McKillop Ann, Crisp Jackie, Walsh Kenneth
Faculty of Medical and Health Sciences, School of Nursing, The University of Auckland, New Zealand.
Prim Health Care Res Dev. 2012 Jan;13(1):48-59. doi: 10.1017/S1463423611000405. Epub 2011 Oct 13.
The aim of this study was to explore the realities of everyday nursing practice associated with the implementation of a guideline for the assessment and management of cardiovascular risk.
The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable and, in spite of much investigation, remains resistant to explanation of what works and why. Exploration of the nature of guideline implementation has the potential to illuminate the complexities of guideline implementation by focussing on the nature of practice. Nurses are well placed at the front line of primary health care to contribute to an understanding of how guideline implementation plays out in their everyday practice.
Qualitative description was used, involving focus groups and interviews with 32 participants (20 nurses, four doctors, five managers and three funder/planners), to explore the use of a guideline in everyday primary health-care practice. Thematic analysis of data was managed through an inductive process of familiarisation, coding, categorising and generation of themes.
Four themes were generated from the data portraying the realities of guideline implementation for primary health-care nurses: self-managing patient, everyday nursing practice, developing new relationships in the health team and impact on health-care delivery. The findings reveal that, even with the best of intentions to implement the guideline, health professionals were frustrated and at a loss as to how to achieve that in practice. Consequently, cardiovascular risk assessment and management was uneven and fragmented. Primary health-care practice environments vary so much that solutions to the difficulties of implementing evidence into practice requires context-specific solution-finding through collaborative teamwork. Furthermore, the attention of guideline developers, health-care policymakers, funders and researchers requires direct focus on the 'how' and the 'what' of evidence implementation.
本研究旨在探讨与心血管风险评估和管理指南实施相关的日常护理实践的实际情况。
临床实践指南的使用对于改善健康结果至关重要。然而，将指南实施到实践中是复杂且不可预测的，尽管进行了大量调查，但对于什么有效以及为何有效仍难以解释。通过关注实践的本质来探索指南实施的性质，有可能阐明指南实施的复杂性。护士处于初级卫生保健的前线，有助于理解指南实施在其日常实践中的实际情况。
采用定性描述法，通过焦点小组和对32名参与者（20名护士、4名医生、5名管理人员和3名资助者/规划者）进行访谈，以探讨指南在日常初级卫生保健实践中的使用情况。通过熟悉、编码、分类和生成主题的归纳过程对数据进行主题分析。
从数据中生成了四个主题，描绘了初级卫生保健护士实施指南的实际情况：自我管理患者、日常护理实践、在卫生团队中建立新关系以及对医疗服务提供的影响。研究结果表明，即使有最好的意愿实施指南，卫生专业人员对于如何在实践中实现这一目标仍感到沮丧和困惑。因此，心血管风险评估和管理参差不齐且碎片化。初级卫生保健实践环境差异很大，因此要解决将证据应用于实践中的困难，需要通过团队协作找到针对具体情况的解决方案。此外，指南制定者、卫生保健政策制定者、资助者和研究人员需要直接关注证据实施的“如何”和“内容”。
