Sicily, in November last year. Taormina, clinging to to implement EBP around the world”.
the side of Mount Tauro, is referred to as the ‘Island The Sicilian experience was magnificent,
of the Sky’. and the conference was regarded by all as
Tiffany Conroy-Hiller, the Manager session was requested by the conference a success. The next conference is
Education and Utilisation for the Joanna convenors. scheduled for 2008, again in Sicily and
Briggs Institute, attended the conference to This address generated an extremely with the backdrop of Mt Etna. Both the
present a brief overview of the JBI PACES positive response from conference evidence based practice movement and
program. The initial short presentation was attendees, most of whom were medical the mighty Mt Etna are sure to still be as
well received and a further, more in depth professionals. One commented, “This is active by then! For more information about
address at the following morning’s plenary what we have all been waiting for. Being the conference visit http://www.ebhc.org/.
57
information •
Fourth Quarter, Volume 3, Issue 1, 2006
Thai students visit JBI headquarters New post for JBI
Executive Director
Professor Alan Pearson
takes up the role of
Chair of Nursing at the
University of Adelaide
from February 2006. He
will continue his work as
executive director of the
Joanna Briggs Institute.
Professor Pearson was Head of the
Pictured from left are Yupin Phianmongkhol, Professor Alan Pearson, Duangrudee Lasuka,
university’s Department of Clinical Nursing
Wilawan Picheansathian, Dr Tim Schultz and Thanaruk Suwanprapisa
when he launched the Joanna Briggs
The JBI recently hosted four postgraduate students Institute in 1996 as a joint venture between
from Chiang Mai University, Thailand, who are the university and the Royal Adelaide
completing their Doctor of Nursing theses under the Hospital. He is supported in his new role at
supervision of Professor Alan Pearson. The students, the university by Dr Judy Magarey, who has
and their research topics are: been appointed Head of the Discipline of
Clinical Nursing.
• Associate Professor Chomnard coping and quality of life in elders with a
Potjanamart “Older Thai people’s chronic illness” Dr Magary said to PACEsetterS that the
understanding of influenza and how this Discipline of Clinical Nursing is looking
The students will be submitting their theses
influences their uptake of influenza forward to an exciting year in 2006. ‘Our
in January 2006. Their colleague, Associate
vaccination” Professor Wilawan Picheansathian was new undergraduate program commences
• Associate Professor Yupin awarded her Doctor of Nursing degree in and in February Professor Alan Pearson
Phianmongkhol “Non-Pharmacological December 2005 for her research on the will commence as Professor of Clinical
pain management in cervical cancer effectiveness of an implementation strategy Nursing and will lead the department's
patients” to improve hand hygiene compliance in a research with the establishment of a JBI
neonatal intensive care unit. Research Unit within the department. With
• Associate Professor Thanaruk
These students are all members of the the Government's Research Quality
Suwanprapisa “Caring for people with
Thailand Centre for Evidence Based Nursing Framework on the horizon it is essential
HIV/AIDS in Thailand”
and Midwifery, a JBI Collaborating Centre. that we develop our research profile and
• Associate Professor Duangrudee Lasuka We wish them the best in their future we are fortunate to have Professor Pearson
“Effects of an empowerment program on research and teaching pursuits. to lead us at this critical time.’
Aged Care Clinical Fellowships a Brilliant Success
Following the success of the first and second intake
of Aged Care Clinical Fellows, the Joanna Briggs
Institute was inundated with applicants for the third
round, which began on February 27th.
JBI Education and Utilisation Manager strong basis for enacting change in their
Tiffany Conroy-Hiller said, ‘We were really workplaces’, she said.
pleased that the importance of this
Dr Tim Schultz, (pictured left) JBI Scientific
initiative was recognised by the Australian
Assistant, said that in general the
Department of Health and Ageing, which
fellowship program has been very well
extended funding for a further six months
received. The first and second intakes of
and allowed places to be increased from
Fellows were supportive of the schedule,
four to five.
the JBI staff, the program, their improved
‘The Fellowship equips aged care understanding of evidence-based practice
clinicians, consultants and managers with a and the perceived benefits to their >
58
information •
Fourth Quarter, Volume 3, Issue 1, 2006
Training dates 2006
employers and clients. They also enjoyed Each Fellow undertook an audit process
Introduction to
the support of being part of a group. using the JBI PACES program and then
Evidence Based Practice Comments from past Fellows relating to sought to implement the best available
the schedule, the amount of preparation evidence in areas where improvement to
May 25
before the program and technological policy or practice was shown to be
October 19 difficulties were used as the basis for required. The fellowship program mainly
improving the program. focussed on providing an understanding of
Getting Evidence Into Practice Importantly, Tim says, the clinical the importance of evidence-based practice,
leadership skills of the participants were and equipping the Fellows with strategies
July 25 for successfully implementing evidence-
improved through their participation in the
fellowship program. ‘We hope that these based practice in residential aged care.
Critical Appraisal for clinical leadership skills will be shared with Given that changing clinical practice is
the Fellows’ colleagues as evidence-based universally regarded as difficult, the
Health Professionals
practice becomes better established in the experiences of the inaugural Aged Care
March 23 aged care sector’, he added. Clinical Fellows are very encouraging.
August 24
JBI Directors’ Meeting
Teaching Evidence Based Practice
April 20 - 21
September 21 - 22
Comprehensive
Systematic Review Training
June 26 - 30
November 27 - December 1
Comprehensive
Systematic Review Training
Directors of The Joanna Briggs Collaborating Centres
‘Train the Trainer’
At the conclusion of the 2005 Joanna Briggs Institute
December 4 - December 8
international convention, the annual face-to-face
A limited number of places are available meeting of JBI Collaborating Centre Directors was
for each program. Early registration is
recommended. All training programs are
held over two days.
to be held at Level 4, Margaret Graham JBI Associate Director other Centres function. It the next teleconference
Building, Royal Adelaide Hospital, North Anthea Court said, ‘We now only happens once a year meeting would be
Terrace, Adelaide, South Australia. have over 20 centres that we can get everyone conducted in regional
spread across the globe together and, as always, it groupings of Centres with
For more information about any of the
and it is always exciting to was a useful meeting.’
above training programs, please refer to similar needs, experiences
have the directors, all Joanna Briggs Collaborating and time zones!
the prospectus available at
leaders in their field, meet Centre Directors meet four
www.joannabriggs.edu.au
in one location. It gives the The next face-to-face
The prospectus is available on the times each year, once face-
directors an opportunity to director meeting is
‘education and training” link which is to-face and the other three
discuss and plan the scheduled to coincide with
under the ‘resources’ menu. Contact times by teleconference. In
continued growth of the a significant initiative, and the 5th Joanna Briggs
Tiffany Conroy-Hiller,
tiffany.conroyhiller@adelaide.edu.au collaboration, and to look at due to the increasing Institute Colloquium to be
Ph: +61 8 8303 4880 working together on number of Collaborating held in Durban, South Africa
projects while learning how Centres, it was agreed that in August 2006.
59
Events •
The
conference
L I N E
Evidence-Based Cochrane Qualitative Research
Methods Group Oceania
Health Care Regional Symposium
Qualitative Research in
A Symposium for Nurses and Midwives
Dates: Wednesday, 5th April 2006 Evidence Based Healthcare -
and Thursday 6th April 2006 an exploration of scope
and methods
Venue: Hotel Grand Chancellor Adelaide July 13th - 14th 2006
707 Wellington Street
Perth, Western Australia CALL FOR ABSTRACTS The Cochrane Qualitative Methods Group
Enquiries: +61 3 9375 7311 invites you to send abstracts for oral or
poster presentation at the Cochrane
An electronic version of this program is Qualitative Research Methods Group
Oceania Regional Symposium.
available at www.ausmed.com.au The deadline for submission of abstracts
is 15 April 2006
Organised by Ausmed Conferences
Please find the details for submission
Pty Ltd in collaboration with The of abstracts on the JBI website:
Joanna Briggs Institute, an www.joannabriggs.edu.au/events
international Research and Abstracts should be related to:
Development Unit of Royal Hosted by:
• The role of qualitative research findings in
Adelaide Hospital, and an Affiliated JBI Research Unit systematic reviews;
A JOINT RESEARCH • Methods of appraising, extracting or
Institute of the University of AND DEVELOPMENT
INITIATIVE OF
synthesizing qualitative research findings;
Adelaide. The Joanna Briggs THE UNIVERSITY OF • Qualitative research findings as evidence; or
Institute promotes and supports ADELAIDE AND
THE JOANNA BRIGGS • Issues related to the nature of evidence for
evidence-based practice. INSTITUTE heath care practice.
National Symposium
Evidence Based
Clinical Leadership
In Residential Aged Care
Adelaide Saturday April 29th 2006
Register Now For This National Symposium
Venue: Education and Development Centre
Milner Street, Hindmarsh. Adelaide, South Australia 5007
9am - 4pm, April 29th 2006
Registration fee (including morning and afternoon tea and lunch) $66.00 including GST
To Register: Tel: +61 8 83034 880
Fax: +61 8 8303 4881
Email: jbi@adelaide.edu.au or
visit the JBI website: www.joannabriggs.edu.au/events
for a registration form.
60
Events •
The
conference
L I N E
Call for poster abstracts
INTEGRIS Health and its partners in the
Quest for Quality: Evidence Based Practice Center of Oklahoma:
Incorporating Evidence Into a collaborating center of the Joanna Briggs
Institute, the University of Oklahoma College of
Nursing Practice Nursing and Veterans Administration Hospital
in Oklahoma City, would like to extend an
May 2006 invitation to your nursing students, staff and
INTEGRIS Health faculty to submit abstracts to our upcoming
conference spotlighting evidence based
Oklahoma City, Oklahoma practice. This year’s conference, Quest for
AN AFFILIATED INSTITUTE OF
Deadline for abstract submission is FEBRUARY 15, 2006 Quality, Incorporating Evidence into Nursing
Notification of acceptance will be by e-mail on March 6, 2006. Practice, seeks to spotlight the role of the
bedside nurse in using evidence to improve
Abstracts should include: the quality of care provided. Abstracts will be
• Poster Title • Abstract: Limited to 300 words accepted in two categories, original research
• Category of Submission • List of Presenters: One presenter should and creative concepts/solutions. Four of the
be identified as primary contact. accepted poster applicants will be requested to
• Submitting for: Poster only or Poster and
provide a 10-minute oral presentation. All
Oral Presentation • Organization(s) represented
presenters will be given a discounted rate for
Please forward abstracts to Ava Wooten, INTEGRIS Health, Nursing Research and conference participation.
Education, 3400 NW Expressway, Bldg. C, Suite 602, Oklahoma City, OK 73112. Electronic
submissions may be made to ava.wooten@integris-health.com
Ava may also be reached by calling: 405-949-3757. We look forward to your submissions.
61
Events •
The
conference
L I N E
Amagagasi Olwazi
( W a v e s o f K n o w l e d g e ) :
5th Joanna Briggs
Colloquium
The search for evidence to
confront contemporary threats
to global health
Papers are invited that address
evidence synthesis, transfer or utilisation
in areas such as: Registrations of interest via
email: jbi@adelaide.edu.au
New disease threats: Phenomena:
or visit
• MRSA • Climate change
• Drug Resistant • Natural disasters
www.joannabriggs.edu.au/events
Tuberculosis
• Terrorism
• Drug Resistant Malaria
• Avian Flu Continuing global issues:
• SARS • Poverty
• HIV / AIDS • War
Hosted by The South African Centre for 6th - 8th August 2006
Evidence Based Nursing and Midwifery Durban, South Africa
It’s your conference
So why not tell the world about it on this page?
You can reach tens of thousands of
health care professionals worldwide by
advertising your conference or workshop
PACEsetterS
A healthcare publication supporting The Joanna Briggs Institute Practical Application of Clinical Evidence System
in our quarterly magazine PACEsetterS.
The cost is only A$27 per centimetre x
per column (three columns per page).
It can work for you!
The minimum size is 5 cm x 1 column
for A$135. This size advertisement “It’s
your conference” is great value at only The Joanna Briggs Institute
A$891. All prices are GST included. jbi@adelaide.edu.au
For more details contact: Tel: + 61 8 8303 4880
62
information •
The expanding
JBI collaboration
Welcome to the Joanna Briggs Institute
The Joanna Briggs Institute was formed in 1996 Queen’s Joanna Briggs Collaboration: a The University of Nottingham Centre for Evidence
as an initiative of Royal Adelaide Hospital and the collaborating centre of the Joanna Briggs Institute, Based Nursing and Midwifery: a collaborating
University of Adelaide, and is based in Adelaide, Queen’s University, Kingston, Ontario, Canada. centre of the Joanna Briggs Institute, at the
South Australia. It is a membership-based, not- Director: Associate Professor Margaret B. Harrison. University of Nottingham, Nottingham, England.
for-profit organisation that develops, promotes
The Evidence Based Practice Center of Oklahoma: Director: Professor Veronica James.
and supports an evidence-based approach to
a collaborating centre of the Joanna Briggs
health care. The Western Australian Centre for Evidence Based
Institute, at the University of Okalahoma,
Nursing and Midwifery: a collaborating centre of
The Institute has collaborating centres across five Oklahoma City, Okalahoma, US.
the Joanna Briggs Institute, at Curtin University,
continents covering the disciplines of nursing, Director: Professor Carole A. Kenner.
midwifery, aged care, physiotherapy, nutrition and Perth, Western Australia.
The Hong Kong Centre for Evidence Based Director: Professor Robin Watts.
dietetics, podiatry, occupational therapy, and
Nursing: a collaborating centre of the Joanna
medical radiation.
Briggs Institute, at The Chinese University of Hong Multidisciplinary
The Joanna Briggs Institute produces a range of Kong. Director: Professor David Thompson.
on-line programs and publications, and conducts Joanna Briggs Collaborating Centre for Evidence-
The Spanish Centre for Evidence Based Nursing: a
training programs to assist clinicians, researchers, based Multi-professional Practice: a collaborating
collaborating centre of the Joanna Briggs Institute,
educators and students to develop best practice in centre of the Joanna Briggs Institute, The Robert
at the Institute of Health Carlos III, Madrid, Spain.
health care based on the best available evidence. Gordon University, Aberdeen, Scotland.
Director: Dr Teresa Moreno Casbas.
Director: Dr Sylvia Wilcock.
Visit our website: www.joannabriggs.edu.au
Taiwan Joanna Briggs Institute Collaborating
The Australian Centre for Rural and Remote
Nursing Centre, Taiwan: a collaborating centre of the
Evidence Based Practice: a collaborating centre of
Joanna Briggs institute, at the National Yang-Ming
Centre for Evidence Based Nursing Aotearoa: a University, Taipai, Taiwan R.O.C. Director: the Joanna Briggs Institute, at the Toowoomba
collaborating centre of the Joanna Briggs Institute, Professor Yann-Fen C. Chao. Health Service District, Toowoomba, Queensland,
The University of Auckland, New Zealand. Australia. Director: Professor Desley Hegney.
Director: Dr Bridie Kent. Nursing and Midwifery
The New South Wales Centre for Evidence Based
Centre for Evidence-based Nursing South Nursing Health and Social Care Research Centre: Health Care: a collaborating centre of the Joanna
Australia: a collaborating centre of the Joanna School of Nursing and Midwifery Cardiff University,
Briggs Institute, at the University of Western
Briggs Institute, at Royal Adelaide Hospital and Cardiff, United Kingdom.
Sydney, New South Wales, Australia.
The University of Adelaide. Director: Prof Davina Allen
Director: Professor Rhonda Griffiths.
Co-ordinator: Mr Craig Lockwood.
The Queensland Centre for Evidence Based
Fudan Evidence Based Nursing Center: a Nursing and Midwifery: a collaborating centre of Allied Health
collaborating centre of the Joanna Briggs Institute, the Joanna Briggs Institute, The Mater Hospital,
Centre for Allied Health Evidence: a collaborating
Fudan University, Shanghai, People’s Republic of Brisbane, Queensland, Australia.
China. Director: Professor Jia Hongli. Director: Professor Anne Chang. centre of the Joanna Briggs Institute –
Physiotherapy, Podiatry, Occupational Therapy,
New Jersey Center for Evidence Based Nursing; a The South African Centre for Evidence Based Medical Radiation, and Complementary Therapy
collaborating centre of the Joanna Briggs Institute, Nursing and Midwifery: a collaborating centre of
— at The University of South Australia, Adelaide,
at the University of Medicine and Dentistry of New the Joanna Briggs Institute, at the University of
South Australia.
Jersey School of Nursing, Newark, New Jersey, KwaZulu-Natal, Durban, South Africa.
Director: Professor Karen Grimmer.
United States. Director: Dr Tony Forrester. Director: Dr Patricia McInerney.
The Australian Centre for Evidence Based Nutrition
Northwest Indiana Center for Evidence-Based The Thailand Centre for Evidence Based Nursing
Nursing Practice: a collaborating centre of the and Midwifery: a collaborating centre of the Joanna and Dietetics: a collaborating centre of the Joanna
Joanna Briggs Institute, at Purdue University Briggs Institute, at Chiang Mai University, Chiang Briggs Institute, at The University of Newcastle,
Calumet, School of Nursing, Hammond, Indiana, Mai, Thailand. Director: Associate Professor Dr New South Wales, Australia.
US. Director: Dr Lisa Hopp. Ratanawadee Chontawan. Director: Professor Sandra Capra.
Join the JBI
International
Evidence
Utilisation
Network
Whether you are excited by CQI or struggling
with it, we invite you to join our global
collaborative network of health professionals,
health service managers and quality managers in
their practical efforts to accomplish best practice.
Tap into that wealth of experience and knowledge
when you establish local continuous clinical practice
improvement programs.
The Joanna Briggs Institute International Evidence Utilisation Network links groups
of health professionals, health service managers and quality managers from across
the world, creating opportunities to share and benefit from ideas and experiences,
and contribute to international efforts to improve global health outcomes.
Made up of Evidence Utilisation Groups (EUGs), the EU Network enables health units
and health professionals to engage in truly international clinical audit and clinical
benchmarking, based on the principles of evidence based practice.
EUGs are made up of clinicians, quality managers or other personnel who wish to be part of
a global network of people and organisations committed to clinical practice improvement.
These groups are self-governing and self-funding partners who accept the terms of the JBI
EUG Letter of Agreement.
For further information, contact Tiffany Conroy-Hiller at tiffany.conroyhiller@adelaide.edu
Download the application form from the JBI website at
www.joannabriggs.edu.au/about/evidence_util_groups_map.php
Thinking globally and acting locally
www.joannabriggs.edu.au
