Acceptance of chronic neuropathic pain in spinal cord injured persons: a qualitative approach.

Chronic neuropathic pain (CNP) in spinal cord injury (SCI) is a significant problem that has physical, functional, and psychosocial repercussions beyond the consequences of SCI. The notion that acceptance may be a viable alternative to suffering when resolution of pain is unattainable was explored. Studies indicate that acceptance of pain is associated with lower pain intensity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily active time, and improved work status in patients who have other types of chronic pain. This exploratory qualitative study examined acceptance of pain in SCI individuals who have CNP. Grounded theory was used to develop a conceptual framework to describe acceptance in people with CNP and SCI. Data were obtained from in-depth interviews with seven SCI individuals. Six phases were identified, including: "comprehending the perplexity of CNP," "seeking pain resolution," "acknowledging pain permanence," "redefining core values," "learning to live with the pain," and "integrating pain." Two driving forces, "increasing independence" and "evolving pain view," were noted to move the process of acceptance forward. The findings in this study suggest that acceptance of pain appeared to be beneficial in terms of reducing suffering and facilitating a more satisfying and fulfilling life in these SCI individuals. A decreased emphasis on continued searching for a cure for CNP and movement toward a self-management approach was associated with increased pain coping for these SCI individuals. Clinical implications suggest that early intervention to facilitate effective coping and an exploration of the notion of acceptance could be beneficial.

Physicians' intentions and use of three patient decision aids.

BACKGROUND: Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them. METHODS: We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid. RESULTS: Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians (<60%) felt the decision aid would improve the quality of patient visits or be easily implemented into practice and very few (27%) felt that the decision aid would save time. Physicians' intentions to use the decision aid were related to their comfort with offering it to patients, the decision aid topic, and the perceived ease of implementing it into practice. While 54% of the surveyed physicians indicated they would use the decision aid, less than a third followed through with this intention. CONCLUSION: Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.

Evidence to practice: pre-post-implementation study of a patient/provider resource for self-management with heart failure.

Background Evidence-based recommendations for heart failure self-management are contained in quality clinical practice guidelines. To implement these in practice requires additional translation. Partners in Care for Congestive Heart Failure (PCCHF) is a set of resource materials developed to encourage heart failure patients and their families to assume greater responsibility and to participate in daily decision-making related to their illness experience by enhancing their self-assessment and self-management skills. The study objectives were to evaluate its use, acceptability and relevance of this approach by heart failure patients, nurses and policy-makers. Methods A pre-post study was conducted across 10 rural-urban, acute and community care sites within three Canadian provinces and one US state. Patients' health-related quality of life was assessed with Minnesota Living with Heart Failure Questionnaire and Medical Outcomes Short Form before and 6 weeks after using the PCCHF program. Nurses completed a survey and participated in focus groups. Policy-makers were interviewed before and post implementation. Results Baseline and 6-week measures were completed by 239 patients. Health-related quality of life measures revealed statistically significant improvement after 6 weeks. Thirty-three nurses and 19 policy-makers participated in interviews post implementation. Most patients, nurses and policy-makers found the resource acceptable and relevant to support information needs. Conclusion The PCCHF program positively benefited both patients and clinical staff. The evidence-based teaching materials were considered a useful resource for self-management with heart failure. Time constraints and high staff turnover underline the need for resources like PCCHF to assist in patient-oriented heart failure self-management. Copyright for PCCHF has been transferred to the Canadian Heart and Stroke Foundation for widespread dissemination.

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD.

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Lost in knowledge translation: time for a map?

There is confusion and misunderstanding about the concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. We review the terms and definitions used to describe the concept of moving knowledge into action. We also offer a conceptual framework for thinking about the process and integrate the roles of knowledge creation and knowledge application. The implications of knowledge translation for continuing education in the health professions include the need to base continuing education on the best available knowledge, the use of educational and other transfer strategies that are known to be effective, and the value of learning about planned-action theories to be better able to understand and influence change in practice settings.

Women undergoing breast diagnostics: the lived experience of spirituality.

PURPOSE/OBJECTIVES: To explore perceptions of spirituality in women who had undergone a breast diagnostic experience. RESEARCH APPROACH: Qualitative, phenomenologic study using Giorgi's approach. SETTING: An outpatient comprehensive breast assessment center. PARTICIPANTS: 20 Caucasian women, aged 30-89, who had just completed the diagnostic process, including definitive diagnosis, regarding a breast abnormality. METHODOLOGIC APPROACH: In-depth, semistructured, tape-recorded, and transcribed interviews analyzed using the Giorgi method of coding, transforming, and synthesizing data. MAIN RESEARCH VARIABLES: Descriptions of spirituality, spiritual needs, and supporting spirituality. FINDINGS: Two themes emerged: creating a focused isolation and seeking connections. Women created a private mental world in which to concentrate on the stressful diagnostic process. Within the isolation, women explored their personal strength and their connection to God or their spiritual beliefs. When the stress began to overwhelm, they sought out loved ones for support and diversion. Women found the center's staff to be supportive; however, many did not wish to speak to an agency chaplain during the uncertain period. CONCLUSIONS: Women needed to handle the stress alone, with reliance on spirituality and God that was balanced with a need for specific connections to family members or close friends. INTERPRETATION: Nurses can support women's need to focus and can assist family members to understand their role during the diagnostic period. The diagnostic period can be used to talk with women about their spiritual beliefs, their needs, and possible referral to a chaplain.

Aboriginal healing: regaining balance and culture.

This ethnographic study explored the question, How do urban-based First Nations peoples use healing traditions to address their health issues? The objectives were to examine how Aboriginal traditions addressed health issues and explore the link between such traditions and holism in nursing practice. Data collection consisted of individual interviews, participant observations, and field notes. Three major categories that emerged from the data analysis were: following a cultural path, gaining balance, and sharing in the circle of life. The global theme of healing holistically included following a cultural path by regaining culture through the use of healing traditions; gaining balance in the four realms of spiritual, emotional, mental, and physical health; and sharing in the circle of life by cultural interactions between Aboriginal peoples and non-Aboriginal health professionals. Implications for practice include incorporating the concepts of balance, holism, and cultural healing into the health care services for diverse Aboriginal peoples.

Methodological issues encountered in a study of hospitalized COPD patients.

A study with hospitalized chronic obstructive pulmonary disease (COPD) patients determined the feasibility of providing and evaluating a tailored education program. This article describes two methodological issues encountered. Issues included recruitment and retention, and selection of outcome measures. The COPD Self-Efficacy Scale (CSES) and Dartmouth Functional Health Status (FHS) charts provided data on evaluation and outcome measurements. Of 67 patients, 55% met eligibility criteria, 73% (n = 27) agreed to participate, and 74% (n = 20) completed the study. Results revealed acceptance and satisfaction with the educational intervention. The median CSES score, significantly (z = 3.51,p = .004) improved from 53% to 82%. In FHS, a 20% improvement occurred in all except social support. Methodological concerns with the CSES reinforced the need for further investigation of the reliability and validity for hospitalized COPD patients. Researchers' observations may assist in planning educational interventions and program evaluations with hospitalized COPD patients.

The Ottawa Model of Research Use: a guide to clinical innovation in the NICU.

PURPOSE/OBJECTIVES: To improve performance of a neonatal transport team by implementing a research-based family assessment instrument. Objectives included providing a structure for evaluating families and fostering the healthcare relationship. BACKGROUND/RATIONALE: Neonatal transports are associated with family crises. Transport teams require a comprehensive framework to accurately assess family responses to adversity and tools to guide their practice toward parental mastery of the event. Currently, there are no assessment tools that merge family nursing expertise with neonatal transport. DESCRIPTION OF THE PROJECT: A family assessment tool grounded in contemporary family nursing theory and research was developed by a clinical nurse specialist. The Ottawa Model of Research Use guided the process of piloting the innovation with members of a transport team. Focus groups, interviews, and surveys were conducted to create profiles of barriers and facilitators to research use by team members. Tailored research transfer strategies were enacted based on the profile results. OUTCOME: Formative evaluations demonstrated improvements in team members' perceptions of their knowledge, family centeredness, and ability to assess and intervene with families. The family assessment tool is currently being incorporated into Clinical Practice Guidelines for Transport and thus will be considered standard care. CONCLUSION: Use of a family assessment tool is an effective way of appraising families and addressing suffering. The Ottawa Model of Research Use provided a framework for implementing the clinical innovation. IMPLICATIONS FOR NURSING PRACTICE: A key role of the clinical nurse specialist is to influence nursing practice by fostering research use by practitioners. When developing and implementing a clinical innovation, input from end users and consumers is pivotal. Incorporating the innovation into a practice guideline provides a structure to imbed research evidence into practice.

Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators.

BACKGROUND: Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline. METHODS: This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals. RESULTS: Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use. CONCLUSIONS: When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

Innovations in knowledge transfer and continuity of care.

In summary, the transfer of continuity-of-care innovations to practice is a complex process. Knowledge transfer is complex in and of itself, and in the case of continuity-of-care innovations this complexity is compounded by the need to simultaneously target multiple sectors, settings, agencies, and providers. Although there are a number of knowledge transfer theories/models, their use in guiding implementation activities is not yet commonplace. If the health-care system and patients/clients are to benefit from continuity-of-care research, researchers and implementers will need to become better versed in the knowledge transfer literature, experiment with these frameworks when implementing innovations, and test their usefulness with different innovations in different contexts.

Linking aboriginal healing traditions to holistic nursing practice.

With a phenomenal expected growth in the Canadian Aboriginal population and the fact that less than 1% of Canadian health professionals are of Aboriginal ancestry, there is an increased need for culturally competent health professionals. This article explains diverse healing traditions and links those traditions to holistic nursing practice. Respect for culturally sensitive care is necessary for understanding Aboriginal peoples in different contexts. We suggest that nursing practice, which takes into consideration the understanding of Aboriginal healing traditions, strengthens the intention of nurses to be holistic. Holism in nursing allows the profession to be on the fore-front of understanding Aboriginal healing traditions; the linking of holistic nursing practice with Aboriginal healing traditions offers a foundation on which to build culturally competent care.

Using the Ottawa Model of Research Use to implement a skin care program.

Addressing skin care issues requires a systematic and comprehensive approach. We used the pragmatic Ottawa Model of Research Use to guide the implementation of clinical practice guidelines in a surgical program of a tertiary care hospital. Assessments were made of existing clinical practice guidelines, the practice environment, and the potential adopters. With this information, we tailored strategies to address the barriers and to implement the guidelines. A formative evaluation demonstrated positive results.

A qualitative study of physicians' perceptions of three decision aids.

The study objective was to investigate physicians' perceptions of three patient decision aids (DA). Semi-structured telephone interviews were conducted with 20 family physicians and 12 gynecologists about a DA for women considering long-term hormone replacement therapy; with 16 respirologists about a DA for the use of intubation and mechanical ventilation for patients with severe chronic obstructive pulmonary disease; and with 19 physicians (geriatricians, gastroenterologists, internists) about a DA for long-term placement of feeding tubes in the elderly. Participants were identified by a snowball sampling technique. The interviews were analyzed using standard qualitative methods. Most participants (81%) indicated some willingness to use the DAs. The characteristics of the DA viewed positively included it being: balanced, well organized, a useful tool, evidence-based, improves decision making process and multimedia. Some of the negative characteristics were stated as: too complex, the cost, the availability, only appropriate for certain groups of patients, and time consuming. The DAs were acceptable to most participants. Perceived positive and negative factors were similar for all DAs. Uptake of decision aids may be facilitated if physicians have an opportunity to examine and try them, and if they can have unfettered access to them for distribution purposes.

A toolkit to facilitate the implementation of clinical practice guidelines in healthcare settings.

In the early stages of development and pilot implementation of the guidelines, it became apparent that organizations were struggling to identify ways to introduce and implement the guidelines. The majority of the pilot sites were providing education sessions to facilitate CPG utilization with little attention to other implementation strategies. Those charged with introducing the CPG into the clinical setting were soon faced with a myriad of implementation challenges for which they needed a solution. It became clear that a planned systematic approach to facilitate implementation of CPGs was needed.

Development and evaluation of a decision aid for patients with stage IV non-small cell lung cancer.

Although guidelines for treating stage IV non-small cell lung cancer suggest that the patient's values should be considered in decision-making, there are no practical tools available to assist them with their decision-making. OBJECTIVE: To develop and evaluate a decision aid that incorporates patient values. DESIGN AND SAMPLE: (1) Before/after evaluation with patients referred to a regional cancer centre. (2) Mailed survey of thoracic surgeons and respirologists in Ontario. INTERVENTION: An audio-tape guided individuals to review a booklet describing stage IV non-small cell lung cancer, its impact and possible coping strategies, treatment options, benefits and risks, and examples of the decision-making of others. Patients then used a worksheet to consider and communicate personal issues involved in the choice, including: personal values using a 'weigh-scale'; questions; preferred role in decision-making; and predisposition. MEASURES: (1) Patient questionnaires eliciting knowledge, the decision, decisional conflict and acceptability of the decision aid. (2) Physician questionnaires eliciting attitudes toward the decision aid. RESULTS: (1) Twenty of 30 patients used the aid in decision-making. Users thought that the aid was acceptable and significantly improved their knowledge about options and outcomes (P < 0.001), and reduced their decisional conflict (P < 0.001). (2) The majority of the 29 physicians who reviewed the decision aid found it acceptable, were comfortable providing it to patients and said that they were likely to use it. CONCLUSION: The decision aid is a useful and acceptable adjunct to personal counselling.