Engaging clinicians in evidence based policy development: The case of nursing documentation

Diana Jefferies
Adjunct Fellow, School of Nursing and Midwifery, University of Western Sydney, and Project Officer, Centre for Applied Nursing Research, Liverpool NSW

Maree Johnson
Research Professor, School of Nursing and Midwifery, University of Western Sydney; Director, Centre for Applied Nursing Research, Sydney South West Area Health Service, Penrith NSW

Rhonda D Griffiths
Head of School, School of Nursing and Midwifery, University of Western Sydney, Penrith NSW

Kathy Arthurs
Flight Nurse, Royal Flying Doctor Service, Alice Springs NT

David Beard
Director of Nursing and Midwifery Services, Westmead Hospital, Wentworthville NSW

Tanghua Chen
CNC Vascular Surgery, Liverpool Hospital, Liverpool NSW

Maureen Edgetton-Winn
CNC-ICU Liverpool Hospital, Liverpool NSW

Tony Hecimovic
Nurse Practitioner, Community Acute Post Acute Care, Prairiewood Community Health Centre, Fairfield Hospital, Prairiewood NSW

Margaret Hughes
CNC-Area Mental Health, Sydney South West Area Health Service, Liverpool NSW

Karen Linten
CNC 3, Cardiac Services, Liverpool Hospital, Liverpool NSW

Julie Maddox
Tresillian Family Care Centres, Belmore NSW

Damien McCaul
CNC, Missenden Unit, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW

Kim Robson
CNE/S, Paediatrics, Canterbury Hospital, Campsie NSW

Shelley Scott
CNS (Orthopaedics), Bankstown-Lidcombe Hospital, Bankstown NSW

Tina Zarkos
Royal Prince Alfred Hospital, Camperdown NSW

PP: 254 - 264

Abstract

A lack of consistent policy direction, revealed by a review of nursing and midwifery documentation, presented researchers with an opportunity to engage clinicians in the process of evidence based policy development. By utilising the framework informed by both practice development and the principles of evidence based practice, clinicians were taken through an education program and a series of activities to develop their skills in discerning how research evidence and other literature can inform policy development.

The clinicians' involvement maximised their investment in the final policy. Clinicians synthesised all the evidence associated with nursing and midwifery documentation and produced a set of seven guiding principles that formed the basis of an area wide policy for nursing and midwifery documentation.

The strength of this approach to policy development was that the clinician's experience ensured that the concerns of the clinicians were included in the policy. Difficulties in completing tasks outside meeting times were highlighted.

Keywords

nursing, documentation, policy development, practice development, communication, evidenced based practice

Article Text

Strategies designed to encourage the uptake of research into clinical practice have demonstrated only a modest (≤10%) to moderate (>10% to ≤ 20%) effect (Cheater et al., 2006) in changing practice. A systematic review published in 1998 showed that the most common methods of disseminating research evidence were ineffective because clinicians were not engaged in an active learning process. Clinicians were receiving information passively through publication of consensus conferences in journals, the mailing of educational materials, and didactic lectures (Bero et al., 1998). According to other writers, the best method of implementing research evidence into clinical practice is to engage clinicians in professional communities and social networks (Dopson et al., 2002).

A Clinical Development Group (CDG), consisting of interested clinicians, was established in a metropolitan health service. The purpose of the CDG was to engage clinicians in the process of examining research evidence and developing policies to produce a quality improvement in nursing practice throughout a large area health service. This paper describes the process of developing an evidence based policy by engaging clinicians in an active learning process of accessing and assessing the evidence, as well as acting as consultants so that policy development remained relevant to the local context.

The integration of evidence based approaches to policy development and practice change within organisations has resulted in some refinement of the processes. The St. Luke's Evidence Based Practice Model describes discrete stages of practice change. These stages are the identification of a problem, clarification of the clinical issue, literature review, research analysis, and evaluation of findings. If a need to change practice is demonstrated, the model requires an evaluation of feasibility including the designing of a practice change strategy, the pilot testing of the strategy, and the measurement of the change (Anderson et al., 2009). Policy or guideline development is central to this process. Thomas (2007) describes the stages of guideline development as the selection of the topic, composition of the development group, defining the scope of the guideline, systematic review of the literature, formation of recommendations, consultation and peer review, dissemination, implementation, audit, and review (Thomas L., 2007). Osborne and Webster (2005) define the characteristics of ‘effective clinical guidelines' (p. 185) as being: outcome-focussed; based on the best available evidence or evidence that demonstrates a link between recommendation and outcome; combining the evidence with the strongest method available; development by multidisciplinary teams and consumers; flexible and adaptable to local conditions; considerate of resource limits; thoughtful of the target audience; reviewed regularly; and evaluated for effect, value, validity and usage (Osborne and Webster 2005). Taking all these approaches into consideration, this paper outlines a strategy used to develop a policy relating to nursing and midwifery documentation and focuses on the methods used to support this change in practice.

Nursing and midwifery documentation as a focus for change:
Nursing and midwifery documentation is an essential component of the nurse's or midwife's care of their patient. However, documentation is also an aspect of care that many nurses and midwives find burdensome (Staunton and Chiarella, 2008). Confusion about what is required in nursing and midwifery documentation has resulted in numerous changes initiated by legal precedent and public enquiries. Quality nursing and midwifery documentation not only protects the nurse or midwife if they are required to explain their care, but also improves patient care outcomes. Quality nursing and midwifery documentation facilitates the continuity of care by keeping all members of the health care team informed of the patient's condition and care (Gebru et al., 2007).

The impetus to change arose from a review of patient safety incidents. A retrospective audit of root cause analyses of Incident Information Management Systems (IIMS 1st April 2003 to 30th September 2004) exposed the lack of an area wide policy on nursing and midwifery documentation (Middleton et al., 2007). Further analysis of the documentation found that although aspects of care such as hygiene, family visits, and mobility were recorded, it was difficult to establish the patient's physiological state and response to treatment. Consultation with senior nursing management described current nursing and midwifery documentation as recording a series of tasks the nurse had completed for the patient rather than a description of the patient's condition or their response to care received. The description of documentation being primarily a lists of tasks performed by the nurse was verified by another study reported in the literature (Gregory et al., 2008). Thus, nursing and midwifery documentation was identified as an issue that had organisational relevance and importance (Kitson et al., 1996). This organisational importance and relevance ensured that the CDG project had the support of senior nurse managers in the area health service (Rycroft-Malone et al., 2004a). Participating clinicians were supported to attend regular meetings and to complete tasks while they were rostered on duty (Rycroft-Malone et al., 2004a, Newhouse et al., 2007).

Describing the strategy
We sought to use a strategy that blended attributes of systematic review and guideline development with aspects of Practice Development (PD) to develop change agents or champions to promote evidence based practice change in the clinical setting.

PD is an imprecise term and its meaning continues to be a matter of debate. In 1994, Kitson et al. described PD as a strategy by which identified or appointed change agents used research evidence and clinical experience to work with clinicians to implement change and innovation (Kitson et al., 1994). In 1999, McCormack et al. expanded Kitson's and others' original definition to include the notion that PD produced cultural change in the clinical context by instituting a continuous process of improvement towards person centred care (McCormack, 1999). A further recent theoretical development put forward by Wilson and McCormack in 2006 emphasised how PD empowered clinicians to use their knowledge and expertise to identify solutions to problems in the clinical setting through the use of skilled facilitation (Wilson and McCormack, 2006). Looking at each of these definitions, three elements were identified as the core of PD: first, using evidence, second, changing practice and culture, and third, empowering clinicians to improve the care of the individual patient by supporting clinicians to identify solutions to clinical problems.

PD was selected as an appropriate strategy to implement research evidence into clinical practice because it encouraged clinicians to take leading roles in all aspects of the process (FitzGerald and Solman, 2003). PD employs facets of Action Research in its approach because it encourages clinicians to participate in a collaborative and participatory framework (Garbett and McCormack, 2004).

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