Meeting Report

Report on the 3rd Australasian Joanna Briggs Institute Colloquium for Evidence Based Nursing and Midwifery

Jane Brosnahan
Clinical Nurse Consultant, Centre for Evidence Based Nursing, Aotearoa, New Zealand

Catherine Tracy
Acting Director, Centre for Evidence Based Nursing, Aotearoa, New Zealand

PP: 61

Article Text

The 3^rd Australasian Joanna Briggs Institute Colloquium for Evidence Based Nursing and Midwifery was hosted by the Centre for Evidence Based Nursing Aotearoa in Auckland, New Zealand on March 4^th and 5^th, 2002. The theme of the conference was "integrating quality and evidence".

Professor Peter Davis, professor of public health, Christchurch School of Medicine, Otago University, was the first of the keynote speakers to present on the New Zealand Quality of Healthcare Study (Davis et al., 2001). The study is the first nationally representative survey of the impact of adverse events on the quality and safety of hospital care, and Professor Davis explained that analysis of the quantitative data had resulted in identification of the particularly vulnerable patient groups, he sited the elderly, as an example. He also described the work of his clinician colleagues who have completed a qualitative analysis to attempt to identify the particular areas of concern and the implications these render for training, support and practice. Adverse drug events and hospital-acquired infection were sited as examples of particular areas of concern clinically. Professor Davis admitted that the study was very medically orientated and needed to expand its focus to include nursing.

Professor Nicky Cullum, Director Centre of Evidence Based Nursing, Department of Health Studies, University of York, United Kingdom, firstly presented the recent study conducted with her colleagues investigating the use of research evidence in nurses' decision making (Thompson, McCaughan et al., 2001a; Thompson, McCaughan et al., 2001b; Thompson, McCaughan, Cullum, Sheldon, Thompson et al., 2001). This mixed methodology study investigated:

• the extent to which nursing involves making clinical decisions that require research evidence;
• the perception of nurses' as to the need for research to inform practice;
• the perceived barriers to access and use of research in practice;
• how do nurses access and use research based information?

Based in three large acute care case sites and three large community and primary care sites in the north of England, the study involved one hundred and eight interviews with nurses in clinical settings and one hundred and eight hours of direct observation of the interviewed nurses in practice. Documentary audit and Q methodological modelling of shared subjectivities among the nurses and regression modelling of associated demographics was also completed.

Results found that nurses were generally positive about the need for research to inform practice. Human contact was found to be the most useful source for decision making rather than information technology or text based information. Professor Cullum explained the four perspectives for useful information:

• Is directive or prescriptive
• Based on experience (especially for graduates)
• Supported by the organisation (Senior nurses)
• Blends experience with research and technology (more experienced nurses)

Three different perspectives were also described as to how nurses in the study accessed research. Firstly the desire for nurses to gain information from human resources. During the observational data collect nurses were rarely seen accessing text based resources or libraries for information. On the other hand referrals to clinical nurse specialists or 'link nurses' to access information was far more common, and the longer nurses had worked in a specialty the more likely they were to access information in this way. Local information was the second perspective identified, as local experts were seen as in touch and accessible, although some nurses commented that local experts might not be up to date with research evidence. Most areas had locally compiled resources and specialised areas such as the Coronary Care Unit was found to be more likely to have locally produced protocols and less than half of these referred to the research evidence. The final perspective noted on access to research was the move towards technology. Those adopting this perspective found accessing local guidelines, protocols and online databases (MEDLINE/CINAHL) relatively simple, however the perception of librarians was they were not a resource for clinical problem solving but rather for use for consultation for continuing practice development educational activities.

The four barriers to research utilisation were listed as:

• Lack of confidence in interpreting products of research
• Organisational and cultural barriers
• Lack of prescription, direction and clinical credibility
• Individual scepticism

Professor Cullum also presented the audit results of four thousand documents, of which they found only 42% had a traceable heritage and had an average age of 5 years and only 10% had an explicit evidence base. In conclusion she stated that nurses do make the kinds of decision which are amenable to research, however many do not recognise research as a strategy for dealing with clinical uncertainty instead as a tool for assisting with gaining educational achievement. And that nurses lack the confidence and the skills for research retrieval, appraisal and utilisation. Human sources of information remain important especially senior nursing roles such as nurse specialists. She then went on to make the following recommendations:

• Nurses need to learn to identify uncertainty and strategies for decision making
• Nurses need to be taught to use research as a tool for practice not vice versa
• Senior nursing roles should be supported in their role as information brokers.
• There is a need for pre-appraised information for example guideline, systematic reviews, evidenced based journals.
• Decision support systems need to be developed for nurses.
• The role of opinion leaders in nursing needs development and evaluation.
• More clinically relevant to nursing, research is needed.

On the second day of the conference Professor Cullum gave a presentation entitled "Finding the evidence". She presented a strategy for focusing questions from nurses' clinical practice. She demonstrated some of the available sources of pre-appraised research available to nurses, www.evidencebasednursing.com and www.clinicalevidence.org. She then followed through a worked example of a search for valid research using a specific clinical question and the 4S approach progressively moving through the following steps until valid evidence is found:

• Search evidence based journals for synopsis of a valid, up to date systematic review
• Search The Cochrane Library for a valid, up to date systematic review
• Search evidence based journals for synopsis of primary research e.g. RCTs
• Search Medline, CINAHL, Cochrane Library (Cochrane Controlled Trials register) for primary research

The third of the keynote speaker was Associate Professor Linda Johnston, The Victorian Centre for Nursing Practice Research and The Royal Children's Hospital, Melbourne, Australia, who firstly discussed the limited the evidence for evidence based practice. Evidenced based clinical practice was described as decision making by clinicians using the best evidence available, considering patient preference through consultation and available resources. She acknowledged that it is generally recognised that the most appropriate research methodology for determining the effectiveness of an intervention is a randomised control trial (RCT). And to evaluate the effectiveness of evidence based practice in improving outcomes of interventions this study design should be used. In the past there has been a major lack of RCT studies published on nursing interventions and this resulted in very few meta-analyses of nursing practice, however Dr Johnston demonstrated via a search of CINAHL and MedLine that this is improving. She also acknowledged diversity of nursing research methodologies as a contributor to the broader context of improving health outcomes. In her second presentation Dr Johnston shared her experience of the 'pearls and pitfalls' to teaching evidence based practice. In particular the Victorian Centre for Nursing Practice Research programme for clinically-based nurses, which is a Clinical Research Fellowship program designed to support nurses in the development of skills in searching for and appraising current best evidence and the implementation of such evidence in routine practice. The program forms the basis for the Australian State of Victoria's Department of Human Services funded seminar series for the health disciplines. These seminars are complemented by a series of internet-based case scenarios designed to assist clinicians in the use of the comprehensive on-line resources already developed by the Department www.clinicians.vic.gov.au. Dr Johnston also explained the Centre's plans to collaborate with the University of Nottingham in the United Kingdom in the development of an internet-based evidence based practice paper for postgraduate students.

The final keynote speaker was Professor Maralyn Foureur, Victoria University of Wellington, New Zealand, and Clinical Professor Capital Coast District Health Board, who discussed the link between evidence and quality health care. She particularly focused on the impact that the cycles of major structural change have on the quality of care that nurses and midwives can deliver. Invited speaker Mr John McArthur, Clinical Services Manager, Dunedin Hospital, New Zealand examined evidence based health care and quality from the managers' perspective. He outlined the importance that evidence based practice should be integral to all levels of decision making in health, for example the direction of health expenditure on interventions based on proven clinical outcomes. Mr McArthur explained that the convergence of evidence based practice and quality through guideline development, clinical audit and pathway analysis has also increased clinicians interest in examining systems of care has exposed the lack of an evidence base for quality programmes. This has posed problems for managers. Management decisions are rarely evidence based, there is a lack of research for management decisions, there is also a deficit of skills to access and assess the research that does exist on management and there is a lack of commitment to evidence based practice on the part of many managers.

The key message was that the use of research evidence and 'evidence' from within organisations will assist managers in more effective actions and projects by using evaluation concepts to plan management interventions (Ovretveit, 1998).

Associate Professor John Buchanan, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand another of the invited speakers discussed the concepts of quality evidence and audit.
He firstly discussed the concepts in terms of the varying definitions of each depending on the environment and who is defining them. He used the Institute of Medicines definition of quality of healthcare "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current, professional knowledge". Clinical audit he advocated, is about improving the quality of care by addressing the question "are we following best practice?" He then explained the information from which assumptions can be made about quality of care has been classified by Donabedian under three categories – structure, process and outcome. But before quality assessment can be made there must first be knowledge about the links between structure and process. Clinical audit can involve measuring of standards relating to structure, process and outcome but clinical audit is not designed to establish the presence of a relationship between the three and standards in general focus on process. The clinical outcomes, although monitored to ascertain that they stay in acceptable limits, are often beyond the clinicians control.

Dr Buchanan stated that clinical audit is a systematic critical analysis of the quality of healthcare and as such embraces the work of all healthcare professionals. Therefore, there is a need to achieve consensus locally about best practice so that the standards for such an analysis care able to be disseminated with evidence based practice.

Mr Ron Paterson, New Zealand's Health and Disability Commissioner also addressed the colloquium on his work as the commissioner and his view on how complaints and patients' rights can be a catalyst for improving the quality of nursing care that patients' receive.

He explained the commission's mission to firstly educate by promoting the rights and responsibilities of consumers and providers and secondly to resolve complaints through fair processes and credible decisions to achieve just outcome. He referred to several high profile recent enquiries into health organisation and the anonymised reports of past cases on the web-site www.hdc.org.nz. to illustrate how the commission contributes to quality in the New Zealand Health system.

Free papers
The following is a brief summary of each free paper presented at the colloquium.

Identifying consumer participation through a medical record review
PATTERSON K, Maxwell S, Sorensen R, Coyle B, Degeling P, Zhang K, Crookes P, Shorten A
Centre for Clinical Governance Research
University NSW Dept of Nursing
University of Wollongong
This paper was academic work in progress that will be completed in 2002.
Four Queensland Public Hospitals with Obstetric services were reviewed in March and April 2001 to examine the hospital medical record as a quality tool for evaluating evidence of consumer participation in women electing to have a caesarean section in public hospitals. The method was medical record audit triangulated with clinician and consumer survey and an environmental review. The samples included random sample of 158 medical records; purposive sample of consumers and clinician/managers. A review of current literature along with Commonwealth and Queensland Health policy documents was also completed.
The environmental review was conducted by systematic collation of evidence of intention and enactment within the clinical setting for consumer participation, through Interview, observation/field notes and the medical record audit.
The Medical Record and Clinical Practice Review combined the results of the medical record audit for quality and overt/implied evidence of consumer participation; self-report survey of work practices; and clinician survey.
The Consumer Perspective Survey was gained from both a postal survey and telephone interview.
The results of the study found that consumers could only be defined as passive participants in the organisations reviewed. The emphasis remains on organisational defined outcomes rather than consumer focussed. Processes intended to incorporate the consumer in designing and evaluating their healthcare are marginalised by a lack of systemisation and incomplete documentation in the clinical setting. The Hospital Medical Record in its current use and format is an inadequate source of evidence of consumer participation. The implications of the study are that by systematising access, accuracy and completeness of the medical record, the propensity for evidence-based practice in clinical decision-making will be enhanced.

The Endless Cycle: Integrating Evidence And Outcomes Through Action Research
Robert COOK¹, Cameron Mayne^{1, 2}, Tania Lawrence², Dawn Nusa^2
1The Canberra Hospital
²University of Canberra Research Centre for Nursing Practice
The Neuroscience Unit nurses at Canberra hospital found standard hospital policy for managing aggressive behaviour to be contextually inappropriate and impracticable for the care of patients suffering traumatic brain injury. Neuroscience Unit staff therefore collaborated with the Research Centre to improve practice outcomes for the traumatic brain injured patient through policy development.
Action research methods were used to: identify current and best practice in the management of aggressive behaviour in patients with traumatic brain injury; establish an evidence based strategy for managing the aggressive behaviour; and formalise the evidence based strategy in a best practice framework through policy development.
The project involved repeated cycles of planning, action, observation, and reflection, the Neuroscience Unit nurses gathered evidence of best practice; and explored controversial unexamined aspects of their own practice; and transformed their findings into improved practice through participatory policy development. A best practice workshop led practitioners to reflect on their current practice.
Regular planning meetings, literature searches, and interdisciplinary expert consultation clarified issues and identified management strategies that were then formalised in a unit-specific policy. Neuroscience Unit staff gave feedback on the draft policy, and a final version was ratified for use. An interdisciplinary investigative team used the pragmatic, bottom-up approach of action research to directly improve patient care outcomes through the discovery of new knowledge. Quality and research were therefore complementary, integral, and indispensable parts of the same process. Importantly, the participatory and interdisciplinary nature of that process allowed practitioners to 'own' knowledge and evidence that was contextually meaningful and practicable. The project was funded by the NRMA-ACT Road Safety Trust.

Using The Evidence To Improve Quality In Residential Aged Care
Dean GEMMILL
Good Shepherd Aged Services Inc.
Melbourne, Australia
A quality system was implemented into three Australian aged care facilities followed by a two-year evaluation of its effectiveness with regards to resident satisfaction, ongoing self-assessment, and internal auditing of care standards.
Scant research has occurred in regards to the successful establishment of a quality system in residential aged care facilities and the inherent benefits this has for resident care and staff morale. This research aimed to establish a quality system, which was responsive to providing contemporary, individualised resident care.
The quality system was based around a resident centred care model.142 residents, relatives and 90 staff participated in focus groups, internal audits of care standards and satisfaction surveys to identify areas for improvement and recommendations towards improvement of the quality system over a two-year period. The overall satisfaction of residents was maintained over a two-year period with 180 improvement requests actioned as a result of focus groups, internal audits, satisfaction surveys and contemporary care practices being maintained and improved.
The findings support the application of a quality system in providing contemporary care standards that is driven by a commitment to resident centred care and residents reporting ongoing satisfaction with care.

Getting Evidence Into Practice: A Survey Of Nurses' Perceptions Of The Barriers And Facilitators To Research Utilisation In Practice
Alison HUTCHINSON
University of Melbourne, Melbourne, Australia and
Royal Children's Hospital, Melbourne, Australia
Increasing calls for evidence based practice highlight the nursing research-practice gap, and draw attention to our limited knowledge about the influences on nurses' utilisation of research findings in practice.
Nurses working at a tertiary Melbourne hospital were surveyed in order to elicit their opinions regarding the barriers to, and facilitators of, research utilisation in their practice. The tool used for the survey was titled the BARRIERS Scale (Funk et al., 1991), this survey was developed in the United States and has been utilised extensively around the world.
The survey was administered to all nurses working in the organisation. The sample of 317 nurses (45% response rate) were asked to rate 29 barrier items on a 5-point Likert scale and then nominate what they believed to be the top three barriers to research utilisation. In addition, they were asked to rate eight facilitator items on the same 5-point Likert scale and again were asked to nominate which items they believed to be the top three facilitators to research utilisation.
Among the findings, the top three barriers were identified as insufficient time to implement new ideas, not enough time to read research and lack of cooperation from physicians to implement new ideas. The top three facilitators were nominated as increased time available for reviewing and implementing research findings, conduct of more clinically focused and relevant research and improved understandability of research reports. These results, consistent with those of international studies, should be seriously considered when promoting the future development of evidence based practice in nursing.

How Bereavement Follow-Up Impacts On Quality Of Practice
S CUTHBERTSON
Auckland Hospital
Auckland, New Zealand
Deaths in intensive care are commonly unexpected and shocking for the family. In 1995 the bereavement follow-up service was commenced.
Six years of bereavement follow-up interviews have been reviewed accessing the prospective bereavement follow-up database and comparing 1995 findings to the subsequent five years. Changes to practice as a result of this continuous audit include specific bereavement education, training of a bereavement team and findings are reported in bi-monthly. Other improvements resulting from the service include: communication systems and skills; specific cultural issues addressed; improved written information; and early bereavement issues resolution. Next-of-kin's value attributes of the staff such as compassion, caring, consideration and the way information provided.
Incorporating bereavement service into critical care practice ensures the continuous quality loop is maintained and provides staff with pertinent feedback and skills to meet families needs during this difficult time.

Improving Patient Outcomes In Cardiac Surgery Through Preoperative Nursing Intervention
Kylie DOWNES, Karen Oliver
The Canberra Hospital
Canberra, ACT, Australia
An extended length of stagy (LOS) than benchmarked was identified for patients' post Cardiac Surgery through data collection since July 2001.
It was identified that some factors which directly influence patient outcomes and therefore LOS could possibly be eliminated with the introduction of a comprehensive nursing assessment, intervention and education in the pre-admission phase of care. This information is the basis for developing a comprehensive nursing assessment, intervention and education tool.
Data has been collected on patients undergoing surgery covered by specific Diagnostic Related Groups (DRGs) pertaining to Cardiac Surgery, initially through retrospective collection and later by prospectively. The data collection incorporated the following: Type of operation; Coronary Artery Bypass Graft Surgery (CABG); Coronary Valve Surgery and CABG plus Valve Surgery; Surgeon; Date of Admission/ Surgery/ Expected Discharge/ Actual Discharge; Reasons for Delay in Discharge; Clinical Field – INR stabilisation; fever; unstable rhythm; poor mobilisation; wound inflammation/ infection/ breakdown; diabetes stabilisation; other; social field – lives alone, poor social supports; demographic field – local versus interstate.
Initial findings were presented to the conference which did not specifically relate to the original hypothesis, but rather illustrated a broader range of issues that will need to be addressed. These issues are planned to be addressed after a prioritisation of the areas of greatest need is completed. The introduction of a pre-operative nursing assessment could still be a valuable tool.

Smoking cessation strategies for hospitalised patients in the acute care environment – results of an integrative review of systematic reviews
Richard WIECHULA, Craig Lockwood
Royal Adelaide Hospital, Adelaide
Smoking has been identified as the primary cause of avoidable death and disease when compared with other drugs. To identify best practice related to smoking cessation for hospitalised smokers. We reviewed all English language published systematic reviews on the effectiveness of smoking cessation strategies and presented the results in a combined narrative summary. Screening systems, Assessment strategies, Intervention programs, specific clinical interventions and follow-up assessment strategies.
Smoking cessation, smoking reduction, withdrawal symptoms, weight gain and intervention-specific side effects. Based on the JBIEBNM protocol for Integrative Reviews, databases where the content was primary and secondary research were searched. Methodological quality assessment and data extraction were conducted using JBIEBNM tools. Data synthesis was by narrative summary. 36 systematic reviews were identified, 21 were excluded or had been superseded by recent reviews. The effectiveness of screening strategies, advice giving, type of clinician involved, self help treatments, individual and/or group counselling, intensity of advice/counselling, aversion therapy, complimentary therapies, and pharmacotherapy are highlighted.
The problem of smoking cessation is a complex one that requires a systematic and multifaceted approach. A range of interventions and strategy alternatives are strongly supported by research based evidence. Programs of multiple interventions including an appropriate pharmacotherapy with advice and support tailored to the individual, are most likely to achieve success. These interventions can only be effectively applied if there are systems in place to effectively and consistently screen, assess and follow up patients who wish to quit.

Teaching Or Preaching: Evidence-Based Practice In The Classroom
Jackie CRISP, Donna Waters
Nursing Professorial Unit
Sydney Children's Hospital
Randwick, Australia
Evidence based practice (EBP) remains a minor component of undergraduate curricula. This paper argued that current educational approaches based on 'how to do research' are not only superficial and unsatisfactory for advancing EBP but also fail to provide students of nursing and midwifery with an adequate schema for using research in practice. A discussion of alternate approaches to conceptualizing and teaching EBP aims to challenge the basic dogma of nursing education.
A National Review of Nursing Education was conducted in Australia during 2001. This presents a unique opportunity to challenge the current strategies, direction and curriculum content of nurse education. EBP is often 'tacked-on' to curricula and taught from a limited perspective, using a language that is foreign to students. Despite this, nursing and midwifery graduates are expected to be competent evidence-based practitioners. While current arrangements may have increased the research capacity of an elite few, the research base for much of clinical nursing remains undeveloped.
The move of nursing into higher education has clearly not been the catalyst for research activity and evidence integration that was hoped for. The apparent inability of current educational approaches to develop research capacity in nursing indicates that the teaching of EBP may require a different approach. This paper poses a challenge to curriculum developers and educators to reflect on what, when and how EBP is introduced in order to provide nurses with the best learning experiences and appropriate schema for integrating evidence into their role.

Ensuring quality in aged care residential facilities: Examination of the relationship between clinical care indicators and quality of life of residents living in aged care facilities
Mary Courtney, Helen Edwards, Joyce Stephan, Cate DUGGAN, Maria O'Reilly
School of Nursing
Queensland University of Technology
Brisbane, Australia
In view of the increases in life expectancy and adding numbers of older people utilising residential aged care, there is a need to improve the quality of care and promote an optimum quality of life for older people.
To identify, develop, trial and evaluate a consistent approach to measuring and recording clinical care indicators and quality of life measures in residential aged care. Nominal groups with stakeholders have been conducted to help develop quality of care indicators. Over 35 participants were involved, representing key stakeholders and players in the aged care industry. Focus groups were also undertaken to further explore quality of life issues for the residents of aged care facilities.
Data collected from the nominal groups has been incorporated into developing a clinical indicator tool.. Piloting the tool is underway with a nation-wide validation of the tool to follow. Data from the focus groups have been used to guide the selection of an appropriate tool to measure indicators of quality of life for the residential aged care recipient. Collecting clinical care data, currently not routinely collected, will provide a quantifiable, objective measure that can be recorded, compared and benchmarked on a national scale, providing a pro-active way to demonstrate baseline evidence of improved quality of care.
The project is also taking the innovative step of involving the residents of aged care facilities in the project. Currently, there is little evidence of consumer views being sought, an essential component of a resident-centred model of care

Preventative Pressure Management Framework
Beth McERLEAN, Lesley Jeffers
Repatriation General Hospital
Daws Road, Daw Park
Adelaide, SA 5142, Australia
Patient safety is a core value and central to the developed clinical governance framework at Repatriation General Hospital (RGH). Commitment to the protection of the patient from for-seeable harm requires the creation and continual evaluation of systems and processes of work to ensure that the care provided is satisfactory, consistent, responsive and effective.
RGH has recently developed a comprehensive pressure prevention management framework that focuses the attention of the nurse on: the identification of risk factors associated with pressure ulcer development; communication of the risk to other health care workers; implementation of evidence based targeted interventions associated with the identified risk; continual evaluation of individual and organisational success; and lastly appropriate documentation to describe the risk, interventions undertaken and outcomes.
The framework was developed from a wide review of the literature, an evaluation of the patient groupings specific to the hospital and an understanding of the culture of nursing at RGH.
Introduction of the framework required an intensive staff education and information process. However, the process was considered vital to the sustained success of the framework as ensuring that staff have an adequate and current level of knowledge and the correct skills to provide the best care forms one of the most important elements in promoting quality care for patients.
Success of the framework has been measurable. We have seen greatly increased numbers of patients being identified at risk on admission resulting in a decreased incidence of pressure ulcer development.

The Appropriate Prescribing Of Hormone Replacement Therapy
H ROBERTS
The New Zealand Guidelines Group
The New Zealand Guidelines Group commissioned the Effective Practice Institute (EPI) of the University of Auckland to facilitate the updating of a 1993 document on hormone replacement.
Several events prompted the need to revisit the original recommendations of this report. The principal reason was the publication of the results of the Heart and Estrogen/progestin replacement study (HERS) study in 1999, which brought into question the 1993 recommendations about the use of Hormone Replacement Therapy (HRT) for the prevention of heart disease. A recent New Zealand survey has shown that the use of HRT to prevent coronary heart disease increased from 13% in 1991 to 25% in 1997. The decision was also made to examine the evidence in areas such as depression, sexuality and skin to provide guidance for women and practitioners considering the use of HRT for such conditions. This survey had also reported that a substantial number of women were using HRT for mood and skin benefits.
For each symptom or condition, evidence for the effectiveness of HRT was sought from systematic reviews, meta-analyses or randomised controlled trials (RCTs). Where no evidence from these sources was available, evidence from large cohort or case control studies was evaluated. The evidence was ranked according to a system trialed by the Scottish Intercollegiate Guidelines Network (SIGN).
The key messages from this best practice, evidence based guideline regarding the benefits were summarised as: HRT is not recommended for routine use in the menopause; decisions about the short-term (<5 years) use of HRT for the treatment of climacteric symptoms should be made separately from decisions about the long term use of HRT for the prevention of osteoporotic fractures; HRT is the single most effective therapy for the management of troublesome hot flushes and night sweats (A); there is insufficient evidence that HRT improves cognition or prevents or delays Alzheimer's disease; HRT is contraindicated for the secondary prevention of coronary artery disease (B); there is insufficient evidence at present of benefit or harm from HRT for the primary prevention of coronary artery disease (D); short term HRT use <5 years) does not increase the risk of breast cancer diagnosis. Longer term HRT use (>5 years) may be associated with an increase in breast cancer diagnosis but it remains uncertain if mortality from breast cancer is affected (B).
The guideline is available from the New Zealand Guidelines Group web-site at www.nzgg.org.nz.

The Marriage Of Medical Audit And Quality Assurance Produces Better Patient Care
Carol CHAMLEY, Dr Colin McArthur
Auckland Hospital
Auckland, New Zealand
Auckland Hospital Quality Assurance Service is a medical auditing programme based on an Australian model, which derived from the Australian Health Care Study1. Auckland Hospital is the largest tertiary teaching hospital in New Zealand that services a population of 1.5 million.
The programme aims to identify breaches in standards of care, adverse events and medical error.
Quality Care Reviewers (who are required to be Registered Nurses) firstly review the flagged case notes. Issues of concern are then taken to medical staff where specific questions are then generated to be raised during their Specialty audit meetings. Full disclosure by the Clinicians then often generate process changes to improve patient care. AHQAS and senior medical consultants including a clinical leader then provide peer review and feedback.
This process has legal privilege for medical staff but as in New Zealand currently have no legal protection from disclosure they were excluded from the programme for their safety.
Examples of issues investigated and the positive outcomes that were achieved are a new medical appointment, extended recovery care along with improvements in protocols and clinical pathways. There have been difficulties both in implementing and maintaining the programme.
The benefits of this internal auditing service allow for a non-blame approach to quality assurance and improving patient care within a public hospital.

Central Venous Catheter Dressings: A Systematic Review
Donna GILLIES, Libba O'Riordan, Debbie Carr, Ida Cacouratos, Judy Frost, Robbie Gunning
The Children's Hospital
Westmead, Australia
This study took place to identify whether there were any differences between gauze and tape and transparent polyurethane film dressings in relation to central venous catheter-related infection, catheter-related septicaemia, catheter security, tolerance to dressing material, dressing condition and ease of application in the hospitalised population.
The Cochrane and Ovid databases, bibliographies of studies, reviews, conferences proceedings and any product information were searched to identify trials comparing dressings for central venous catheters. In total, 20 studies were selected for review.
Fourteen studies were excluded. In nine of these studies, further data was required but could not be obtained. Four studies had major confounders and one study was excluded because the outcomes differed from the review definition. The study also included a subgroup analysis between adults and children as these groups may differ in outcomes.
Of the six included studies, two compared gauze and tape with Opsite IV3000®, two compared Opsite® with Opsite IV3000, one Tegaderm® with Opsite IV3000, and one compared Tegaderm with Opsite. There was no evidence of any difference in the incidence of infectious complications between any of the dressing types compared in this review. However, each of these comparisons were based on the findings of no more than two studies. In addition, all studies reported data from a small patient sample. Despite the high number of studies identified in this review, no conclusions regarding the risk of infectious complications with these dressings for central venous catheters can be made until further rigorously conducted trials are conducted. It is particularly important that future studies measure the incidence of catheter-related sepsis and site colonisation. This review is currently being developed into a Cochrane Review with the Wounds Review Group.

A Multidisciplinary Approach To Fatigue Management In Newly Diagnosed Cancer Patients
Ann MITCHELL
Nursing Research Centre/Queensland Centre for Evidence Based Nursing and Midwifery
Brisbane, Australia
Fatigue is one of the most common side effects of cancer treatment. It can be so debilitating that patients are significantly restricted in their everyday activities and may cut short their regime or cease their treatment altogether. Unfortunately, fatigue is over-looked, under-recognised and under-treated, particularly when it is not anaemia related.
The objective of the project was to implement and evaluate a multifaceted fatigue management program (FMP) that aimed to educate patients and staff, monitor and compare fatigue (using the BFI and Fact-AN) and haemoglobin levels, and provide patients with coping strategies. A convenience sample of nurses and doctors in the Cancer Division of an acute Metropolitan Hospital, and newly diagnosed cancer patients commencing chemotherapy (aged over 17years), were recruited to this action oriented study. Interventions included a pre-post staff survey and education and a fatigue management program. Data from the staff surveys were analysed descriptively and thematically, whilst data from the FMP were descriptively and statistically analysed.
Interim results from the 38 patients highlighted a number of issues including, the diversity of symptomatology, the benefit of a multidisciplinary approach to managing cancer treatment related fatigue, an increased awareness of fatigue as an issue, and increased referral amongst health care professionals. The effectiveness of the multidisciplinary collaboration was also evident. Based on the interim findings, supportive care and education about fatigue deserve active inclusion in cancer treatment, and that there is a need for greater recognition of the role this plays in improving patients' quality of life and outcome.

Parents Of Hospitalised Children: Contributing To Evidence Based Paediatric Nursing Practice
Prabha RAMRITU
Queensland Centre for Evidence Based Nursing and Midwifery
Brisbane, Australia
As consumers of nursing care provided to their sick children, parents provide valuable evidence on quality of care provided and ways to enhance that care.
Two research studies in which parents were primary sources of evidence were described. The implications of the findings in promoting evidence based paediatric nursing care was also identified.
Seventy-five parents of children having a tonsillectomy or adeno-tonsillectomy recorded the intensity of their child's pain, dietary intake, any disturbances to sleeping patterns and incidence of vomiting for 13 days following discharge. In another study, 90 parents of children hospitalised for at least one night completed a questionnaire to describe their experiences of participation in their child's care. Data recorded following surgery provided valuable evidence for use in information provision to parents in management of children at home. Evidence of areas in which nursing care can be improved was identified. Findings of the study into parent participation in children's care provided evidence of types of care that parents preferred and did not prefer to provide.
Methods of improving nursing care were identified, such as allowing parents a choice rather than expecting them to provide some aspects of care, and maintaining the vital parenting role during hospitalisation. Findings of both research studies validated some aspects of current paediatric nursing practice and consolidated practice with supportive evidence from the consumer's perspective. Findings of the two research studies have shown that parents play an important role in promoting an evidence based paediatric nursing practice.

Awareness While Unable To Move In The ICU
Deirdre O'DALY
Department of Critical Care Medicine (DCCM)
Auckland Hospital
Auckland, New Zealand
Awareness under anaesthesia in the operating room is rare but often devastating. The extent of this awareness in ICUs is unknown. To determine the recalled experience while unable to move in the ICU, a routine clinical audit attempts to contact surviving DCCM patients at approximately eight weeks after transfer. The conduction of a structured telephone interview was attempted (providing both quantitative and qualitative data) with the 2,758 DCCM survivors who had been admitted from 1/1/1998 to 31/12/2000.
Contacted patients were asked, "Can you remember being unable to move, not even your little finger while you were awake and aware of your surroundings?" Those who did remember were asked to rate the subjective stress of the experience on an ordinal scale (0 none 10 maximum) and to describe their experience.
Data were secured on a secure local area network within the organisation. In the three-year period, 1745/2637 hospital survivors (63%) were interviewed; 59/1745 (3.4%) reported being aware and unable to move. Reported stress ranged from 0 (12 patients) to 10 (8 patients) the median was 8. Thirty-seven patients described their experiences. Most common descriptions were: overhearing conversation (11), attempting to eye-open and/or scream (10), fear of being dead or dying (7), recalling procedures (4), and out-of-body experiences (3) including one who thought his brain was in a glass jar outside his body.
Awareness whilst unable to move, while uncommon in the ICU is a real and often horrific experience for some patients. Intensive care staff need to be vigilant to this problem.

Fall Prevention
Grace Yee-mei CHENG, Sui-han Chan
Queen Elizabeth Hospital
Hong Kong SAR, China
In view that patient fall accounted for over 93% of the patient accidents in an acute hospital with 2000 beds, a fall prevention program was implemented and an evaluation study was conducted in parallel to evaluate the effectiveness of the program grounded upon evidence-based framework.The program aimed to promote awareness of nurses in prevention of patient fall through a systematic approach in identifying patients at risk, standardizing prevention strategies and constant tracking of incidence rate.
A literature review was performed regarding fall risk assessment and preventive strategies. Based on available evidence, the Morse Fall Scale was adopted. The fall prevention protocol was designed and a standardized care plan was formulated. Information about the programme was disseminated through forums and lectures to clinical staff. The program was piloted and implemented in clinical departments in phases.
Quantitative and qualitative data of falls were retrieved from care plans, incident reports and evaluation surveys. Hospital statistics such as monthly falls rate, nurse count and number of patient days data were also utilised. Continual evaluation was carried out through audits. The falls rate decreased significantly with implementation of the program. No significant correlation was found between the falls rate and the nurse count and number of patient days in the hospital as a whole, yet correlation was revealed in individual departments. Preventive measures perceived effective by nurses were different from those frequently documented in care plan. Audits revealed discrepancies between standards and practice
. The falls prevention program was effective in reducing patient falls environmental variables and consistency of practice were influential factors.

The Timing Of Intravenous Line Changes: A Systematic Review
Donna GILLIES¹, Libba O'Riordan¹, Margaret Wallen¹, Karen Rankin¹, Anne Morrison¹, Sue Nagy²
The Children's Hospital, Westmead¹
The School of Nursing, Family and Community Health
University of Western Sydney, Australia²
The objective of this review was to determine the optimal time interval for the routine replacement of intravenous administration sets when crystalloids or parenteral nutrition are administered via a central or peripheral catheter.
The Cochrane Controlled Trials Register and Ovid databases (– July 2001), bibliographies of reviews, studies, conferences proceedings and product information were searched to identify trials addressing the frequency of replacing intravenous administration sets. The twelve included studies were separated into line changes every 24 hours compared to line changes at intervals of 48 hours, line changes every 48 hours compared to 72 hours, and line changes every 72 hours compared to 96 hours. Data was collected for the outcomes, infusate-related contamination, infusate-related sepsis, catheter-related contamination, catheter-related sepsis and mortality. Subgroup analyses were performed on studies that included patients with central lines and studies that included patients receiving parenteral nutrition.
Good evidence was found that supported changing intravenous administration sets at an interval of 72h that this does not increase the risk of infusate-related sepsis in patients with peripheral or central lines although data regarding the risk of catheter-related sepsis was less conclusive. There was insufficient data regarding the incidence of sepsis in patients receiving parenteral nutrition and in particular, lipid-containing parenteral nutrition. It appears that central or peripheral administration sets containing crystalloids can be changed at an interval of 72h without increasing the risk of sepsis. However, it is not possible to conclude that lines which contain parenteral nutrition can be changed at this interval.
This review is currently being developed into a Cochrane Review with the Anaesthesia Review Group.

Management Of Behaviours Of Concern Among Residents Of Nursing Homes: A Clinical Guideline
Rhonda Nay, Sam Scherer, Anne PITCHER, Susan Koch, Michael Browning, Leon Flicker
The Royal Freemasons' Homes of Victoria, and
La Trobe University
Melbourne, Victoria, Australia
There is a high incidence of behaviours of concern among nursing home residents which are problematic because they are disruptive and intrude upon staff and other residents. The aetiology of these behaviours is diverse, however, a diagnosis of dementia appears to be the most common contributor. Several different behaviours of concern have been identified by researchers, each of which has consequences and detrimental effects on residents and staff.
The objective of this research project was to develop a multidisciplinary clinical guideline based on the best available evidence for the management of behaviours of concern in nursing home residents. The instrument was to be used in assisting staff with the identification and assessment of challenging behaviours and their causes, and also provided a guideline for effective evidence based strategies for their management.
The guideline was developed from a systematic review of the literature and in consultation with an expert reference group. It was developed from the premise that behaviours of concern are 'need-driven' and it guides assessment in view of these unmet needs. The guideline sets out evidence based strategies for initial safety management, and subsequent interventions for longer term management. It also provides guidelines for counselling and debriefing of staff after traumatic episodes.
The clinical guideline which has been developed informs the process by which the multidisciplinary health team assesses, evaluates and implements strategies in caring for nursing home residents who display behaviours of concern.

Reducing Restraint Usage
Beth McERLEAN
Repatriation General Hospital
Adelaide, SA Australia
Commitment to the protection of the patient from foreseeable harm requires the creation and continual evaluation of systems and processes of work to ensure that the care provided is satisfactory, consistent, responsive and effective. Analysis of incident data identified that 37% of patients who fell over bed-rails injured themselves. This, together with 3 near miss incidents, and an audit result of 5.5% incidence of physical restraint usage and a 28% incidence of bed rail usage prompted Nursing Services at RGH to explore the use of physical restraint in more detail.
In response RGH has developed a comprehensive "least restrictive" physical restraint management framework that focuses the attention of the nurse on:

• The implementation of alternative strategies to support challenging behaviour;
• The provision of restraint alternative or least restrictive equipment;
• The provision of adequate monitoring and care interventions; and
• Review and evaluation mechanisms.

Introduction of the framework required an intensive staff information process as we were required to challenge staff's core belief's – "restraining the patient was keeping them safe". By supporting staff through the implementation process and including ward staff in the development of the framework itself, a widespread cultural change has been achieved The success of the framework has been measurable. A decrease in the incidence of physical restraint usage did lead in the beginning to an increase in the number of falls but not an increase in the number of injuries. However, the concomitant development of falls prevention strategies and the promotion of a patient safety culture has seen a decrease in fall rates over time.

Commentaries In Evidence Based Nursing: New Zealand Vs Australia
Andrew JULL
Centre for Evidence Based Nursing Aotearoa
Auckland Hospital
Auckland, New Zealand
The purpose of this study was describe Australasian commentators and commentaries in the abstract journal Evidence Based Nursing.
A descriptive design was used and the sample includedll Australasian commentators currently listed on the database of potential commentators held by Evidence Based Nursing and all commentaries published by Australasian commentators since the journal's inception.
Method of data collection involved retrieval of all records of commentators that were described by country, qualification, highest level of education, areas of expertise, and organisational affiliation. Commentaries published between January 1998 and October 2001 were described on the same basis.
Results indicated that since 1998 Evidence Based Nursing has published 384 abstracts and commentaries, 24 every issue. During that period, Australian nurses have published 11 commentaries and New Zealand nurses have published 5 commentaries. In 2001, Australia was reported as having 158,100 registered nurses and New Zealand 29,154 so publication rates favour New Zealand. In conclusion, commentaries published in Evidence Based Nursing are dominated by the northern hemisphere, principally nurses from Canada, the United States of America and the United Kingdom. The southern hemisphere is inadequately represented both in the published commentaries and the lists of commentators.

The patient and clinician g.u.i.d.e.: a model for generating, utilising interdisciplinary evidence into daily clinical practice
A FOGARTY, H MURDOCH, G Han, L Pan, B Sun, M Chen
Auckland District Healthboard
Auckland, New Zealand.
The Clinically Integrated System (CIS) is a computerised interdisciplinary model that links the philosophies of evidence based practice; clinical redesign; outcome management and participatory action research together to form a single framework for managing patient care. The evidence-based component of the CIS Model has evolved at a rapid pace as clinicians have begun to understand the importance of having relevant guidelines to support their decision making process.
The objective of the project is to identify and utilise evidence based practices based upon academic studies, clinician expertise and patient preferences. A two dimensional approach for implementing and analysing evidence based practice is used.
The process involves hyperlinking documents to each activity of patient care delivery established within the clinical setting. If the activities of patient care delivery are established within a clinical setting a hyperlink documented is linked to each activity. This document contains information on issues such as: the recommended practice, source of evidence, and references. The recommended practices contained in these hyperlinks are further modified into short statements that can be directly downloaded into individual patient notes. A tracking system is initiated resulting in a direct link between the recommended intervention and the patient outcome. Previous perceptions that complications equated to bad practice have been challenged with the provision of direct links between the evidence and patient outcomes.
This system provides clinicians with meaningful data that can immediately highlight practices that are very effective in the prevention or management of adverse outcomes. Directly linking evidence based practice to patient outcomes.

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