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Keywords:

  • change theory;
  • evidence implementation;
  • oncology care;
  • participatory action research;
  • qualitative research

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Aim

To implement evidence in a nursing unit and to gain a better understanding of the experience of change within a participatory action research.

Methods

Study design of a participatory action research type was use from the constructivist paradigm. The analytical-methodological decisions were inspired by Checkland Flexible Systems for evidence implementation in the nursing unit. The study was carried out between March and November 2007 in the isolation unit section for onco-haematological patients in a tertiary level general university hospital in Spain. Accidental sampling was carried out with the participation of six nurses. Data were collected using five group meetings and individual reflections in participants' dairies. The participant observation technique was also carried out by researchers. Data analysis was carried out by content analysis. The rigorous criteria were used: credibility, confirmability, dependence, transferability and reflexivity.

Results

A lack of use of evidence in clinical practice is the main problem. The factors involved were identified (training, values, beliefs, resources and professional autonomy). Their daily practice (complexity in taking decisions, variability, lack of professional autonomy and safety) was compared with an ideal situation (using evidence it will be possible to normalise practice and to work more effectively in teams by increasing safety and professional recognition). It was decided to create five working areas about several clinical topics (mucositis, pain, anxiety, satisfaction, nutritional assessment, nauseas and vomiting, pressure ulcers and catheter-related problems) and seven changes in clinical practice were agreed upon together with 11 implementation strategies. Some reflections were made about the features of the study: the changes produced; the strategies used and how to improve them; the nursing ‘subculture’; attitudes towards innovation; and the commitment as participants in the study and as healthcare professionals.

Conclusions

The findings throw light on the process of change in the healthcare sector. The results are useful to modify nursing practice based on evidence.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Evidence-based clinical practice (EBCP) is one of the main global research trends emerging in the healthcare world, and nursing professionals play a key role in providing effective and efficient healthcare to the population.[1] With the aim of bridging the gap between research and practice, it has been argued that EBCP could lead to the following contributions: CP guides, up-to-date knowledge, advances in nursing science, improvements in the credibility of nurses as autonomous professionals, improvements in the healthcare outcomes of patients and the control of healthcare costs and, finally, a faster utilisation of the results of the most up-to-date and reliable research in order to produce an improvement in the quality of healthcare in the mid to long term.[2]

Several EBCP models have already been implemented in nursing departments to bring about change in CP.[3-5] Other authors have also made recommendations for improving EBCP models in CP.[6] Additionally, there is an extensive literature reporting on the introduction of evidence into CP by evaluating multiple interventions.[7-9] However, introducing evidence into CP cannot be achieved solely by improving knowledge but requires a change in attitude and behaviour[10, 11]; nevertheless, there continue to be difficulties and barriers preventing the clinicians from following the recommendations made in light of research results.[12, 13]

Most of the previously quoted research proposes vertical implementation models, from top to bottom, but in recent years it has been considered necessary to find a new approach for achieving changes. In our organisations, CP is becoming more and more complex, making it essential to understand how it works. In our own professional practice, we are required to work as researchers and in this role we should take the following assumptions as starting points: research in organisations should be collaborative; participants should be researchers of their practice; and research should be a key tool for improving quality.[14, 15]

Action research[16] is an ongoing, holistic and egalitarian process involving researchers and practitioners, a process through which professionals decide and carry out changes in their practice and which needs to be experienced and reflected upon to be able to improve and change practice. This research method has been considered as a way of introducing evidence in CP. In fact, a review in 2009 found 21 studies that sought to implement evidence-based practice through action research,[17] assessing its effects on the professional's knowledge and performance, and patient and contextual outcomes. This review indicates that the implementation of EBCP using action research may be promising; in all the studies included, positive results have been reported for one or more of the outcome measures and action research would therefore seem to be a useful way of bridging the gap between research and practice.[17] The assessment of patient outcomes is the least reported outcome measure in the literature.[17] This is another relevant aspect in our overall project, although the evaluation of the impact of the action taken goes beyond the scope of this article.

Currently, we are carrying out participatory action research (PAR) to implement evidence related to an onco-haematology nursing unit in a tertiary level general university hospital in Spain. The findings of the present article are part of the process of change in CP and the investigation into the nature of change itself in a European and oncological CP context which has not been researched very extensively in the past. Accordingly, the following research objectives have been proposed: to implement evidence in a nursing unit; to describe in detail the changes and strategies considered by the actors involved; and to gain a better understanding of the experience of change within PAR.

Another factor making this research more relevant is that unlike the articles included in the aforementioned review,[17] the current study presents aspects of the four typologies of user participation:[18] our process of change encompasses experimental aspects (more researcher focused), organisational contexts (more system focused) and, to a lesser degree, professionalising and empowering typologies (more user/practitioner focused).

In this way, the present article will be useful for the following: (i) researchers who are interested in demonstrating how PAR can lead to the implementation of evidence in CP; (ii) healthcare managers who are committed to strengthening the professional groups they manage; and (iii) clinics due to the clear improvement in their CP.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Design

A PAR study design was adopted from a qualitative methodological approach. Participatory researchers use methods based on democratic, cooperative, transparent and efficient ways of investigating and intervening in daily life, trying to reveal the complexity of problems through dialogue and collaboration.[16] We decided to frame the investigation within the constructivist paradigm rather than more frequently socio-critical one because the research team understands that reality only exists in the shape of multiple mental and social constructions, which fits in with the learning paradigm. What we were attempting to do was to understand the experience of change within PAR to modify nursing practice and recognise how PAR could bring about this change.[19]

Checkland's ‘Soft Systems’ Methodology[20] was adopted as the methodological guide for the study for the importance of learning to this methodology (key element for the constructivist paradigm). At the same time, this methodology was chosen because we were aware that there are problems in nursing practice that depend on ‘system’ dysfunctions, assuming the ‘system’ is a nursing unit, a hospital, etc. In order to change practice, we needed to carry out pragmatic and functionalist action, looking to change certain elements in this system. One of the great strengths of Checkland's methodology is its adaptability to the context; in our case, the methodology was widened adding a final reflection stage to close the cycle: (i) detection and expression of the problematic situation; (ii) delimitation of implied systems; (iii) desirable modelling of the systems; (iv) comparison of the desirable model and the problematic situation; (v) conceptualisation of what is desirable and feasible; (vi) putting in place of proposed strategies and observation; and (vii) reflection about the change.

Moreover, there are many ways of using PAR, giving it a technical, practical or emancipatory focus.[21] The fundamental criterion for this classification is based on the researcher's role. In the present study, it was decided to opt for a practical type of investigation in which the expert (main researcher) initiates the PAR and is able to facilitate and organise the process. Self-understanding and responsibility in practice was encouraged; as a result, the participants became co-researchers empowered to take decisions and change aspects of the research process, everyone's opinion was taken into account and decisions were taken through a democratic process.

Study setting

The study was carried out in the isolation unit section for onco-haematological patients in a tertiary level general university hospital in Spain in 2007. This unit was chosen because of its more stable nursing staff. There was a nurse–patient ratio of 4:1, and the nurses were young and enthusiastic about learning although they had little research experience. In Table 1, information can be seen about the patient and nursing characteristics, which will help to contextualise the setting where the PAR is taking place. In the same way, in this unit, the research culture was very prevalent among doctors but limited among nurses: nursing protocols were not up to date and the basic EBCP criteria had not been used for their elaboration. However, the management team of the unit and the hospital were very committed to the project (members of the research team). The project was approved by the Hospital's Clinical Research Ethics Committee.

Table 1. Sociodemographic characteristics of nurses and patients
  1. mean ± standard deviation.

Nurses 
Age31.3 ± 8.1
Professional experience6.0 ± 5.4
Professional experience in oncology3.0 ± 3.5
Previous knowledge of evidence-based clinical practice 
Yes33.3%
No66.7%
Gender 
Male0%
Female100%
Patients 
Age45.9 ± 15.8
Hospital stay (days)30.8 ± 12.9
Bone marrow transplant53.6%
Neutropenia87.5%
Gender 
Male57.1%
Female42.9%

Study participants

The unit had 40 nurses on the staff. They carried out seven project presentation sessions to recruit participants (covering all the work shifts) with the aim of explaining the objectives and the study design and inviting the nurses to participate voluntarily. Using this purposive sampling procedure, 14 nurses came to the first group meeting but, after the second meeting, the PAR team consisted of 6 nurses. These losses were due to the inability of the nurses to be involved in all the activities, which are part of the process of change requiring a considerable amount of dedication and personal time.

The group consisted of relatively young nurses (mean age of 32 years), each having less than 10-year professional experience and most group members did not have family responsibilities. All six members of the group were highly motivated and committed to the organisation of the unit. One of the participants was a master's degree student and most had very basic knowledge of EBCP. The unit managers were the members of the research team who were made responsible for data collection through observation and who facilitated the field work into the unit. Although the work environment was not measured, there were no coercion or power struggles between the nurses and unit managers given that there was a good personal and working relationship beforehand, which prevented these conflictive situations from occurring. This good working relationship was crucial for the optimal development of PAR given that power relationships can arise when unit managers and nurses participate in this type of research.

In addition, the main researcher from outside the unit acted as an expert guiding the PAR group through the research. To do this, the main researcher was available to answer any questions of the participants by phone or email.

Throughout the study, just as with all PAR, the researcher and participants played an organisational, supportive and methodological role.

Data collection

Different data collection techniques were used throughout the stages of the Checkland model: group interviews, participant reflections written in their personal diaries and participant observation by researchers (Fig. 1).

figure

Figure 1. Summary of the change process and the implementation of evidence in CP exemplified using mucositis as the clinical topic. CP, clinical practice.

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Initially, three group meetings were planned, but in the end the PAR group democratically decided to meet on five occasions. In all the meetings, an interview guide (to reflect on the CP problems and their solutions) was used and interviews were tape recorded and transcribed verbatim in their entirety. The identity of the moderator or the facilitator could have inhibited access to and/or participation in the group; therefore, the meetings were moderated by the main researcher who was outside the unit. After each group meeting, the moderator and the observer did a first provisional audit of the recorded data to obtain possible clues to guide subsequent meetings.

At the same time, the participants used a personal diary to register notes and reflections about what had been said and done, their reaction, their progress, etc. Then, in the group meetings, the participants voluntarily shared their notes that served as a tool for collective reflection. The participating nurses became co-researchers with this data collection and reflection/analysis.

In addition, the participant observation technique was carried out by two members of the research team who worked in the same unit. During their day shift, these investigators literally took notes in an open way, providing descriptions of the events, the people and their interactions. They were crucial for obtaining this kind of information between the ward team, which warned that it would be observed.

Finally, many reflections were made in the main researcher field diary that served as a reflexive audit throughout the process.

In total, there were five group meetings each of 2-h duration, 75 personal diary notes and 55 observation notes.

Data analysis

A preliminary analysis was carried out, by the main researcher, after each group meeting in order to summarise findings, interpretations and observations about the dynamics of the meeting that helped to establish codification schemes for structuring the later analysis.

Data analysis was carried out using content analysis, both on a semantic level (the meaning of words and the analysis of categories either designed a priori or emerging during the process) and on a pragmatic level (circumstances in which the research occurs). The data were repeatedly coded; the categorisation process was profiled with the help of memos and analytical reports to build each model component with the help of the ATLAS.ti v.6A program (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). The transcripts were revised and work was carried out on codification, subcategorisation, categorisation and the relationship between categories of the verbatim of group discussions, personal diaries, field diary and observation notes with the aim of elaborating explanations that ‘made sense’ of the texts.[22]

During the first phase of analysis, codification was carried out between two researchers, and afterwards there was a counter-codification of the relationships between the codes and the explicative model. Finally, feedback from the participants was achieved by requesting that they collaborate and verify the final analysis.

Rigor and ethical considerations

The methodological rigor criteria included credibility, confirmability, dependence, transferability[23] and reflexivity.[24] The data were compared and contrasted on several occasions by different members of the research team. To achieve the confirmability and credibility criteria, the following procedures were used: the participants contrasted the summary of findings and triangulation (of techniques, researchers and sources). In order to provide clues about the replicability of findings (dependence), the roles of the participants were made explicit and the contexts were explained. An attempt was made to make a rich and detailed description looking for maximum transparency and transferability in handling the data. Finally, the main researcher carried out a reflection process about all the decisions taken throughout the research process, her relationship with the participants and how their concerns and interests influenced the study.

The project was approved by the Hospital's Clinical Research Ethics Committee and all participants took part in a voluntary way, giving their signed informed consent, and were able to withdraw from the study at any time. The anonymity of participants is protected: the participants were assigned with an identifying code number to be used for tape and transcript identification and the unit managers were not present in the meetings to prevent coercion. The transcripts do not contain any information that could identify the participants.

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The findings presented are addressed to show the process of change in CP and to gain a better understanding of the experience of change within a PAR group. During the whole PAR process, the reflections made by participating nurses have been a powerful way to explore the gap between personal and professional experience in practice. In addition, they have led to the best possible action for their context.

Guided by Checkland's model, we have shown how the world of ‘thought’ and ‘action’ are joined together to implement evidence in nursing practice in the unit (Fig. 1).

Phase 1: detection of the problematic situation and expression of the problem

By exposing the participants to statistics, videos, data of evaluations about their unit[25] and a battery of open questions, a situation of enormous variability in CP emerged and there were also repercussions for the quality of care and the healthcare results of the patients. The group identified a lack of the use of evidence in CP as being their own problem.

Nurse

Already before the first meeting you find differences in the way everybody works and it's happening now more than ever (after the meeting) I have found differences between the units, dealing with the same patients- there is great variation in the way we deal with the same cases.

Nurse

… you don't know if what you are using is the result of the research or word of mouth and you start to consider ‘Why do I do it this way, why don't I do it a different way?'; some practice is partly based on evidence, however in other cases practice comes from an opinion.

Phase 2: demarcation of the involved systems

Different factors such as a training deficit and limited institutional support and resources were identified as the cause of the lack of the use of evidence.

Nurse

Another problem that can arise, is that we really don't know how to critically read a scientific paper and so on many occasions we see an article which seems to be ‘ok’ but if you start to analyze it in greater depth it is very biased, and we probably need some training for critically reading both qualitative and quantitative scientific papers to know if we can use them in practice or not.

Nurse

When they (the managers) make resources available for you, people change and people adapt; when they (the managers) make things more difficult … well, how are you going to adapt? {…} if the managers don't provide you with more personnel or resources or motivation, people can't be bothered in the end.

On occasions, they are sceptical and believe that the evidence obtained from daily experience is enough for CP. However, at the same time, the participants are critical of nurses' collegues and social values such as the lack of commitment, motivation and conformism of the professionals. Attempting to change established practices could be potentially criticised by the other colleagues and changes in CP might therefore be discouraged.

Nurse

Personally, I don't like transparent dressings, and this is based on ‘my evidence’.

Nurse

When you are new in a unit … you do what others tell you to do, those who have been there longer. I don't stop to think if it's good or not … they tell me to do it, I do it and that's the end of it.

Diary

I believe that it is very important (in order to apply EBCP in CP) that the research, ‘the world of the unknown’, becomes an accessible field, known and necessary. {…} Basically what exists is ‘the fear of the unknown’, a barrier that stops us from enriching our knowledge. In the first meeting we reached the conclusion that we work according to our experience, I think this is a mistake. To carry out our daily practice we should be guided by the experiences (hundreds of them) of expert researchers. In this context, what ‘I’ have to say is not so important.

Phase 3 and 4: desirable modelling of the systems and comparison of the desirable model with the problematic situation

In these phases, the aim was to conceive a model of desirable practice (the direction in which to go) comparing it with daily practice.

On a day-to-day basis, the complexity of taking decisions impregnates daily CP; the lack of consensus produces insecurity and even sensations of guilt. The participants believe that in an ideal world evidence would be used and it would be possible to standardise practice to work better in teams, improving confidence and professional recognition.

Diary

I can't understand why it's so difficult to change some things, how long do we have to wait before we replace the antiseptic used for wounds with the one proposed by the evidence? We know what is most effective and done in other hospitals. Are we making fun of our patients?

Nurse

If we researched more and received more scientific support, they {the physicians} would see that we are not just there to follow their treatment.

Nurse

It is clear that EBCP is improving! The first thing you are doing is working in a stable and calm way, through studies and with support.

Phase 4 and 5: a comparison between a desirable model and the problematic situation and an assessment of what is desirable and feasible

An attempt was made to reach stages 4 and 5 in the Checkland model by lowering levels of abstraction and being more specific in cases involving the clinical topics studied in the global project (selected because of their importance for the cancer patient): mucositis; pain; anxiety; satisfaction; nutritional evaluation; nauseas and vomiting; pressure ulcers; and problems related to the venous catheter. Participants compared real situations (their daily CP connected with these topics) with ideal ones (evidence about these topics) and considered attainable changes and implementation strategies. With the PAR functioning, the participants were able to acquire knowledge in a reflexive way about their own practices, the situations in which these are carried out and how to modify them. The PAR group had the capacity to self-organise and one great change that led to an improvement in the use of evidence in CP was the revision of the evidence about these clinical topics. This revision was guided by expert researchers (team research members) who played a mentor role (searching and summarising the evidence); after, they edited structured summaries and they formulated proposals for changes to implement evidence and strategies for doing this.[26-28]

The changes proposed were more pragmatic than theoretical given that the PAR group acted as a ‘user’ of evidence which had already been accepted, synthesised and evaluated by other ‘creators’ of evidence.[29]

The seven changes in CP involving individual and organisational behavior are shown in Table 2 with the 11 strategies proposed to implement changes. The 11 strategies would be put into place by three groups of actors with different roles: nurses, patients and managers (Fig. 2).

figure

Figure 2. Strategies for implementing changes and their actors. CVC, central venous catheter; PU, pressure ulcer; WHO, World Health Organization.

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Table 2. Changes and implementation strategies
  1. CVC, central venous catheter; PU, pressure ulcer.

  • To use diluted chlorhexidine as an antiseptic for managing CVC.
  • To evaluate nausea, mucositis, PU risk and pain using validated instruments.
  • To evaluate patients at risk from PU by nutritional experts.
  • To provide musicotherapy.
  • To use cryotherapy during the administration of cytostatic 5-fluorouracil.
  • To encourage the inclusion of patient preferences when taking decisions.
  • To encourage the inclusion of helping relationships in patient care.
  • Use of informative posters in the unit.
  • Use of fortnightly rotational reminders through signs.
  • Diffusion among equals.
  • Edition of individual cards to evaluate mucositis of the World Health Organization scale.
  • Distribution of the hospital PU guide among the nurses.
  • Modification of the registries in clinical histories including patient self-evaluation of nausea and pain.
  • Management of changes in the antiseptic using alliances with the Pharmacy Commission and the Hospital Infection Control Unit.
  • Systematic carrying out of interconsultation in the nutritional unit in patients at high risk of PU.
  • Acquisition of a music player device to provide musicotherapy.
  • Elaboration of cards to help the patient to choose the type of dressing that he or she prefers for healing the CVC.
  • Training about helping relationship.

Phase 6: putting into practice the proposed strategies and observation

The implementation of changes started in July 2007 and new practices were added until October 2007. This was a summer period when a lot of temporary staff are employed, making it difficult to inform peers about the research.

Some of the strategies put into effect by the hospital managers took the longest to be introduced because the strategies were very complex or because the managers were only indirectly related to the project.

During this phase of implementing the changes, the participants were leaders in the implementation of the strategies through the dissemination among equals to the rest of the nurses of the unit. In this phase, the participants wrote down reflections in their field diaries. These individual reflections, related to change, were a starting point for group reflection, making it possible to validate as a group those that were more positive and feasible from the point of view of the participants.

Phase 7: reflections on the change

Finally, the fifth meeting dealt with stage 7 of the model and it aimed for participants to reflect on the process. Reflections emerged about the changes, the strategies and how to improve them, the nursing ‘subculture’ and its importance for introducing changes, attitudes to innovations and the commitment of participants to the study and as healthcare professionals.

The overall research process was attractive for the participants. They have gained confidence in themselves, just as Mme. Curie proposed: ‘We stop fearing those things that we learn to understand’. However, they agree about the difficulty in producing changes in CP.

Diary

I have had a great time taking part in the project, at the beginning I didn't think I was capable, but I know what EBCP is and I am able to explain it to my colleagues.

Diary

It has been so difficult to want to implement EBCP; what is sure is that when I joined the research group it seemed really interesting to me, as I understood it was about working to improve our own work, this was exciting for me and it encouraged me to continue; {…} but it has been a long road, implementing EBCP in CP has been difficult, in terms of resources, means, time … I think that the effort made by a few people was the only thing that kept us going.

Positive and negative attitudes of the professionals from the unit have been identified among those who are not directly involved in the project which occasionally served as support and motivation for members of the PAR group.

Nurse

However, in some things, everyone has lent a hand {my colleagues}, and what is more, they looked at us saying ‘you are doing it very well!’.

Observation

I am in the office and a nurse comes in criticizing the lack of unified criteria. I take advantage of the situation and comment that these concerns could help the PAR group; this nurse doesn't pay any attention to me, claiming that there isn't enough time and leaves without saying any more.

These attitudes can be influenced by nurses' feelings of inferiority about their capacity to bring in changes. It appears that nurses need to feel that their proposals for change are supported by other disciplines. The nurses are silencing and underestimating their own work as professionals.

Nurse

I have sometimes considered that if changes had been made at a higher level {…}, if a physician had come along and said this and that should be done, How would we have acted? Although I think the same situation would have occurred. But, maybe the changes would have happened without being questioned’.

Observation

I see a physician waiting and reading a poster about the research study we are carrying out; after a nurse from the PAR team approaches her and asks her ‘Do you like it?’. The physician says ‘yes’ and encourages the nurse to continue; the nurse is proud of the interest shown by the medical colleague.

The changes have been evaluated as favourable, especially those involving patients in the decision-taking process. Similarly, the strategies involving ‘pairs’ were well considered, probably because of the importance of social interaction (formal and informal) as a source of knowledge. One future strategy we considered was the introduction of the figure of the clinical nursing leader as a ‘reference for nursing’.

Nurse

The cards for the dressings are very nice! {…}, because you feel closer to them (the patients). When you go to the foot of their bed at the end of your shift and you ask them about their pain (with the new registry), and you are speaking to them, you are showing interest, they have the feeling that you are there and you are worrying about them; you are not the nurse who just deals with medication, takes their blood pressure, and ‘see you later’, it is trust, it creates a relationship of trust which is vital for carrying out health care.

Nurse

People who are experts in clinical matters to whom you ask ‘Am I doing this right? What do you think about this? What have you seen? What literature have you found? Or look for something else for me’, I get a lot of support from this type of nurse as a clinical reference.

One of the main pitfalls was the language problem. The reading of evidence was mainly in English (a language that is different from that of the participants), leading several professionals to abandon the project and those who remained experienced anxiety.

Nurse

I have had a fantastic time, where I've suffered most is with the translation of articles, but I've had a good time.

Observation

Two members of the PAR group ask about the articles and documentation which we are going to provide them with; when they see that they are in English they get very frightened saying ‘oh no! What now?’.

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Through the project, it has been possible to modify the practice of implementing evidence using PAR. The findings have provided us with a model for generating changes in CP, introducing evidence and finding out the attitudes of professionals towards EBCP. As in other similar research,[17] our results seem to be a useful way of bridging the gap between research and practice. What is more, in this article many aspects have been described in detail: the process of change brought about by PAR; the reason for the changes considered; the strategies for their implementation; and how the process has been experienced, etc., and all of the information is very useful for replicating further studies. In this line, we have learned several key elements in the evidence implementation process in CP settings: the effectiveness of multi-intervention, working with various disciplines and sectors as a whole, and the importance that the initiatives arise from bottom to top. Also, the process of change was conveyed using Checkland's ‘Soft Systems’ Methodology, demonstrating its utility in the healthcare sector not only for generating knowledge but also changes.[20]

The key to success is based on the self-generation of practical knowledge from the reflections made by the PAR group. The fact that it is the same group that detects the lack of the use of evidence in their CP, the effect of this on patients and the possible reasons for the gap between research and practice facilitated the stimulus needed to change their practice. The depth of knowledge of their daily CP was vital for choosing adequate strategies for change. In fact, coinciding with other authors,[30] the greatest problems for change implementation were due to organisational factors (vacation period and strategies put into practice by the managers and not by members of the PAR group). The great strength of the process of change in this research is that it came about from bottom to top (from a group of care nurses), also counting on the formal leaders (the unit managers were members of the research team). This situation was experienced as yet another advantage rather than a difficulty unlike in other studies.[31]

The key elements for the successful implementation coincide with previous research: the nature of the evidence, the context and the facilitating elements.[6] Also, our findings, about the attitudes of professionals towards EBCP, coincide with those of the literature and it is notable that experiential knowledge (the practice itself) together with social interaction is an important source of knowledge.[11] In addition, the factors identified that impede the use of results of research in CP (training, values, abilities, accessibility and institutional support) coincide with barriers identified in other studies.[12, 13] Specifically, in Spain, the language problem has been identified as an important barrier. In this respect, a special mention should be made of institutions such as The Spanish Collaboration Center of The Joanna Briggs Institute for Evidence-Based Nursing[32] and The Cochrane Library Plus for the work they have carried out in translating evidence into Spanish, thereby reducing the language barrier.

These findings raise new questions about future research. Firstly, they open up new professional and research areas that make the role of Clinical Nursing Leader much more relevant[33] as a figure of reference for the management of knowledge in the nursing units, which has spontaneously come about from the reflections made by the PAR group. Secondly, the real repercussions of change need to be evaluated, opening new lines of research into the effectiveness of the implementation of EBCP in the quality of daily healthcare practice in terms of healthcare outcomes in patients. Thirdly, we should explore the finding that through a process of group reflection it is possible to reach evidence implementation strategies that have already proved to be effective in previous systematic reviews, such as summaries of evidence, reminders, active multi-intervention and expert nurses.[7-9] Finally, we should study in more depth the knowledge used by the nurses in the PAR group analysing them according to patterns of scientific, esthetic, ethical, personal[34] or sociopolitical knowledge[35] or that described as ‘emancipatory knowledge’.[36]

We should be aware of the limitations of this present research study given the qualitative nature of the study. Generalisations about the results cannot be made, but we should extend them to similar situations and contexts. However, it seems that the contextual factors of the unit are very similar to the many practice settings because the same barriers and facilitators have been detected. What is more, the participant sample was self-selected, the changes might not have been put into practice by most of the nurses of the unit and the final group of participants in the PAR was small. These losses could have been due to the fact that the PAR involved a great amount of personal effort (meetings, translations, training, etc., outside their normal timetable). However, there is also a possibility that the group was too large and difficult to motivate at the beginning. The temporary staff employed in the period of the study may be a limitation to the diffusion of changes. Finally, one of the major limitations of the PAR is that, with the passage of time, the unit misses achieved changes; currently, our research team is concluding an investigation along this line.

Conclusion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

In spite of these limitations and that the research design does not allow or establish a causal relationship between reflection and change, we believe that PAR has been useful for introducing evidence in complex settings such as that of healthcare as stated by other authors.[17, 37]

This study has served to modify nursing practice based on evidence, throwing light on the processes of change in the healthcare sector and potentially improving healthcare results in patients. In our local context, researchers, managers and healthcare workers should take this method into account when their main aims are to improve our knowledge and to change and to evaluate CP.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

We acknowledge the work of the participants of the PAR group for their dedication, enthusiasm and persistence.

Thanks also to Antonio Paredes Sidrach de Cardona for their general support. We would also like to thank Nicholas Jarvis for his collaboration in translation work.

References

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
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