Design, Evaluation, and Translation of Nursing Interventions

Souraya Sidani, Carrie Jo Braden

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9780470961513
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Nurse-led intervention research is a core component of the global initiative to improve quality of care. Though research in this area has already contributed much to the advancement of patient care, future strides depend on the dissemination of practical, how-to instruction on this important area of research. Design, Evaluation, and Translation of Nursing Interventions aids in this endeavour by presenting both general approaches and specific methods for developing nursing interventions. Logically organized to facilitate ease of use, the book is divided into four sections. The introduction provides a firm grounding in intervention science by situating it within the broader topics of evidence-based practice, client-centred care, and quality of care. Section Two describes each step of intervention design, including correct identification of the health issue or problem, clarification of the elements comprising an intervention, and application of theory. Section Three is centred on implementation, highlighting such topics as development of the intervention manual, training interventionists, and intervention fidelity. The book concludes with methods to evaluate interventions enacted and suggestions for their translation into practice.

Design, Evaluation, and Translation of Nursing Interventions distills the authors' years of expertise in intervention research into comprehensive, easy-to-follow chapters. It is a must-have resource for students, researchers and healthcare professionals wishing to impact the future of patient care.

Section 1

Introduction

Chapter 1

Introduction to Intervention Research

In many countries around the world, nursing has achieved recognition as a scientific discipline (Lutzen, 2000). Nursing research is developing rapidly (Hallberg, 2009), evidenced by the quantity and quality of nurse-led studies reported in regional and international journals describing the health and/or illness experience and response to interventions of individuals residing in countries that vary in cultural beliefs and values, and in healthcare systems. To preserve recognition as a scientific discipline, nurses need to generate, expand, and refine the knowledge base that demonstrates the unique contribution of the discipline to meet the needs of individuals, families, groups, and society at large. Nursing's contribution is reflected in the provision of high-quality care that successfully promotes health, addresses clinical problems, and produces beneficial outcomes. Therefore, it is imperative to prioritize efforts to advance nursing science so that it supplies the theoretical and practical knowledge required for the provision of high-quality care (Evers, 2003; Hallberg, 2009).

The nursing process forms the foundation of high-quality nursing care. The nursing process consists of four steps: (1) assessment, (2) diagnosis, (3) intervention, and (4) evaluation, which nurses implement when caring for individuals, families, or communities (thereafter referred to as clients). Nurses assess the biophysiological, physical, psycho-behavioral, and sociocultural conditions of clients in order to identify their health needs, values, and preferences, and to formulate a diagnosis. A nursing diagnosis clearly delineates the nature of the actual or potential health-related problem with which clients present and requiring remediation. An in-depth and lucid understanding of the clients’ condition and presenting problem is necessary for selecting appropriate and effective interventions to be implemented for, on behalf, or with the clients, with the goals of promoting and restoring health through resolution of the presenting problem. Evaluation refers to monitoring clients’ status on a regular basis to determine the extent to which the interventions were successful in achieving the intended goals. This description of the nursing process highlights the centrality of interventions. Interventions constitute the essential element that characterizes nursing care (Tripp-Reimer et al., 1996).

Carrying out the nursing process in the context of day-to-day practice requires a sound knowledge base that informs nurses of interventions that are effective in addressing the clients’ presenting problem and in promoting their health (Evers, 2003; Kim, 2002). Nursing interventions that are effective in producing the intended beneficial outcomes are carefully designed, systematically evaluated, and successfully translated into the day-to-day practice setting. The process of designing, evaluating, and translating interventions is conducted in a way that maintains rigor within a context characterized by evolving perspectives or paradigms underlying science and practice. This chapter begins with an overview of the paradigm shift, then highlights the steps of the process for designing and evaluating interventions prior to translating and using them in the day-to-day practice setting.

1.1 Overview of paradigm shift

The new millennium is witnessing a shift in paradigm of what constitutes high-quality care and of what comprises acceptable evidence to guide provision of high-quality care. Although evidence-based practice was introduced as an approach for delivering high-quality care (Guyatt et al., 2002), efforts to implement it in the day-to-day practice setting is raising many questions about the utility of available knowledge in guiding practice. For example, while evidence is becoming available about the effects of interventions on specific outcomes, there is much less evidence about the specific mechanisms underlying the intervention effects. There is even less evidence to guide intervention translation within specific practice settings. Insufficient evidence about mechanisms linking interventions to outcomes for specific clients, coupled with a growing demand of enlightened clients for a participatory role in health-related decision-making, is bringing the person or client-centered approach to the forefront of what defines high-quality care (American Nurses Association, 2003; Institute of Medicine, 2001; McCormack & McCance, 2006). Person- or client-centered care is congruent with the philosophical orientation underpinning nursing practice. In addition, it complements evidence-based practice in defining high-quality care (Sidani et al., 2006). The emergence of this conceptualization of high-quality care led some scholars in various disciplines, including nursing, to reflect on the methods used throughout the process of designing, evaluating, and translating interventions. There is a growing request to embrace alternative methods that have the potential to generate theoretical and practical knowledge to inform delivery of care (e.g., Gross & Fogg, 2001; Nallamothu et al., 2008; Sidani et al., 2003) and to plan effective knowledge translation and implementation strategies (Eccles et al., 2005) that are relevant to a variety of practice settings within and across countries (Hallberg, 2009).

1.1.1 Evidence-based practice: a review

Evidence-based practice was introduced as an approach for delivering high-quality care (Guyatt et al., 2002; Jennings & Loan, 2001). It is broadly defined as “the conscientious, explicit, and judicious use of current, best evidence in making decisions about the care of individual patients” (Sackett et al., 1997, p. 2). Proponents of evidence-based practice believe that interventions found effective and safe on the basis of best available evidence can be delivered in a consistent manner to produce the same effects in clients presenting with the same problem, under the conditions of day-to-day practice (Victora et al., 2004). They advocate the development of guidelines to inform practice. Guidelines are systematically developed statements of recommendations to assist health professionals in decision-making about client care (Lugtenberg et al., 2009). The guidelines specify the target population in terms of experience of the presenting problem, the intervention(s) to be used to address the problem, and the procedures for monitoring the intervention outcomes (Titler et al., 1999). The guidelines are disseminated to health professionals who are expected to implement them as recommended. The end results are provision of best available care and improvements in clients’ condition.

The above definition of evidence-based practice underscores the importance of best evidence in guiding practice. Proponents of this approach to care place high value on research as compared to other sources of evidence. In particular, they consider most appropriate evidence derived from primary or meta-analytic studies that used the randomized controlled or clinical trial (RCT) design to investigate the effects of interventions. The RCT is deemed the gold standard for intervention evaluation research (Richardson, 2000). The features that characterize the RCT design include careful selection of participants on the basis of stringent eligibility criteria; random assignment of participants to the experimental and comparison groups; concealment of treatment allocation; manipulation and standardization of intervention delivery; blinding of research staff and participants to allocated treatment; and control of contextual factors. These features are believed to minimize the influence of potentially confounding factors, which is required for demonstrating the causal effects of the intervention on outcomes.

To date, experience with evidence-based practice raises concerns with the nature of the evidence forming the basis for developing guidelines for practice, with the emphasis on using and/or adhering to these guidelines in practice, and with the strategies for transferring the guidelines into the practice setting. The relevance of empirical evidence on intervention effects derived from RCT studies to the practice setting has been questioned. Recent critique of the RCT design highlights its limitations in maintaining internal and external validity. The limitations stem from the features of the RCT. The application of strictly defined inclusion and exclusion criteria confines the accrued sample to a very selective and homogeneous subgroup of the target population seen in the practice setting. Random assignment does not reflect the process of selecting and providing interventions within the context of practice. This method of treatment allocation is often not well received by clients participating in an RCT and the health professionals responsible for their care. It may contribute to self-selection into the trial, to attrition, and to dissatisfaction and nonadherence of participants with the allocated treatment and subsequent poor outcome achievement; these, in turn, result in inaccurate estimates of the intervention effects that may not be replicable in the practice setting. Manipulation and standardization of the intervention are not congruent with day-to-day practice, where treatment is not withheld from needy clients, and interventions are modified to fit the needs and values of clients, and/or given sequentially in response to changes in clients’ condition. Therefore, interventions validated in RCT studies may not be transferable to and easily incorporated in the practice setting. The experimental control that characterizes the RCT is unrepresentative of the complexity of the practice context; thus, the intervention effects may not be reproduced in practice (Grapow et al., 2006; Huibers et al., 2004; Lindsay, 2004; Richardson, 2000; Robitaille et al., 2005; Valentine & McHugh, 2007).

The emphasis on using and/or adhering to guidelines has been criticized for reducing practice to a mechanistic application of empirically supported interventions that is informed by generic algorithms (Sehon & Stanley, 2003). The algorithms instruct health professionals which interventions to select and implement to address the clients’ presenting problem. This mechanistic application of generic algorithms does not take into consideration the clients’ experiences, needs, beliefs, and perceived acceptability of the intervention. Also, it disregards the health professionals’ skills at critical thinking, and obligations to respond flexibly to the clients’ needs. Further, the guidelines’ recommendations are often stated in general terms that simply identify the interventions to be given. They do not clearly specify the conditions under which the interventions are most effective, and do not explain how the intervention effects are produced. Yet, knowledge of who benefit the most from the intervention given at what dose and in what mode is essential for guiding practice (Brown, 2002; Sidani & Braden, 1998).

Numerous projects have been undertaken to transfer, translate, and implement evidence into practice. Various strategies have been utilized in these endeavors, of which education is the most common. Typically, educational strategies are didactic, involving passive learning, where health professionals are informed of the evidence and expected to apply the intervention in their day-to-day practice. However, recent literature on knowledge translation indicates that overall, attempts to implement evidence-based practice in particular settings were not successful at sustaining changes in health professionals’ practice and hence in improving the quality of client care (Sales et al., 2006). Considerable variation in success rate was observed within an individual intervention and across interventions (Eccles et al., 2005; Lugtenberg et al., 2009). Findings of relevant studies consistently pointed that health professionals, including nurses, do not depend on research as a source of evidence to guide practice. Rather, they rely on other sources, primarily clinical knowledge either gained personally or shared by colleagues, as well as patient experience (French, 2005; Spenceley et al., 2008).

This state of affairs has contributed to reconsideration of different sources of evidence as acceptable for generating the knowledge needed to guide practice, and the client-centered as an approach to provide high-quality care (see Section 1.1.2). Acceptable sources of evidence include local knowledge and client experience, as well as research. Local knowledge is embedded within particular practice settings and is accumulated in two ways. First, local knowledge is obtained through performance evaluation and/or quality improvement initiatives undertaken in the setting. The results of these initiatives represent valuable information about the practice area requiring change; unmet needs of clients and of health professionals working in the setting; and the type and impact of interventions delivered to address the health problems of the locally served population (Rycroft-Malone et al., 2004). Second, local knowledge is gained through health professionals’ experience and is embedded in the human capital, that is, expert professionals available in the setting. Local knowledge is critical for translating evidence. It directs efforts at adapting guidelines to fit the contextual characteristics of a particular setting. Client experience is emerging as a useful source of evidence to guide the process of making decisions about care of individuals, families, and communities. Patient experience is not clearly defined in the literature on evidence-based practice; however, it appears to connote attendance to the clients’ characteristics, needs, and preferences (Mykhalovskiy & Weir, 2004), as advocated in the implementation of client-centered care. Research evidence has been expanded to include quantitative and qualitative studies. Accumulating results suggested that non-RCT designs (e.g., quasi-experimental and cohort) provide meaningful evidence supporting the effectiveness of interventions delivered under usual conditions of day-to-day practice (Concato & Horwitz, 2004; Nallamothu et al., 2008; Vandenbroucke, 2004). Findings of non-RCT designs, in combination with those of studies investigating factors that moderate and/or mediate intervention effects, address questions of concern to health professionals. In other words, they enhance the clinical relevance of research findings, which can promote uptake and application of interventions in the practice setting.

1.1.2 Client-centered care

Client-centered care has been, and still is, highly valued in nursing (Lauver et al., 2002). It is resurging as an approach aimed to provide high-quality care (Naylor, 2003). Client-centered care is congruent with the philosophical orientation of nursing practice (Rolfe, 2009). Nurses are instructed, socialized, and expected to deliver client-centered care. Nurses recognize the multidimensionality of clients’ experience, acknowledging the biophysiological, physical, psycho-behavioral, and sociocultural domains of health; respect the uniqueness of clients’ needs; and individualize care to be consistent with the clients’ needs. The description of client-centered care, available in the literature, has focused on characterizing this approach to care at the individual client level. The features that distinguish client-centered care are: (1) acknowledging the client as a unique person; (2) understanding the individual characteristics, needs, beliefs, values, and preferences of the person; and (3) responding flexibly to the persons’ characteristics, needs, and preferences (McCormack, 2003; Radwin, 2003). Responding flexibly, also termed responsiveness (Radwin et al., 2009), involves participation of persons in decision-making and individualization of care (McCormack & McCance, 2006; Sidani, 2008). Participation of persons in the process of decision-making consists of a joint effort between the health professionals and the person to identify his or her needs and preferences, and to select the intervention that will address the person's needs and that the person views as acceptable (Sidani et al., 2006). Individualization of care involves customization of the intervention activities, dose, and/or mode of delivery so that they are mindful of the person's characteristics, resources, and/or context. The client-centered approach has also been applied to the care of families. Family-centered care encompasses similar features; however, the focus is on the family as a unit. The application of the client-centered approach to the care of communities is reflected in the collaborative participation of community members in identifying health needs and in developing, adapting, or selecting relevant interventions.

The implementation of client-centered care is expected to benefit the individuals, families, and communities. It is proposed that this approach promotes clients’ sense of independence and control through their participation in treatment-related decisions (Reid Ponte et al., 2003); increases satisfaction with care related to the receipt of the intervention of choice; enhances adherence to treatment; and, subsequently, achievement of intended outcomes (Sidani et al., 2010). The limited number of studies that investigated the benefits of the client-centered approach to care have focused on either participation of clients in decision-making or individualization of educational interventions. The results of these studies were promising, showing improvement in health outcomes for clients who participated in decision-making and/or received client-centered care or individualized interventions (e.g., Fremont et al., 2001; Lauver et al., 2002; Sidani, 2008; Wensig & Grol, 2000).

Responding flexibly to clients’ characteristics, needs, and preferences raised the issue of discrepancy between the selected intervention and the intervention considered most effective on the basis of the best available evidence. That is, clients may find acceptable, express a preference for, and choose interventions which may not be effective or may have been minimally effective in managing the presenting problem or producing the desired outcomes (Wensig & Grol, 2000). To address this issue, Coyler and Kamath (1999) proposed an integrated “patient-centered evidence-based” approach to care. Briefly, this approach entails identifying evidence-based interventions, incorporating only those interventions as alternatives from which clients can choose and/or nurses can individualize to be consistent with clients’ characteristics and preferences (Sidani et al., 2006). The integrated client-centered evidence-based approach has implications for the definition of high-quality care.

1.1.3 High-quality care redefined

High-quality care refers to the delivery of interventions that are appropriate, acceptable, effective, safe, and efficient. Appropriate interventions are logical, reasonable, and sound treatments that specifically address the health problem with which clients present. This implies that the nature of such interventions is consistent with the nature of the presenting problem, where activities comprising the interventions should fit with the defining characteristics and/or the determinants of the presenting problem, and the dose with which the interventions are given is compatible with the severity with which the problem is experienced. For instance, educational interventions in...

Table of contents

• Cover
• Title Page
• Copyright
• Preface
• Acknowledgment
• Section 1: Introduction
• Section 2: Designing Interventions
• Section 3: Implementation of Interventions
• Section 4: Evaluation of Interventions
• Section 5: Translation of Interventions
• References
• Index