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Receiving accurate results is important for any medical worker, but with the evidence-based nursing fidelity of the results could be improved. As Brown (2013) points out, professional care providers should always consider what parts of practice can be performed better and how it will help the patient (p. 286). For this paper, the synopsis from the book Evidence-Based Nursing: The Research-Practice Connection will be used to analyze the study on guideline recommendations for post-stroke patients care.
What Was the Purpose of the Study?
The authors of the study stress out the importance of implementation, i.e. the transformation of evidence into practice. However, the implementation may be violated by the barriers that arise during the work. The authors name various barriers (lack of knowledge, outdated attitudes, inefficient systems, etc.) and point out that barriers can also be enablers (McCluskey, Vratsisas-Curto, & Schurr, 2013, p. 2).
As to clinical guidelines for stroke management, they sometimes can include various recommendations, so the clinicians have to choose one of them. The purpose of the study was to identify the local barriers and enablers that hinder or help the implementation of stroke guideline recommendations (McCluskey et al., 2013, p. 3). Common barriers were also presented. Lack of professional resources (articles, books, notes), poor clinical skills, no willingness to change the working process, and skepticism towards suggested recommendations were reported by the authors. These barriers are not questions per se, but rather research topics that the study addresses.
To successfully implement new recommendations, identification and discussion of the barriers are necessary (McCluskey et al., 2013, p. 3). The purpose of the study was not only to detect the barriers but also to obtain results from personal interviews rather than from surveys (McCluskey et al., 2013, p. 4). This is important because interviews allow a more profound look into the problem of barriers and enablers than surveys.
According to the authors, they had to determine what professionals knew about the existing research on guidelines, if they approved the practice changes that the research suggested, and if they were able to successfully follow the recommendations and implement the suggested interventions (McCluskey et al., 2013, p. 5). Regular coaching, audit, and feedback were used to bring in necessary practice changes, target the barriers and enablers that the professionals had to face during their work.
Who Participated or Contributed Data?
The following health disciplines participated in the study: occupational therapy, physiotherapy, and speech pathology. Additional disciplines that were also engaged in stroke patients care included nursing, orthoptics, and medicine. Geriatricians, rehabilitation specialists, neurologists, and registrars in training were also participants of the research (McCluskey et al., 2013, p. 4). To obtain data, the members met each weekday morning and weekly at conferences.
Twenty-eight participants were interviewed. The participants formed groups (up to six people) according to their discipline and were interviewed together. Only two participants were interviewed individually because they worked during different parts of the day (McCluskey et al., 2013, p. 4). The researchers were an occupational therapist with 30 years of clinical experience in stroke rehabilitation and a clinician with 11 years of experience in acute care and rehabilitation.
Twelve participants were doctors; five were occupational therapists. There were four physiotherapists and two speech pathologists engaged. Two registered nurses and two orthoptists were interviewed. Only one therapy assistant took part in the study. Fourteen participants were female, only two participants male. Nine participants had zero to five years experience working in stroke. Four participants have been working with stroke patients for six to ten years.
Zero participants had 11 to 15 years experience, and only three clinicians had more than 15 years experience in stroke (McCluskey et al., 2013, p. 6). Overall, nine participants had zero to five years clinical experience, only one participant had from six to ten years of clinical experience, two participants had ca. 11-15 years clinical experience, and four participants had more than 15 years clinical experience.
What Methods Were Used to Collect Data?
A qualitative study design was used to present data. The authors of the article used semi-structured focus groups to collect data for the research. Individual interviews were also available and conducted with the two orthoptists. All participants were employed at the same stroke unit in Sydney, Australia, so the results were easier to obtain (McCluskey et al., 2013, p. 3). All interviews continued for one hour and were conducted at the hospital; the meetings were moderated by the first and the second author. The second author provided notes about the speakers and their quotes. Audio-recording was not available due to problems with equipment.
Some of the participants did not wish to be recorded, so the second author took in-depth handwritten notes to summon data and information from the interviews. The questions considered the treatments that needed practice improvement, e.g. treadmill training, sitting balance, management of upper limb sensation, etc. (McCluskey et al., 2013, p. 4). During the interviews with the medical staff, anxiety and depression management, sexual functioning and driving were discussed. Moreover, evidence-based practice gaps were discussed with the staff; during the interviews, guideline recommendations and audit findings were engaged.
Barriers and enablers were also mentioned, and the authors, together with the participants, tried to find possible solutions. All these discussions were documented for future analysis (McCluskey et al., 2013, p. 5). After the first interviews had been conducted, the analysis of the data began. The Theoretical Domains Framework, developed for implementation in various disciplines, was used to analyze the data; all statements were divided into various categories of the framework (Cane, OConnor, & Michie, 2012, p. 2). Some statements could be allocated into two categories at first, but then, according to their content, they were placed in a particular category. Group members were encouraged to share their beliefs, thoughts, expectations or fears. The routines and attitudes of the staff were also discussed during the interviews.
What Were the Main Findings?
Three main findings were discussed by the authors. First of all, the barriers and enablers varied, depending on a profession (McCluskey et al., 2013, p. 11). Gaps in knowledge were expected and common, as well as the lack of some skills. Participants were able to identify effective strategies during their discussion of the working progress. At last, the study proved that evidence, clinical judgment, and patient circumstances are connected to each other (McCluskey et al., 2013, p. 11).
Some barriers that were detected include underuse of swallowing screening and neglect of discussions about post-stroke sexuality (McCluskey et al., 2013, p. 11). To overcome skill barriers, professionals needed to get acquainted with treatment protocols and take part in trials of effective intervention.
Depression screening was also often neglected (McCluskey et al., 2013, p. 12). As Kneebone, Neffgen, and Pettyfer (2012) point out, post-stroke depression may lead to suicidal thoughts or even suicide, so it is important for physicians to check the mental state of their patients and provide depression screenings (p. 1115). Patient circumstances were considered by speech pathologists who had not conducted any aphasia tests on non-English speaking patients (McCluskey et al., 2013, p. 12). These results show that behavioral change strategies are needed or even obligatory to improve the practice.
Study Findings vs. Clinical Practice Experience
I agree with the study findings because I have experienced some of the barriers myself. For example, speech pathologists admitted that aphasia tests did not pass to non-English patients with low education level. I would like to add that many cognitive tests written in English do not pass to non-English patients because they are too complicated for them to handle. Some patients cannot understand the prescriptions or the description of their condition.
This can also threaten their health in the future or lead to complications (Karliner, Ma, Hofmann, & Kerlikowske, 2012, p. 172). The taboo on sexuality is also what concerns me since it is a normal part of any human life and a good indication of possible health problems. However, not only patients are scared or embarrassed to discuss sexual problems but also physicians tend to avoid such topics (Weeks, 2013, p. 80). Patient circumstances are also often neglected, although they are sometimes as important as the right choice of medicine for the treatment. I believe that such guideline recommendations should be introduced in all hospitals to all professionals, no matter how long they are working in a given field.
References
Brown, S. J. (2013). Evidence-based nursing: The research-practice connection. Burlington, MA: Jones & Bartlett Publishers.
Cane, J., OConnor, D., & Michie, S. (2012). Validation of the theoretical domains framework for use in behavior change and implementation research. Implementation Science, 7(1), 1-17.
Karliner, L. S., Ma, L., Hofmann, M., & Kerlikowske, K. (2012). Language barriers, location of care and delays in follow-up of abnormal mammograms. Medical care, 50(2), 171-178.
Kneebone, I. I., Neffgen, L. M., & Pettyfer, S. L. (2012). Screening for depression and anxiety after stroke: developing protocols for use in the community. Disability and rehabilitation, 34(13), 1114-1120.
McCluskey, A., Vratsistas-Curto, A., & Schurr, K. (2013). Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study. BMC health services research, 13(1), 1-13.
Weeks, G. R. (2013). Integrating sex and marital therapy: A clinical guide. London, UK: Routledge.
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