Chapter 4 Critical inquiry and practice development

Brendan McCormack, Jackie Crisp

LEARNING OUTCOMES

Mastery of content will enable you to:

• Define the key terms listed.

• Recognise the place of ongoing inquiry in nursing practice.

• Appreciate three levels of nursing inquiry: active engagement in everyday practice, ongoing evaluation of local nursing practices, and production and refinement of nursing knowledge through research.

• Recognise the role that practice development plays in stimulating and supporting all levels of inquiry.

• Understand how a PEEP framework—People, Effects, Environment, Praxis—forms a useful organising structure when thinking about different broad domains of nursing inquiry and the integration of the products of inquiry into effective nursing practice.

• List the characteristics of systematic practice evaluation and research processes.

• Understand how different research methodologies and methods are relevant to different research questions and provide different kinds of knowledge for practice.

• Explore different issues surrounding the translation of evidence into practice.

Being effective as a nurse is a constant state of ‘becoming’; that is, being an effective clinical nurse requires continuous development of the self and of practice through critical inquiry. This requires understanding in two interrelated areas. The first is the different ways that nurses need to engage in ongoing inquiry into practice; the second is the ongoing development of nursing practice produced through the integration of new knowledge and understandings.

All nurses, therefore, need the skills to:

• inquire into, and learn from, their own practice

• evaluate local data or information

• access and evaluate the relevance of existing research to their practice, and

• determine the most appropriate ways of making use of evidence in practice.

The majority of nurses will not necessarily undertake their own research projects, although many will be involved as collaborators or participants in research undertaken by others. All nurses do, however, need to reflect critically and systematically on their own practice, work with others to assess the effectiveness of local nursing practice and use the findings of research undertaken by others in the continuous development of that practice (Box 4-1).

BOX 4-1 THREE LEVELS OF NURSING INQUIRY

1. Critical engagement in everyday practice through systematic reflection on processes and outcomes, for example critical reflection on practice undertaken by individuals or groups

2. Collaborative and ongoing evaluation of local practices, for example quality-enhancement projects undertaken by a nursing unit

3. Nursing research for the production and refinement of nursing knowledge, for example researching the effect of a specific nursing intervention on the outcomes of patients with a specific illness

The process of developing the knowledge and skills required for critical inquiry can be overwhelming at times. If that happens to you, we urge you to stay engaged in the learning process and to work with others, provide each other with challenge and support and strive to continue to develop your knowledge and skills. To assist you in the early stages of this journey, this chapter provides material that will help organise some of the complexity and provide some foundational understandings of the nature of nursing inquiry and its role in the development of effective nursing practice.

This chapter explores processes for engaging in critical inquiry as a nurse requiring an understanding of different forms of knowledge, and an understanding of how nurses must work with knowledge critically and translate that knowing into practical action. To achieve that goal we have divided the chapter into three major sections.

The first section draws out the main features of three levels of nursing inquiry:

1. critical engagement in everyday practice through systematic reflection on processes and outcomes

2. collaborative and on-going evaluation of local practices

3. nursing research for the advancement of nursing knowledge.

The second section outlines contemporary ideas around practice development and its place in creating person-centred cultures that enable nursing inquiry and continuous integration of new knowledge into nursing practice. The third section is organised according to the PEEP framework—People, Effects, Environment and Praxis. This framework provides a means of thinking about broad domains of nursing inquiry (People, Effects and Environment), and the integration of new knowledge into nursing practice (Praxis) (see Box 4-2). Within the first three of these four domains (PEE*), we discuss the methods used for both evaluating local nursing practices and undertaking nursing research. Discussion of the fourth domain (***P) focuses on the integration of knowledge through praxis.

BOX 4-2 THE PEEP FRAMEWORK

P People involved, their experiences and their preferences

E relevant evidence of the Effects of nursing practice

E the local Environment or contextual realities of practice

P Praxis as a means of learning and evolving practice actively

Three levels of nursing inquiry

This section provides material that we hope will convince you that nursing inquiry is a part of everyday practice; not, as some would argue, simply the domain of academics or senior clinicians/managers who bear the major responsibility for nursing research. The view that nursing inquiry = formal nursing research projects denies a world of learning and development that is crucial for the provision of effective nursing care.

• CRITICAL THINKING

Think about the kind of information that you feel confident to hold as ‘factual’ and the kind of information that you are less confident about. How easy is it to track the origin of the things that you believe to be true?

Inquiry involving critical engagement in everyday practice

Every experience of working with colleagues and patients is an opportunity to engage with an inquiring mind in order to learn and develop your nursing expertise. This day-to-day practice inquiry and learning is enhanced through critical reflection. Critical reflection can be undertaken by individuals, or by groups of nurses who challenge and support each other to become more self-aware and take action in relation to improving the clinical knowledge, skills or attitudes they require to provide the best possible nursing care.

Reflection

The link between reflection and learning has been around for a long time. According to Boud and others (1985), the process of reflection occurs by returning to an experience and recalling salient events. Dewey (1933) believes that the function of reflective thought is to:

transform a situation in which there is experienced obscurity, doubt, conflict, disturbance of some sort, into a situation that is clear, coherent, settled and harmonious.

The work of Donald Schön (1983, 1991) has been highly influential in the development of reflective practice. He believes that the professional clinician needs to develop ways of understanding the unpredictable, complex everyday world of practice in order to learn from it. Schön also emphasises the need for a safe environment in which reflective conversation can be held.

Jack Mezirow’s (1991) work in reflective practice is significant because it addresses one of the most important aspects of learning for adults; that of perspective transformation. Transforming perspective about practice and about the self is a central objective of guided reflection (McCormack and Johns, 1998). This involves a process of becoming critically aware of how and why our assumptions about the world in which we operate have come to constrain the way we see ourselves, our relationships with patients and our practice.

Mezirow (1991) argues that there are two ways of achieving perspective transformation. First, one can develop a sudden insight. This sort of mirror imaging often occurs when one is faced with a situation that is so challenging that it creates doubt about previously held assumptions. An example of this would be realising in a conversation with a patient that we hold a particular belief or value system that influences the way we respond to the patient’s particular circumstances.

The second way perspective transformation can be achieved is by proceeding through a series of transitions whereby one revises previously held assumptions about oneself and others until a stage occurs where the assumptions are transformed. Mezirow describes six levels of critical reflectivity that assist in this process (Box 4-3). While their hierarchical nature can be criticised, the levels can be of use within the reflective process if they are seen as reflective foci rather than hierarchical levels. In this way they can be used as a means of reflecting on one’s development as a reflective clinician.

BOX 4-3 THE LEVELS THAT MEZIROW DESCRIBES

Reflectivity—having a level of awareness and being able to observe and describe

Affective reflectivity—awareness of how we feel about ourselves and how we think and act

Discriminant reflectivity—awareness of the process of decision making and the effectiveness of our perceptions

Judgmental reflectivity—awareness of value judgments and assumptions made in our practice

Conceptual reflectivity—awareness and understanding of the concepts involved in decision making and the identification of the need for further learning

Theoretical reflectivity—using experience to generate theories. Awareness of how practice is influenced by theory. Recognition of the various forces that influence our perceptions, thoughts and actions

Experiential learning and action

Experiential learning is viewed by Revans (1983), Pedler and others (1991) and McGill and Beaty (1995) to be a more viable alternative for adults in a constantly changing environment than traditional education methods. Inextricably linked to experiential learning is the resultant action. Revans (1983) describes action learning as ‘learning by doing’ and a social process: ‘those who try it learn with and from each other.’ He believes this learning occurs more effectively in small groups (with structure and discipline) than in simple pairs. Revans (1983) believes that action learning is not about teaching. He differentiates between what he calls ‘programmed knowledge’ found in books or passed on by experts and ‘questioning insight’ which engages experience. Like Revans, Pedler and others (1991) emphasise the importance of the action element of action learning: ‘there is no learning without action and no sober and deliberate action without learning.’ Action learning enables the art and the science of nursing to be articulated and made real for the practitioner through the facilitation of reflection on their practice. This reflection enables the practitioner to embody (internalise and make real from one’s own perspective) complex knowledge and theory that would otherwise feel alien and disconnected to the realities of practice.

Professional nursing practice is an art form in itself—a form that is created and recreated with every interaction. However, like all artists, professional nurses have core elements that transcend all relationships, interventions and activities. These are largely hidden to the gaze of the novice clinician; and like any work of art, the first viewing reflects the finished product. It is only through repeated inquiry into the product (and multiple products) that the hidden dimensions of the finished product are revealed. The process of uncovering the hidden dimensions is facilitated by collaborative learning. Several collaborative approaches have been identified as effective in assisting in this process: critical companionship (Titchen, 2003a, 2003b), clinical supervision (Ghaye and Lillyman, 2000), active learning groups (Redmond, 2004) and action learning sets (Wilson and Keachie, 2003), to name but a few. These approaches are collaborative in nature.

In collaborative learning experiences, there is no distinction between knowledge generators and knowledge users. Instead, the process of deconstructing and reconstructing practice experience results in a shared learning that enables individual learning, the development of effective practice and cultural change to occur in parallel.

Inquiry involving collaborative and ongoing evaluation of local practice

All nurses should work with others in the organisation to evaluate the effectiveness of their practice; this may involve you in any of the stages outlined in Box 4-4. The aims of all healthcare services should include continuous improvement in the quality of care provided to service users. Quality of care is a broad concept that is inclusive of aspects such as accessibility, efficiency, effectiveness, safety, and responsiveness to consumer needs. Evaluation of the ongoing improvements in the quality of nursing practice will, therefore, involve comparison of current practice with past performance, and evaluation of current practice against established standards or best practice.

BOX 4-4 STAGES IN CLINICAL AUDIT CYCLE

STAGE 1: IDENTIFY THE FOCUS, PRACTICE, PROBLEM OR ISSUE

This stage involves the selection of a focus for the audit. This selection may be influenced by:

• stakeholder (patient feedback)

• areas where problems have been encountered in practice

• where there is a clear potential for improving practice

• areas of high volume, high risk or high cost, in which improvements may be made.

STAGE 2: DEFINE CRITERIA AND STANDARDS

The overall purpose of the audit should be determined and the specific questions that require answers should be written; these form the audit criteria. The criteria define what is to be measured and what can be measured objectively. A standard is the threshold of the expected compliance for each criterion, usually expressed as a percentage.

STAGE 3: COLLECT DATA

Data to be collected may already exist in a clinical information system, or a new data collection system may need to be developed.

Ethical issues must be considered; the data collected must relate only to the objectives of the audit and staff and patient confidentiality must be respected.

STAGE 4: COMPARE PERFORMANCE WITH CRITERIA AND STANDARDS

This is the analysis stage in which data are compared with criteria and standards and conclusions drawn in relation to how well the standards have been met.

STAGE 5: IMPLEMENT CHANGE

The results of the audit are published and discussed and an action plan developed to record recommendations.

RE-AUDIT: SUSTAIN IMPROVEMENTS

After an agreed period, the audit should be repeated.

Clinical audit involves ongoing cycles of continuous improvement, each of which includes stages that follow a systematic process of:

1. establishing best practice

2. measuring current practice against the established criteria

3. taking action to improve care

4. monitoring to sustain improvement.

Adverse occurrence screening and critical incident monitoring are crucial components of continuous quality improvement. Peer review of cases which have caused concern or from which there was an unexpected outcome is undertaken by a team of clinicians. The goal of this critical analysis is to identify what went wrong and to find ways of preventing similar events in the future. This is sometimes called a significant event audit.

Peer review involves assessment of the quality of care provided by a clinical team with a view to improving clinical care. Individual cases are discussed by peers to determine whether the best care was given. This is similar to the method used for critical incidents, but is not restricted to problematic cases.

Patient surveys and focus groups are methods used to obtain users’ views about the quality of care they have received. In addition, patient stories of their experiences of care can be obtained and reviewed by clinicians seeking to develop deeper understanding of the experiences of patients in their unit or ward.

Evaluating local nursing practices requires the use of approaches that engage practitioners in assessing the processes and outcomes of their practice. Many of these approaches are synonymous with reflection (discussed above) and collaborative inquiry (discussed below). Ongoing practice evaluation contributes to both the development of local practice and the development of workplace cultures where research is valued. Through practice-based evaluation, new avenues for engaging differently in practice can be explored and compared with established external research evidence. For example, while there may be strong international evidence about a particular nursing practice, the way this evidence translates into practice may vary across contexts (Estabrooks and others, 2008; Øvretveit, 2011). Evaluation of models of care, communication, assessment practices, record keeping and multidisciplinary relationships will all help to inform the best use of the evidence. Therefore, we need to use systematic and rigorous approaches to exploring, making sense of and evaluating our everyday practices. Research methods have much to offer us in this respect.

• CRITICAL THINKING

What do you think would be the major barriers to clinicians exploring the experiences of the patients receiving care on their ward? How do you think regular clinical audits might overcome some of those barriers?

Inquiry involving nursing research for advancement of nursing knowledge

Approaches used in nursing research

Nursing researchers use a wide range of research approaches (methodologies and methods), many with their origins in disciplines such as sociology, psychology, epidemiology, anthropology and history. Selection of the appropriate research approach is based both on the intention that the researcher has in mind in undertaking the research and on the specific question to be addressed within the research (Table 4-1). Some research approaches, for example, focus on providing a deeper understanding of the experiences of people and their interpretations of those experiences (see Box 4-5); others focus on measuring the extent to which a particular nursing intervention achieves a desired outcome in order to establish the effects of nursing practice (see Table 4-2). Other research approaches are more concerned with bringing about and researching sustainable practice change in particular environments (see Box 4-6).

TABLE 4-1 INTENTION OF THE RESEARCH AND TYPES OF RESEARCH QUESTIONS ASSOCIATED WITH QUANTITATIVE AND QUALITATIVE DATA ANALYSIS

PURPOSE OF RESEARCH	QUESTIONS FOR QUANTITATIVE DATA AND ANALYSIS	QUESTIONS FOR QUALITATIVE DATA AND ANALYSIS
Identification		What are the phenomena?
Description	How frequent are the phenomena? What are the characteristics of the phenomena?	What are the dimensions of the phenomena? What is important about the phenomena?
Exploration	What factors relate to the phenomena? What are the antecedents of the phenomena?	What is occurring with the phenomena? What is the process by which the phenomena are experienced?
Explanation	What are the measurable associations among the phenomena? What causes the phenomena? Does the theory explain the phenomena?	How do the phenomena work? Why do the phenomena exist? How did the phenomena occur?
Prediction	What will happen if an intervention is used? If phenomenon X occurs will Y follow? How can we make the phenomena happen? Can the phenomena be controlled?

BOX 4-5 APPROACHES USED FOR PEEPING AT PEOPLE

NARRATIVE RESEARCH

This approach is concerned with the interpretation of stories told by individuals in normal conversational situations and involves the in-depth study of personal stories, of those receiving care or of those involved in providing that care. These stories provide insights into the meanings attached to experiences of nursing and healthcare, and are often a rich source of data for identifying improvements needed in care processes, service delivery models and organisational structures and processes.

PHENOMENOLOGY

The focus of phenomenology is what people experience in regard to daily practices or experiences and how they interpret those experiences. The goal of this type of research is a full description of the experience of patients, their perceptions of how these events happened, how they and others made decisions, the meaning of those decisions to them and, finally, how these events have shaped their lives from their perspective.

HERMENEUTICS

Hermeneutics is another form of research that seeks to understand the meanings that people attach to experiences, events and practices. Unlike phenomenology with its focus on describing the meanings people attach to experience, hermeneutic research attempts to interpret these meanings by breaking down each experience into parts and exploring these in the context of the whole experience. Originally used by the Greeks as a method of interpreting texts, hermeneutics is concerned with bringing to understanding the nature of the social world from both the subjective interpretation of the individual and the more general meanings abstracted from individual interpretations.

GROUNDED THEORY

Grounded theory is an approach to collecting and analysing data which has the aim of developing theories and theoretical propositions that are grounded in real-world observations. That is, the goal is development of a theoretical explanation for behaviour observed in qualitative investigations.

TABLE 4-2 DESIGNS USED IN RESEARCH FOR PEEPING AT EFFECTS

GOAL OF RESEARCH	DESIGN LABELS USED TRADITIONALLY IN NURSING RESEARCH	CONTEMPORARY CLINICAL EPIDEMIOLOGICAL DESIGN LABELS
Describe—what is going on?	Descriptive: qualitative or quantitative data	Prevalence
Identify relationships—are factors related?	Correlational	Incidence Case series Before-and-after studies
Test causation—do interventions work?	Quasi-experimental Experimental Integrative review	Cohort Case-control Randomised controlled-trials Multi-site randomised controlled trials

BOX 4-6 APPROACHES USED FOR PEEPING AT ENVIRONMENT

ETHNOGRAPHY

The focus of researchers using an ethnographic approach is deep understanding of the social perspective and cultural values of a particular group by participating with or getting to know their activities in depth and in detail. Ethnography is founded on the idea that a system’s properties cannot be understood in isolation.

CRITICAL ETHNOGRAPHY

The focus of critical ethnographers goes beyond describing ‘what is’ to asking ‘what could be?’ There is no one accepted definition, but in general the approach has a political purpose: of seeking the empowerment of their ‘subjects’ through raising awareness of the structures and processes that maintain inequalities and oppression (Madison, 2005).

ETHNONURSING

The focus of researchers using an ethnonursing approach is the shifting of nurses’ views from the emphasis on medical disease and a perception of reliance on research methods associated with medicine. This approach was developed to help form holistic pictures of cultures through examination of shared cultural care values, meanings and modes of action; leading eventually to the identification of transcultural care concepts. The major goal of ethnonursing is to understand the diversity and universality of care (Leininger and McFarland, 1995).

CRITICAL INQUIRY

Critical inquiry involves using various modes of inquiry and perspectives or methodologies to conceptualise, investigate, derive meaning, challenge taken-for-granted assumptions and generate actions for changing the status quo and the power imbalances reflected within social structures and systems (Manias and Street, 2000).

ACTION RESEARCH

Action is participatory research that focuses on enabling practitioners to gain the power needed to bring about change in their and/or others’ practice. Through processes of critical reflection on experience and methods of research that are practitioner focused, new knowledge is generated. Thus, action research has three purposes: the development of practice, the facilitation of practitioners to learn and become empowered, and facilitation of practitioners to contribute to or refine theory.

EVALUATION

Evaluation is the systematic determination of merit, worth and significance of specific nursing practices to relevant stakeholders through testing of context/mechanism/outcome/configurations (CMOCs). Experimental methods are used to test CMOCs and to inform theory, policy and practice. Realistic evaluation is similar, but focuses on testing more-realistic theories; that is, theories that take into account multiple perspectives and interpretations (Pawson and Tilley, 1997).

Leininger M, McFarland M 1995 Transcultural nursing concepts, theory, research and practice. New York, McGraw-Hill; Madison DS 2005 Critical ethnography. New York, Sage; Manias E, Street AF 2000 Possibilities for critical social theory and Foucault’s work: a toolbox approach. Nurs Inquiry 7(1):50–60; Pawson R, Tilley N 1997 Realistic evaluation. London, Sage.

No matter which approach is used, however, nursing research is a systematic examination of phenomena important to nursing: in the delivery of services to patients and their families; in the advancement of teaching and learning approaches; in the development of leadership and management strategies; and in the advancement of nursing as a professional discipline. Research is needed in order to ensure the effectiveness of nursing interventions, for providing the knowledge necessary for practice and its development, and for helping nurses to be accountable by demonstrating to society the safety, effectiveness and efficiency of services provided.

Approaches used in data collection

A variety of data collection methods are used in nursing research. Broadly speaking, however, data can be categorised as qualitative—most commonly words or text derived from interviews, diaries or discussions; or quantitative—information collected either in the form of numbers, or converted into numbers for the purposes of analysis (Table 4-3).

TABLE 4-3 FORMS OF DATA AND APPROACH TO DATA ANALYSIS

FORMS OF DATA	FORMS OF ANALYSIS
Unstructured interviews, discussions or conversations Written text such as diaries and stories	Thematic analysis: inductive coding for themes Template analysis: predetermined themes based on conceptual model or similar Narrative analysis: used in relation to stories
Semi-structured interviews, observations or surveys	Content analysis: for descriptive categories Coding of responses: with allocation of numbers
Structured interviews, observations, surveys or measures	Statistical analysis seeking to describe, identify relationships or establish cause and effect

Data collection and analysis need to be undertaken in a manner that maximises the rigour of the study—the extent to which the findings can be believed. Some researchers use terms such as validity and reliability in relation to their research processes; others use broader terms such as accuracy, trustworthiness and transparency. The appropriate term is a function of the approach taken and associated assumptions about subjectivity/objectivity and the nature of reality. Meaningful discussion of these issues is beyond the scope of a text such as this. As you develop your interest in nursing research, you will need to access materials and people with the knowledge and expertise to assist you with your learning. Understanding the assumptions and beliefs associated with particular approaches to research is a vital part of making sound decisions about the relevance of any findings to your practice.

The major push over the past decade for the use of research evidence in clinical decision making has led researchers to convey their findings in a form more easily understood by clinicians. Within research employing quantitative analysis this has meant a move away from focusing on statistical significance—the probability of obtaining a particular result by chance; with probabilities of less than 5 times in 100 deemed by convention to be significant. (You may have seen this expressed as p < 0.05.) Researchers are now more likely to report their findings using more intuitively meaningful measures of clinical significance (Box 4-7). Research and professional journals have also moved to publishing a broader range of research and to encouraging researchers to present their findings in a manner that makes their knowledge claims or relevance to nursing practice more explicit.

BOX 4-7 MEASURES OF CLINICAL SIGNIFICANCE

Numbers needed to treat (NNT): the number of patients who would need to be treated in order for one patient to gain the desired outcome

Relative risk (RR): the risk of a negative outcome for one group compared with the risk of that outcome in the comparison (control) group

Odds ratio (OR): the odds of a patient benefiting from a treatment over the odds of benefiting from the alternative

Coefficient of determination (R²): the percentage of the variance in an outcome accounted for by a particular factor (or group of factors)

Mean difference: the difference between the extent of achievement of an outcome of one group compared with the extent of achievement of an outcome determined through comparison of group averages

Confidence interval (CI): a range established around any point estimate (mean difference, RR, %, etc), within which there is 95% confidence that the population ‘difference’, ‘risk’, ‘percentage’ actually falls

Approaches to bring research evidence together

The findings of nursing research, and the research of other health disciplines with relevance to nursing, are published in a vast array of research and specialist journals. One of the greatest challenges in using research evidence is the overwhelming number of articles that need to be accessed and considered. An alternative challenge is the complete absence of relevant work to be found in relation to areas of nursing practice. In the latter case, you will need to rely on your own clinical expertise, the expertise of others with whom you work, and locally produced knowledge as a basis for your practice.

When there is an abundance of research evidence, however, there is a need for both clinical and research expertise to determine the ‘so what?’ of the research in relation to clinical practice. In recent years there has been exponential growth in the production of materials/publications that summarise the relevant research and/or make recommendations for practice. Some of the most common of these are included in Box 4-8.

BOX 4-8 COMMON APPROACHES TO BRINGING TOGETHER THE FINDINGS OF MULTIPLE RESEARCH STUDIES

SYSTEMATIC REVIEW

Involves the application of a precise method to accessing, assessing and combining the results of all valid and reliable research undertaken in relation to a specific clinical question—normally comparisons of two or more interventions or treatments—in order to make as definitive a statement as possible concerning best practice (e.g. the approach to administering bronchodilators that has the largest effect on length of stay in hospital). Systematic reviews may or may not include a meta-analysis, which is the use of statistical procedures to combine the findings of several studies. The data from individual studies can be combined into a larger data set as long as the studies used similar interventions (e.g. nebulisers versus spacers in emergency departments) and similar outcomes (e.g. admission to hospital, number of hours spent in emergency department, spirometry) (see Egger and others, 2001).

META-NARRATIVE REVIEW

Is an approach that is broader than systematic reviewing; it covers a wide range of issues within a given topic. In addition, a narrative review bases the decision to include or exclude studies on descriptive grading of forms of evidence, rather than the narrow hierarchy of evidence used in systematic reviews. The outcome is, therefore, a comprehensive overview of the topic or area of interest (e.g. Greenhalgh and others, 2004).

REALISTIC REVIEW OR SYNTHESIS

Similar to a narrative review, but more heterogeneous and iterative in terms of the sources of evidence and their contribution to the findings. The processes used in accessing evidence from a full range of sources, making decisions about the inclusion of material, sifting and assessing the material and bringing together synthesised findings and recommendations are rigorous and systematic (e.g. McCormack and others, 2006).

RESEARCH-BASED GUIDELINES

Systematically developed statements, based on the best available research evidence, generated to assist healthcare professionals and patients make decisions about screening, prevention, treatment or care for specific illnesses or conditions (National Health and Medical Research Council, 1999).

Egger M and others 2001 Systematic reviews in health care: meta-analysis in context, ed 2. London, BMJ Books; Greenhalgh T and others 2004 Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 82(4):581–629; McCormack B and others 2006 A realist synthesis of evidence relating to practice development. Edinburgh, National Health Service/Healthcare Improvement Scotland; National Health and Medical Research Council (NHMRC) 1999 A guide to the development, implementation and evaluation of clinical practice guidelines. Online. Available at www.nhmrc.gov.au/publications/synopses/_files/cp30.pdf, 14 February 2008.

The growth in systematic summaries of research and practice guidelines based on the best available research evidence has been driven by the evidence-based practice movement and responses to it. Evidence-based practice has been defined by many clinicians across the spectrum of healthcare disciplines (Box 4-9); and there are ongoing debates concerning the hierarchies of evidence and the ways in which particular approaches to research (e.g. randomised controlled trials, RCTs) are valued over others. The major issue is, however, finding and assessing the usefulness of research that addresses the question at hand. For example, if the question is about the effectiveness of a particular approach to treating pressure ulcers, an RCT provides the ‘best’ evidence. If, however, the question is about the feasibility and acceptability of that approach to treatment in particular contexts, other research designs, probably employing qualitative analysis, would provide more useful insights.

BOX 4-9 A COMMON DEFINITION OF EVIDENCE-BASED NURSING PRACTICE

‘The practice of nursing in which the nurse makes clinical decisions based on the best available current research evidence, his or her own clinical experience and the needs and preferences of the patient.’

From Harris and others 2010 Mosby’s Dictionary of medicine, nursing and health professions—Australian and New Zealand edition, ed 2. Sydney, Elsevier.

Given the expertise and time needed to integrate research evidence into clinical decision making, adequate resources and support are crucial (see Research highlight).

Accessing relevant research literature demands the development of some fundamental skills in database searching. You need to take advantage of library teaching sessions so you can become familiar with the systems in place within your library and online. Locating the forms of publications outlined in Box 4-8 will be particularly useful, particularly in sourcing research evidence in relation to best practice. For example, the Joanna Briggs Institute (www.joannabriggs.edu.au) supports the development of a range of reviews and guidelines relevant to nursing; the Cochrane Collaboration (www.cochrane.org) provides systematic reviews which, though predominantly relating to medical diagnosis, prognosis, therapies and harm/risk, cover topics relevant to nursing practice. Both of these organisations have broadened the focus of their reviews to be more inclusive of the full range of research approaches associated with meaningful integration of research into practice.

In summary, nurses must use the knowledge generated within each of the three levels of inquiry to improve both processes and outcomes of care for patients. One means of overcoming some of the major challenges to ongoing practice improvement is what has become known as practice development (PD). The next section outlines some of the most important aspects of PD.

RESEARCH HIGHLIGHT

Research focus

A good deal of research is being undertaken to identify strategies to improve the utilisation of research evidence in everyday nursing practice. While early work focused on the clinicians themselves, there is now growing interest in the role of context on knowledge utilisation or transfer.

Research abstract

The purpose of this research was to explore the organisational context within a 16-bed paediatric critical unit to understand the ways in which context influenced nurses’ use of research evidence.

The researchers used ethnographic methods and collected data from two sources: in-depth observation over a period of seven months, and interviews with unit nurses, managers and other healthcare professionals. Observations occurred over all shifts, three to four times a week; and lasted up to 2 hours. Interviews involved 29 staff members, and ranged from 1–4 hours (mean = 75 minutes). The data were analysed using a two-phase approach that involved ‘making order of the data’ followed by ‘interpretation’. Four criteria were used to guide the trustworthiness of the data analysis: credibility, confirmability, dependability and transferability.

The researchers found that ‘A lack of certainty keeps nurses on “shifting sand”, unable to satisfactorily anticipate events in their environment. This in turn can lead to significant reticence to consider new ideas and new ways of working—important factors in enabling the use of research.’

Evidence-based practice

Four major sources of uncertainty were seen as instrumental in shaping nurses’ behaviours and rendering research evidence irrelevant:

1. The precarious condition of the patients nursed within the context.

2. The inherent unpredictability of nurses’ work.

3. The complexity of teamwork within the paediatric intensive-care unit environment.

4. Inconsistency in patient management.

Reduction of uncertainty is, therefore, a necessary precursor to strategies that seek to increase the use of research evidence.

Reference

Scott SD, et al. A context of uncertainty: how context shapes nurses’ research utilization behaviours. Qual Health Res. 2008;18(3):347–357.

• CRITICAL THINKING

You are concerned about the likelihood that an older, immobilised patient will develop pressure ulcers. What are the best sources of evidence related to preventing ulcers? Where would you find that evidence? How would you determine if the evidence is a good basis for your practice?

Practice development

Contemporary nursing practice requires nurses to develop their practice continuously, through ongoing inquiry into practice and taking action to improve practice wherever change is needed (see Essentials of care chapter available through the online Evolve site). This is not easy to do in a systematic way, and nurses require help and support to do this. The following overview establishes the crucial role that practice development can play in stimulating and sustaining nursing inquiry and the integration of new knowledge into practice.

PD has been described as meaning many things to different people. However, the most contemporary definition, developed by Manley and others (2008), forms the basis of our discussion here (Box 4-10). As you seek deeper understanding of PD, you will need to access a number of the theoretical and research papers that are becoming increasingly available. The books produced by McCormack and others (2004) and Manley and others (2008) provide a sound basis for that learning.

BOX 4-10 DEFINITION OF PRACTICE DEVELOPMENT

‘Practice development is a continuous process of developing person-centred cultures. It is enabled by facilitators who authentically engage with individuals and teams to blend personal qualities and creative imagination with practice skills and practice wisdom. The learning that occurs brings about transformation of individual and team practices. This is sustained by embedding both processes and outcomes in corporate strategy.’

From Manley and others 2008 International practice development in nursing and health care. Oxford, Blackwell, p. 9.

Garbett and McCormack (2004) identify five elements of PD. These are:

• an emphasis on improving patient care

• transforming the contexts and cultures in which nursing care takes place

• the importance of employing a systematic approach to effect changes in practice

• the continuous nature of PD activity

• the nature of the facilitation required for change to take place.

Manley and McCormack (2004) outline what they call technical practice development. Technical practice development focuses on the development of technical knowledge to improve technical skills and emphasises the changing of specific aspects of practice. Best practice is universally defined (i.e. what is considered best practice in one part of the world will apply everywhere else in the world), therefore, and there is a central assumption that if clinicians know the evidence, then their practice will be effective. In many respects this form of practice development resembles more traditional, passive approaches to research utilisation whereby it is assumed that practice change flows naturally from awareness of deficiencies in clinical practice and education concerning best practice. However, contemporary research suggests otherwise, and critiques of technical approaches to helping people use knowledge in practice have highlighted the naivety of assuming that acquired knowledge will automatically lead to a change in practice (Kitson and others, 1998).

Manley and McCormack (2004) contrast the technical approach with emancipatory and transformational practice development. Emancipatory practice development is an approach that emphasises sustained development of practice through the helping of practitioners to free themselves from the taken-for-granted assumptions they make about practice. Through facilitated approaches, practitioners are helped as individuals and teams to make changes that bring about more-empowered practice cultures. Facilitating these processes involves cycles of reflective learning and action, so that clinicians develop awareness of the need for change by identifying contradictions between what is espoused about practice and the realities of practice. The process therefore involves action to change practice and refines action through reflection. Transformational practice development focuses on both getting the products of inquiry (knowledge and research evidence) into practice and creating a culture of innovation and clinical effectiveness (Manley and others, 2011). It focuses on helping practitioners to transform their practice and to achieve person-centred cultures of practice through their engagement with multiple intelligences and both the art and the science of practice.

These facilitated processes help clinicians remove barriers to action and enable cultures of effectiveness to be developed. While research evidence is important to transformational practice development, best practice is locally defined and contextually bound. So for evidence to be understood and used, it has to be placed in a local context that makes sense to the immediacy of practice experience. Thus, evidence in this context comes from a variety of sources—clinician experience, user preferences, local data and research evidence—and is understood through reflective engagement with collective practice experience (see Rycroft-Malone and others, 2004).

In terms of evaluating effectiveness, therefore, the emphasis is on both the outcomes achieved from the development of practice and the processes used to achieve those outcomes. Thorough understanding of the processes used to achieve particular outcomes makes these processes more likely to be transferred appropriately to other contexts, thus creating cultures of continuous improvement that are committed to increasing effectiveness in person-centred care.

The key processes of emancipator or transformational practice development include:

1. identifying a particular practice requiring consideration

2. clarifying values and beliefs among team members about the particular practice

3. identifying the existence of these values and beliefs in day-to-day practice

4. identifying the gap that exists between the espoused and the real values through processes of inquiry and evaluation

5. negotiating systematic approaches to developing practice and creating action plans to develop practice

6. using collaborative, inclusive and participatory approaches (McCormack and others, 2007) to increase the likelihood that key stakeholders (i.e. those affected by potential developments) have a sustainable commitment to learning from the processes, via reflective learning strategies such as action learning (McGill and Brockbank, 2004) and supported reflective practice (Johns, 1998).

The example presented in Box 4-11 highlights the central role that facilitation plays in enabling the processes involved in PD to evolve fully and the goals to be achieved.

BOX 4-11 EXAMPLES OF THE IMPLEMENTATION OF EPD PROCESSES

Scenario: A nurse within a ward providing care for older adults with mobility problems starts to observe an increase in the number of patients with pressure sores. The nurse would collaborate with others in the ward to:

1. Gather any data that exists in relation to the incidence of pressure sores in the ward to confirm or disconfirm the observation. If there is a cause for concern, they would then move on to the second step in the process.

2. Clarify values and beliefs held by others in the ward about pressure-area care practices (Manley, 2000).

3. Seek evidence that these values and beliefs influence day-to-day practice through auditing pressure-area care or structured observations of care (Clark, 2001).

4. These structured observations enable the identification of any gaps between what nurses value and identify as important and the values evident in practice.

5. Using a systematic approach, such as claims concerns and issues, all stakeholders would be invited to create action plans to develop practice around pressure-area care (McCormack and Manley, 2004).

6. Reflective learning strategies, such as action learning (McGill and Brockbank, 2004) and supported reflective practice (Johns, 1998), would be used to support ongoing engagement with the practice of pressure area care within the ward.

Clark P 2001 What residents are not learning: observations in an NICU. Acad Med 76:419–24; Johns C 1998 Opening the doors of reflection. In: Johns C, Freshwater D, editors, Transforming nursing through reflective practice. Oxford, Blackwell Science; McCormack B, Manley K 2004 Evaluating practice developments. In: McCormack B and others, editors, Practice development in nursing. Oxford, Blackwell; McGill I, Brockbank A 2004 The action learning handbook. London, RoutledgeFalmer; Manley K 2000 Organisational culture and consultant nurse outcomes. Part 1: organisational culture. Nurs Stand 14(36):34–8.

Facilitation of practice development

Facilitation is fundamental to practice development (Crisp and Wilson, 2011). Facilitation refers to a process of enabling individuals and groups to understand what they have to go through to change aspects of their behaviour or attitudes in relation to themselves, their work or other individuals (Marshall and McLean, 1988). A similar interpretation is apparent in some approaches to practice-based learning in healthcare (Barrows and Tamblyn, 1980; Nolan, 1998; Titchen, 1987), the aim being to challenge existing practice and support the development of new ways of working (Figure 4-1).

FIGURE 4-1 Collaboration is at the heart of nursing inquiry.

Just as there are two types of practice development (technical and emancipatory/transformational) (Manley and McCormack, 2004), facilitation styles can be dichotomised. Task-orientated facilitation may increase the use of theoretical or empirical knowledge in practice; however, this requires the facilitator to have a lot of expertise in facilitation as well as technical knowledge associated with the practice in question (Kitson and others, 1998). Knowledge expertise alone is inadequate because it is still the facilitator who is ultimately responsible for success or failure of the initiative and the development of practice (Box 4-12).

BOX 4-12 SKILLS USED IN TECHNICAL FACILITATION

The skills used in technical facilitation are narrow and focus on:

• Sourcing information

• Assessing the relevance and adequacy of that information

• Translating the information into differing formats (e.g. protocols, guidelines, information sheets)

• Developing training programs

• Training

• Information giving

• Audit and monitoring

In contrast with the task or technical approach, the overall aim of the emancipatory or transformational facilitator is to enable individuals and teams to become empowered to develop a transformational culture in their individual and collective service that can nurture and sustain the development of a particular goal or task (Manley and McCormack, 2004). Although the overall approach may encompass elements of technical facilitation, it is essential to recognise that technical facilitation must be integrated into holistic approaches if the different needs of stakeholders are to be met. The work of Wilson and others (2005) and Barrett and others (2005) provides useful examples from an Australian context of facilitators moving between differing roles and styles of facilitation. Crisp and Wilson (2011) provide a framework that helps make sense of the development of expertise required for the transformation of individuals and practice.

Within a holistic facilitation approach, the focus is on the social system as well as individuals’ or groups’ own practice. Facilitators help participants become aware of, and freed from, taken-for-granted aspects of their practice and the organisational systems constraining them. They foster a climate of critical inquiry through reflective discussion; incorporating the various ideas of group members enables individuals and groups to act. Responsibility for action rests with the individual or group (Kemmis, 2006). By considering the external climate and broader social system in which nurses work, collective insight, understanding and ownership develop through clinicians’ own actions, rather than the actions of others (Box 4-13).

BOX 4-13 SKILLS OF THE HOLISTIC FACILITATOR

The skills of the holistic facilitator are broad and responsive:

• Working with values, beliefs and assumptions

• Challenging contradictions

• Developing moral awareness about the most appropriate way to act

• Focusing on the impact of the context on practice, as well as practice itself

• Using self-reflection and fostering reflection in others

• Enabling others to ‘see the possibilities’

• Fostering widening participation and collaboration by all involved

Practice development, then, has a central focus on developing person-centred cultures that facilitate human flourishing, clinical effectiveness and the development and integration of knowledge through ongoing inquiry.

• CRITICAL THINKING

Before reading the next section, think about what person-centred workplaces might look like. What do you think such workplaces would feel like to those working there?

Person-centredness and person-centred practice

The word person aims to capture those attributes of people that represent our humanness and the factors we regard as the most important and the most challenging in our lives. A person should always be treated as an end in themself and not as a means to another’s end—a principle that guides many ethical, legal and moral frameworks in Western society. What this means is that we should never do things to people that are not going to benefit them as a person. Thus Tom Kitwood (1997:8) defined personhood as:

a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being. It implies recognition, respect and trust.

If we accept this well-respected and widely used definition of personhood, then four core concepts can be identified as lying at the heart of person-centred nursing (Box 4-14).

BOX 4-14 CORE CONCEPTS AT THE HEART OF PERSON-CENTRED NURSING

• Being in relation

• Being in a social context

• Being in place

• Being with self

Being in relation

Relationships are central to person-centredness. Indeed, models of nursing (see Chapter 3), irrespective of their philosophical underpinnings, have emphasised the importance of relationships (for example Boykin and Schoenhofer, 1993; Johns, 1994; Peplau, 1952; Rogers, 1986; Watson, 1985). In person-centred nursing, the relationship between the nurse, the patient and others important to the patient is paramount. Sustaining a relationship that is nurturing to both nurse and patient requires valuing of self, moral integrity, reflective ability, knowing of self and others, and flexibility derived from reflection on values and their place in the relationship.

Being in a social context

This concept recognises that patients have a social context and that this context contributes to shaping who they are as people, how they respond to stimuli and how they might make sense of things they experience. Listening to, collecting and analysing patients’ stories help us to understand who the person is in a social context. Stories afford us the opportunity to understand the local spheres of meaning that bear on and enter into the nurse–patient relationship and to understand the person’s context.

Being in place

The context in which care is provided has the greatest potential to enhance or limit the facilitation of person-centred practice (McCormack, 2001a; Tonuma and Wimbolt, 2000). Indeed, Andrews (2003) argues that the concept of place and its impact on care experiences is poorly understood in nursing. Paying attention to place in care relationships is increasingly recognised as important (Andrews, 2003).

When facilitating person-centredness, nurses find they not only balance competing care values, but often they find it necessary to consider organisational values too. Nurses are not free to fulfil a moral obligation to the patient without considering organisational and professional implications. While the freedom of the nurse is a significant issue in the facilitation of person-centredness, other characteristics of context have been found to be of equal significance; these include systems of decision making, staff relationships, organisational systems, power differentials and the potential of the organisation to tolerate innovative practices and risk taking.

Being with self

Respect for values is central to person-centred practice (Clarke, 2000; Dewing, 2004; McCormack, 2001b). It is important to develop a clear picture of what patients value about their life and how they make sense of what is happening to them. This provides a standard against which the nurse can compare current decisions and behaviours of the patient with those values and preferences made in life in general and which form the basis of a care plan. Assisting the patient to find meaning in care may help them to tolerate the incongruity of their situation in order to create a future. Brown and others (1992) emphasise the importance of having a clear picture of what the patient, and others important to them, really value about their life and how they make sense of the things happening to them. For this reason, nursing-care decision making ought to adopt a negotiated approach between nurse and patient.

To work effectively as a person-centred nurse and to create care environments that are person-centred requires the integration and blending of different kinds of knowledge: knowledge about people, knowledge about what it means to be clinically effective and knowledge about the care environment. Nurses need to know the person in their patients; know their colleagues as people; understand what it means to be clinically effective; and understand the culture of the place in which they work. To do that, they need to take a PEEP.

• CRITICAL THINKING

You have found what you believe to be best evidence related to preventing pressure ulcers. How would you ensure that your use of that evidence is person-centred?

Taking a PEEP

Within the PEEP framework (see Box 4-2), the people domain is about variation in individuals’ needs and preferences for care, as well as the ways in which different stakeholders experience receiving or giving care and use different kinds of knowledge. The effects domain refers to the kinds of evidence used in determining best practice. Research evidence is one kind of evidence, and this informs and is informed by the evaluation of outcomes and the cost–benefit of these outcomes. However, it is increasingly recognised that the environment in which care is provided has an impact on effectiveness. The environment of care is often referred to as the context, and how much that context supports a culture of learning and change through supportive challenge is an essential consideration in the use of knowledge in practice. It is increasingly acknowledged, however, that an environment that takes account of people’s perspective, choices and preferences; that uses a variety of sources of evidence to inform the evaluation of effectiveness; and which provides a culture of learning through supportive challenge is an effective workplace. Clinicians and leaders in such workplaces demonstrate praxis; that is, they engage in critical practice development as part of everyday practice.

Taking a PEEP at people

When reading research studies, nurses should avoid automatically generalising the findings to individuals or groups for whom they care. While the researchers may have identified best practice in relation to a specific nursing intervention—for example, a particular approach to healing venous leg ulcers—the decision to use that practice in relation to a specific patient requires both an understanding of the evidence and an understanding of the patient’s circumstances and preferences.

Effective nursing care needs to work with variation in individual needs and preferences for care, as well as the ways in which different stakeholders experience receiving or giving care. It also needs to use different kinds of knowledge. Patients, for example, may express preferences that are not consistent with what is known to be the best evidence; or nurses may find particular care practices personally distressing. In such situations, decision making will be influenced by the balance between expressed preferences, the priorities of the nurse and the personal and professional beliefs and values of all those involved in the decision. Thus thinking about how people engage in decision making and the factors that influence decision making is important to being clinically effective as a nurse.

Working effectively requires the formation of therapeutic relationships between nurses and patients (and others significant to them in their lives), between nurses as colleagues and between nurses and the wider healthcare team. These relationships are built on mutual trust, understanding and a sharing of collective knowledge (Binnie and Titchen, 1999; Dewing, 2004; McCormack, 2001b; Nolan and others, 2004). Nursing literature on therapeutic caring where the concept of person is central, for example Leininger’s theory of culture care (1988), Watson’s theory of human caring (1985), Boykin and Schoenhofer’s theory of nursing as caring (1993) and Roach’s conceptualisation of caring relationships (1987), support this view.

To be person-centred in a relationship with a patient and others significant to them, nurses need to be able to work with the patient’s and family’s beliefs and values; have an engaged relationship with the patient and family; demonstrate understanding of the patient’s feelings; share decision making; and provide for physical needs. Liaschenko and Fisher (1999) delineate three types of knowledge that may assist you in working effectively with patients. These are case knowledge, which is generalised and objective knowledge such as anatomy and physiology and pharmacology; patient knowledge, which is knowledge of how individual patients are experiencing and responding to their illness situation; and person knowledge, which is knowledge of the unique individuality of the patient (Stein-Parbury, 2005).

Working with patients’ beliefs and values reinforces one of the fundamental principles of person-centred nursing, which places importance on developing a clear picture of what the patient values about their life and how they make sense of what is happening to them. This is closely linked to shared decision making, and focuses on nurses facilitating patient and family participation through providing information and integrating newly formed perspectives into established practices. This must involve a process of negotiation that takes account of individual values to form a legitimate basis for decision making, the success of which rests on successful processes of communication (Chapter 12).

The extent to which you are successful in achieving the forms of relationships and ways of working with patients that lead to effective care can be evaluated through ongoing reflections and critical discussions with colleagues, a mentor or a critical companion (Titchen, 2003a, 2003b). Evaluation of the extent to which local practices meet the needs of patients in a person-centred way involves systematic data collections, such as patient stories and collection of patient satisfaction surveys. Nursing researchers seeking to generate new knowledge in relation to the experiences of people cared for by nurses will commonly use one of the approaches outlined in Box 4-5. This material may be brought together within narrative or realistic reviews or syntheses that can be used to inform your thinking about your work with patients and their families (Box 4-8).

Taking a PEEP at practice effects

As you develop expertise in nursing, you will accumulate expertise related to specific nursing practices and the outcomes that you achieve. The area in which you work will undertake clinical audits and other forms of quality enhancement projects that identify the outcomes being achieved in relation to current practice. Both of these forms of inquiry are vital to understanding the extent to which specific practices achieve their desired outcomes; or, conversely, identifying factors that are having negative impacts on achieving the desired outcomes.

If an intervention appears to work for most patients, the nurse may be satisfied with this success without questioning whether there might be a better way. If the intervention is not successful, the nurse might use an approach practised by a colleague or try a different sequence of accepted measures. Even if an intervention discovered with this approach is effective for one or more patients, it may not be appropriate for those in other settings. Practices must be tested to determine the measures that work best with specific patients; that is, those that determine best practice.

Research approaches associated with testing the effectiveness of nursing practices include those listed in Table 4-2. This form of research is most easily drawn together in systematic review with meta-analysis; and as long as the studies that have been undertaken are rigorous and able to be combined, some clear pointers to the most effective approach may be available.

• CRITICAL THINKING

A registered nurse decides to investigate the effectiveness of pressure-area care within the ward. What level of inquiry is needed? How would the nurse go about this investigation?

Taking a PEEP at impact of environment on nursing practice

As discussed previously, the environment of care is often referred to as the context, and how much that context supports a culture of inquiry, learning and change through supportive challenge is an essential consideration in the use of knowledge in practice. The competence of nurses particularly in relation to interpersonal and communication skills has been drawn out in a recent qualitative study by McCabe (2004), who concluded that nurses can communicate well with patients when they use a person-centred approach, but that the ability to do so is heavily influenced by the work and culture of the organisation; that is, the care environment. The care environment focuses on the context in which care is delivered and includes the following: appropriate skill mix, systems that facilitate shared decision making, effective staff relationships, organisational systems that are supportive, the sharing of power, and the potential for innovation and risk taking. Key characteristics of context include the culture of the workplace, the quality of nursing leadership and the commitment of the organisation to the use of multiple sources of evidence to evaluate the quality of care delivery.

Research approaches associated with the environments or context in which nursing takes place are outlined in Box 4-6. These approaches fall into two categories: describing the context and culture in order to provide a deeper understanding of the social relationships and systems that influence the way that things are done; or working with people within particular contexts to identify and bring about change in the way things are done.

Taking a PEEP at engagement through praxis

As discussed previously, effective workplace cultures demand that all nurses demonstrate praxis; that is, engage in critical inquiry and practice development as part of everyday practice. An enormous amount of effort has gone into research and thinking about ways of achieving practice change based on the local knowledge generated through the quality-improvement processes, or getting the products of research into practice (Greenhalgh and others, 2004; Kitson and others, 1998). However, continuous practice improvement is complex and requires critical reflection, systematic evaluation, behaviour change and facilitation. The PARiHS model (Promoting Action on Research Implementation in Health Services) is a framework that recognises and accommodates this complexity (Kitson and others, 1998; Rycroft-Malone and others, 2004). This framework suggests that if we are to translate evidence/knowledge into practice successfully, then we have to consider the quality of the evidence, the context in which it is to be implemented and the approach used to facilitate the implementation process—all issues discussed earlier in this chapter. This integration is consistent with the meaning of praxis and involves practising with the moral intent of person-centredness.

Aristotle distinguished between two kinds of action—poiesis and praxis (Welldon, 1987). Poiesis means ‘making action’ and praxis means ‘doing action’. Poiesis involves action that is focused on achieving a predetermined end; that is, the construction of a product or an object is its endpoint (e.g. a successfully completed surgical intervention). Poiesis is, according to Carr (1987:169), ‘a species of rule-following action’. The worth of practice in this way is judged on the quality of the end-product. Worth is decided on by the way the practice is judged to conform to recognised and predetermined standards and current understanding of what counts as good quality in the particular practice area. We see this evidenced in the way that quality of practice is judged solely on diversions from care pathways, adverse events rates, throughput, complaints or levels of satisfaction.

Praxis, on the other hand, is not only concerned with the end-product but also with morally worthwhile action that cannot be predetermined in advance as it is dependent on the context in which the action is undertaken. The achievement of an end-product and the process of getting there are not separate entities, because the quality of the end-product is inseparable from the means of getting there.

Good practice, understood as praxis, involves more than the application of a theory and research evidence or the exercise of a skill. Determining the right thing to do at the right time and in the right way (often seen as the essence of clinical effectiveness) (see for example Kitson and others, 1998) involves a particular kind of knowledge—practical knowledge (Eraut and others, 1998, 2000). Titchen and colleagues (Titchen and Ersser, 2001; Titchen and Higgs, 2001) use the terms professional craft knowledge or practical know-how. This knowledge is expressed and embedded in practice, is often tacit (i.e. it is embedded in our thinking and taken for granted) and intuitive, and it combines perception, reasoning and virtue. Good-quality practice from this view is concerned with technical outcomes (such as the effectiveness of a particular intervention), but it is equally concerned about the experience of achieving the outcome from the perspective of patients and staff and the learning derived from engaging in the process itself.

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Three levels of nursing inquiry

Inquiry involving critical engagement in everyday practice

Reflection

Experiential learning and action

Inquiry involving collaborative and ongoing evaluation of local practice

STAGE 1: IDENTIFY THE FOCUS, PRACTICE, PROBLEM OR ISSUE

STAGE 2: DEFINE CRITERIA AND STANDARDS

STAGE 3: COLLECT DATA

STAGE 4: COMPARE PERFORMANCE WITH CRITERIA AND STANDARDS

STAGE 5: IMPLEMENT CHANGE

RE-AUDIT: SUSTAIN IMPROVEMENTS

Inquiry involving nursing research for advancement of nursing knowledge

Approaches used in nursing research

NARRATIVE RESEARCH

PHENOMENOLOGY

HERMENEUTICS

GROUNDED THEORY

ETHNOGRAPHY

CRITICAL ETHNOGRAPHY

ETHNONURSING

CRITICAL INQUIRY

ACTION RESEARCH

EVALUATION

Approaches used in data collection

Approaches to bring research evidence together

SYSTEMATIC REVIEW

META-NARRATIVE REVIEW

REALISTIC REVIEW OR SYNTHESIS

RESEARCH-BASED GUIDELINES

Research focus

Research abstract

Evidence-based practice

Practice development

Facilitation of practice development

Person-centredness and person-centred practice

Being in relation

Being in a social context

Being in place

Being with self

Taking a PEEP

Taking a PEEP at people

Taking a PEEP at practice effects

Taking a PEEP at impact of environment on nursing practice

Taking a PEEP at engagement through praxis

The complexity of nursing inquiry

ONLINE RESOURCES