Towards knowledge-based practice; an evaluation of a method of dissemination

Pergamon

Towards knowledge-based practice; an evaluation of a method of dissemination* KAREN A. LUKER, Ph.D., B.NURS MARIA KENRICKT, R.G.N., B.Sc.(Hons), M.Sc. fk/~rrrlrwrrfof ,Yur\i/r~. C’rriwr.\i/~ of Liwr/~oo/, P.O.Bos147, Lifwpoo/L6Y 3BX,(:.A’. Abstract-This paper describes a method for the dissemination of researchbased information to nurses. The approach involved the development and evaluation of a clinical information pack relating to the management of leg ulcers. The evaluation incorporated a preepost test two group experimental design, The samplecomprised 171 qualified community nursesworking in five health authorities. Data were collected by meansof two extensive questionnaires administered to groups of nurses. The study collected large amounts of descriptive data pertaining to nurses’ clinical practices in the care of this patient group. It also uncovered important factors. quite independent of leg ulcers, related to relationship between research and clinical practice, and the way information is disseminated to practitioners. These independent findings and their implications are discussedhere.

Introduction

There has been renewed interest in factors which influence nurses’clinical decisionsand the care that they give to patients or clients. This interest, whilst articulated in varied ways by different groups, has come under scrutiny because of fundamental changes in the culture *This paper was presented at the 2nd International Community I993 and a version was also presented at the 1st International Canada, September 1993. t Correspondence should be addressed to this author.

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in the Netherlands, April Research Conference in

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of the British National Health Service. The most notable changes are the introduction of a purchaser-provider split or market economy, and the refocusing of health care away from large hospitals and into primary health care settings (NHS and Community Care Act, 1990). It is not the intention to dwell upon the particular changes in the British Health Care System but rather to highlight some general points which are relevant to health care provision in the community. First, it needs to be said that in a situation of escalating costs where demand outstrips supply there is a need to examine alternatives and to make best use of limited resources. Second, Medicine is changing very rapidly in different fields and this is bound to have knock-on effects in terms of the development of skills and services in other health care disciplines, most notably Nursing. Third, there is a more deliberate attempt to bring objectivity into health care planning, and research has a key role to play in this. In England we now have a National Health Service Central Research and Development Committee (CRDC), with the explicit goal of working towards a “knowledge based health service” (Department of Health, 1993). Fourth, consumerism or the redesignation of patients and clients as consumers or service users with wishes that deserve to be respected, have focused the minds of nurses and other health care workers on issues of quality (Patients’ Charter, 1992). Against this background a number of pertinent questions are being asked concerning how we make best use of health care resources, and how we ensure a high quality of care for our customers. Health economists are coming to the fore and asking questions which take us back to basics like “Which treatments work and how do you change the behaviour of health care providers”? (Maynard, 1993). The focus of this paper is research-based information as a source of influence on community nurses’ practice. However, first it is necessary to set the scene by highlighting some key policy issues, since it is within this context that community nurses work. Policy context The important point here is that when service users views and costs containment are taken into account, the policy imperative is usually to treat as many people as possible in their own homes. Hence, Primary Health Care is very much centre stage, and the role of the Community Nursing Service is crucial to the success of any health care strategy. In the current economic climate we can expect an increased demand for community nursing services related to early hospital discharge, day case surgery, and an increase in numbers of people with chronic illnesses being treated at home. In addition, service users themselves may choose home as the preferred base for treatment. At the request of health care managers objective evaluations are being made of the contribution of qualified nurses to primary care: increased attention to skill mix, team work and greater accountability are inevitable consequences of this trend (National Health Service Management Executive, 1992). In an effort to improve the quality of health care, professional practice has come under scrutiny, and serious questions are now being asked concerning treatment inputs and patient outcomes. Practitioners are under an implicit and sometimes explicit obligation to demonstrate that they are acting according to the most up-to-date and available knowledge, and there is now an expectation that health care should be informed by research as well as practice-based knowledge. It has been said that one of the greatest weaknesses in the British NHS is its failure to disseminate and apply existing knowledge (Health Service Management, 199 1).

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and Research as a Source of Influence

Leaving aside the issuesof whether the findings of nursing research without further replication should be incorporated into practice, it can be argued that in theory research hasthe potential to be a source of inf luence on clinical practice. But the reality is somewhat different, and in many instancesthere is a gap between what is known and what is practised. There has been international concern expressedover the utilization of researchfindings by nurses(Champion and Leach, 1989; Hunt, 1987; MacGuire, 1990). Despite the fact that serious nursing research has been undertaken now for more that 40 years (Brown et u/., 1983), the influence of research on nursing practice has never been clarified. It appears that much practice is inspired by experiential rather than researchbased knowledge. The dissemination and use of research findings poses a challenge in hospital nursing (Lelean, 1982; Hockey, 1987). Since the community baseof district nurses makes them more remote from resource centres such as libraries, one might expect them to encounter more difficulties in accessingclinical update material. In addition the practice of nursesworking in the community is largely invisible, and they rarely have the opportunity for peer review, especially with regard to clinical procedures. Given that most community nurses are highly competent practitioners, it has to be borne in mind that their relative isolation may encourage the development of idiosyncratic practices which may not be shared. When reading the literature on the utilization of research findings in nursing one cannot help but be struck by the preeminence given to the role of individual practitioners, and the lack of emphasison contextual factors. The unspoken assumption is sometimesmade that if nurses had the relevant information available then they would use it. Whilst common sensedictates that information could be a precursor to action the evidence is more diverse. Stocking (1990) suggeststhat in order to change practice the wider climate of opinion has to be in harmony, and the practitioner who runs the risk of being ostracised for carrying out a new procedure will not be willing to experiment with clinical innovations. Studies which have addressedthe influence of information on clinical practice challenge the notion that information leads to action. Again Stocking (1990) reminds us that person to person communication is one of the more effective ways of changing practice; but this may not be an easy option in the community where somework basesare fairly isolated. A study by Mugford et al. (1991) reported in the British Medical Journal sought to establish what is known about the feedback of statistical information in changing practice. In total 36 studieswhich were designedto change clinical practice were subjected to critical review. These studies covered a wide range of clinical activities, someof which were directly relevant to nursing. The helpful distinction was made between active and passivefeedback. Active feedback is where clinicians already have an interest in the topic, for example: practice standards may have been agreed as part of an audit cycle, or the clinician may be engaged in a programme of continuing education. Passive feedback on the other hand involves the unsolicited provision of information with no explicit requirement for changing practice (Mugford et al., 1991). This review supports the notion that feedback of information is more likely to have an influence on clinical practice if it is part of an overall strategy which targets clinicians who have already agreed to review their own practice, with this in mind it is interesting to reflect on the role of audit in changing practice. In addition, it is likely that information feedback is more likely to have a direct effect on practice if it is presented close to the time of decision making. An important area not addressedby the work of Mugford et al. (199 1) relates to exploring

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the best format or media in which to present information. It is likely that we have much to learn in this respect from our marketing colleagues, since evidence exists which suggests that community nurses use the material supplied by drug company representatives as a regular source of clinical up-date (Luker and Kenrick, 1992). A study which was our first attempt at what might be termed practice development sought to identify how community nurses described their work and which factors influenced their clinical decisions; the main focus was on research-based information as a source of possible influence (this study reported in full, Luker and Kenrick, 1992). The fieldwork involved 47 community nurses working in four different health authorities. Data were collected over a 5 month period using a range of approaches including participant observation, interview, and analysis of nursing records. This study, whilst only exploratory, provided some useful insights which have informed our approach to the dissemination of information to community nurses. In brief, the nurses seemed to be aware of research as a potential source of practice-related information, but on the whole did not count research based knowledge as an important influence on clinical practice. Analysis of the interview data revealed that all nurses reported study days as the usual means of up-dating and these were classified by 76% (N = 36) as containing practice-based knowledge. Perhaps the most important lesson we learned from this data was that it is not a useful strategy to ask nurses to make a distinction between research-based knowledge and practice-based knowledge or scientific and experiential knowledge. This it seems is an artificial distinction imposed by outsiders on the work or clinical nurses. We fell into this trap because we were lured by the available literature cited earlier, which tends to articulate practicebased knowledge as separate and different from scientific knowledge. We would certainly advise others against following us down this infertile path (Luker and Kenrick, 1992). It is suggested that the pre-occupation with research utilization within nursing has served to exaggerate the problem sometimes referred to as the theoryypractice gap. It is argued that using the term research-based practice has in itself been a redundant professionalizing strategy on the part of nurses. Far from having the desired effects this strategy has served instead to divide the occupation of nursing into those who know about research and those who say they do not. The more straightforward approach pointed out by this work and reinforced by the contextual factors such as the emphasis now placed on quality assurance, would be simply to talk of significant clinical facts which are illustrative of good practice. This approach would assist in the demystification of research by presenting it as a servant to practice. In cases where practice is informed by research, it is likely that nurses view what they do anyway as good practice rather than research-based practice; in these cases it is suggested that the research findings have become reclassified as professional knowledge (Luker and Kenrick, 1992). Dissemination

and Application

For whatever reason there has been a refocusing of effort in nursing away from the research activity itself toward the question of research dissemination and application (Health Service Management, 1991). An industrial model of health care implies the investment of significant monies in the development of staff and the organization, with the end goal of improving the product or service to the consumer. In the U.K. for example, this has inspired nurses to experiment with clinical development units and other countries, for example Finland (Sorvettula, 1991) have directed effort towards research and development programmes. It seems that development work and not the research activity itself are popular

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approaches and are put forward as the means to improve patient care. But this goal may only be achieved if the development is underpinned by good science. Evaluating

A Model of Diffusion

Our approach to the development of a strategy for the diffusion of clinical information to community nurses was informed by our knowledge of the literature, which suggested that we should select a topic of importance or relevance to community nurses(Mugford et (I/., 1991). In our exploratory work it became evident that nurses were hungry for information as long as it had a direct bearing on clinical practice. Nurses in our exploratory study supplied us with a list of topics on which they required additional knowledge or information. The management of leg ulcers came high on the list as did the management of incontinence and pain. We chose the management of leg ulcers as an area through which we could develop and test our method of diffusion. This clinical topic was selected for the following reasons: l Prevalence of leg ulceration estimated at 1% of population l Up to 85% of patients managed in the community at a cost in excessof &1200per patient per year l Common District Nursing problem: estimated that more than 13% of nurses’ time spent caring for this patient group l Invisibility of District Nursing practice: therefore little processor outcome data available l Difficulties encountered by District Nurses in accessingclinical update material l Uncertainty as to what constitutes excellence in practice l Need for external standard against which leg ulcer care can be evaluated Given the treatment of leg ulcers was part of the everyday work of the community nurses in this study (National Health Service Management Executive, 1992), it meant that the information that we prepared could be viewed as in the active rather than passive mode (Mugford et al., 1991). The timing of the delivery of the information is important in terms of its influence on practice, in so far as information given near to the time of decision making is more likely to influence practice. Therefore, given the nurses’ daily contact with patients with leg ulcers it could be considered that we were maximizing the possible effectiveness of our clinical information. Presenting the Information

In our exploratory work we asked nursesabout how they preferred to receive information. Interestingly. research reports themselves were seen as obstacles to developing research based practice, in so far as the relevant information for practitioners was often buried in many turgid pages. We therefore invested a great deal of time in framing the presentation of the information, and using clinically credible language. In many respectsit could be said that our format resembled the structure of the nursing notes or Kardex, a simple but effective device. We were also conscious of the positive views expressed by some nurses towards the quality of the educational material produced by pharmaceutical companies; in view of this we tried to emulate their high standard of presentation. To this end we were successfulin securing an educational grant from a commercial company, which undertook to oversee the production of the leg ulcer clinical information pack (Kenrick et al., 1992). Clearly the theoretical content of the pack was of equal importance. Our task was to review the material in terms of its scientific merit and to distil the clinically useful infor-

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mation into a user-friendly form. We tried as far as was possible to avoid the use of unnecessaryjargon, and to use subheadingssuch as one would find in nursing notes to act as focal points, for example: l l l l l l

Establishing a diagnosis The nursing assessment Assessmentof patients’ general condition Ulcer related history and clinical investigations Examination of the ulcer Nursing treatment

We also usedfour colour photographs, which showed the progression in leg ulcer resolution from the state of necrosis, through granulation and eventual epitheliatization. The final section of the information pack was a summary of recommended practice. We did not include a description or review of the relevant research in the text, but instead included a list of references for those nurses interested in taking the topic further. For nurseswho preferred to listen to audio tapes we had the information pack read onto audio tape by a well known actor. We piloted the pack on 12 nurses selectedfrom the sample of nurseswho contributed to the exploratory study (Luker and Kenrick, 1992); the pack was revised in accordance with their comments. Method Of Evaluation Of The Information

Pack

The impact of the leg ulcer information pack on reported practice was evaluated using a pre-post test two group experimental design. In total 171 nurses in 5 health authorities responded to the pre-test, and 130 of these completed the post-test. The questionnaire was administered in a group setting and in addition to demographic data it sought information on the assessment,treatment and longterm management of patients with leg ulcers. Respondentswere also encouraged to identify constraints on their practice. The respondentsin the three experimental authorities (N = 146 pre-test, N = 109 post-test) were given the leg ulcer clinical information pack immediately after the pre-test questionnaire. The two control authorities (N = 25 pre-test, N = 21 posttest) were not given the information pack until after the post-test. The post-test was similar in content to the pre-test and both questionnaires were designed in such a way that it was possible to calculate an individual knowledge score for each respondent. Findings

The total number of pre-test questionnaires entered into this analysis was 171. There were 109 post-test questionnaires related to the experimental group and 21 to the control group. The pre-test knowledge scores are presented (see Fig. l), for the total sample (N = 171); these scoreswere not impressive; out of a possible total score of 62 the mean was 26, a percentage scoreof 42%. If the scoreis broken down to reflect the three dimensions of the questionnaire, namely Assessment,Treatment and General Knowledge, then the meanswere: 11, 9, and 5, respectively. The post-test was conducted approximately six weeks after the pre-test. In brief the information pack had the desired effect and the respondents’ knowledge scores in the experimental group improved from 26 points to 33 points (seeFig. 2). Using the paired ttest this result was highly significant (t value - 10.54, 2 tailed P < 0.000 95% C.I.5.1-7.5).

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I 62 Max 60-1 ------I 1 I so -I

Total Fig. 1. Mean

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Assessment Treatment Section of questionnaire pre-test

scores, whole

Gen.knowledpr

sample (n = 171).

lnterestingly the change in knowledge score was consistent across the three areas of the instrument, namely assessment, treatment and general knowledge. The control group on the other hand did not exhibit a statistically significant change in knowledge score (see Fig. 3) (t value 0.05, 2 tailed P < 0.963 95% C.I.-2.4-2.5). From this data we conclude that the use of clinical information packs has the potential to improve community nurses’ knowledge and reported practice on the management of leg ulcers. Further statistical analysis is underway, and interview data from key informants in the organizations is being analyzed to identify contextual factors which might explain the differences between health authorities. Constraints on Practice

In terms of constraints on practice the following were identified on the basis of pre-test data (N = 171). It is interesting to note that most of the factors highlighted in Table 1could be considered

0

Fig. 2. Mean

Total

Assessment Treatment Section of questionnaire

scores of pre-test:post-test

experimental

Gen knowledge group

(II = 109)

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10

n

Ki 8 s 5 20

Pretest Postest

5

0

Total

Fig. 3. Mean

Table

1, Factors

Treatment Gen. knowledge Section of questionnaire scores pre-test/post-test control group (n = 20). Assessment

constraining

practice

(multiple

response

Number of respondents

Constraint Patient non compliance Understaffing Consultant’s instructions Unable to get preferred products Caseload too big Too few resources Lack of experience in leg ulcer care

141 75 70 59 35 35 26

question) Proportion sample

of

82% 44% 41% 35% 20% 20% I5%

as beyond the control or sphere of direct influence of the average nurse. Improving a nurse’s knowledge base, with the longer term goal of improving the quality of care that patients or clients receive, is just one step towards a research-based health service. Given the factors identified below, we are keen to emphasise that changing practice is not just about changing individuals. As indicated in Table 1, constraints on practice transcend the individual practitioner. Much of the nursing literature places the responsibility for quality service provision upon the individual practitioner. However, the organization and policy context in which community nurses work is a major factor in creating the climate for good practice. and this is a responsibility that managers within organizations should be encouraged to take more seriously. Rewards need to be built into the system and obstacles removed, such that good practice is the easy option and not an up-hill struggle, as is so often the case for community nurses. Conclusion

In conclusion it should be emphasized that the important issueswhich emerge from this study are not specific to leg ulcers. We are not primarily trying to show that leg ulcers are being poorly treated, or that they could be treated better; even though both claims are consistent with the data. On the contrary, the choice of leg ulcers was almost arbitrary, any

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high volume activity would have been acceptable, and served the same function in terms of patentiating the experimental design. The important findings, which are quite independent of leg ulcers are these: first, we have shown that research-based knowledge can be used to directly affect the knowledge and reported practice of a group of nurses. Second, we have shown that this effect was achieved by presenting the research-based information in a particular way, which translated the knowledge into a form which had meaning for practitioners. Finally, the success of this model of knowledge diffusion depends not only upon available knowledge per se, but on packaging, marketing, presentation, and careful emulation of those authoritative forms of knowledge which the practitioner is already accustomed to. This approach has been shown to work. If we are serious in the U.K. about moving toward a research-based health service then there is a need to develop a strategy to assist nurses to achieve this goal. .4~~X-rlon’lc~c~yc~ttl~~t?~.~ -We would like to acknowledge

the contribution of Dr Nicola Cullum who shared her expertise in systematic review and leg ulcer management, and we also acknowledge the statistical advice provided by Dr Jane L. Hutton. Special thanks are due to all the district nurses and their managers who so willingly participated in this study. We are grateful to Convatec Ltd for the provision of an educational grant which covered the production costs of the leg ulcer pack and audio tape. The evaluation of the pack was made possible by a development grant from the Department of Health. Finally we would like to thank Rod Coombs for his extremely helpful comments on an earlier draft of this paper.

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