Teaching EBP : part 2 – making sense of clinical practice guidelines

Previously, we indicated that we wanted to address the dialogue pertaining to education and teaching approaches to increase the use of specific types of evidence that exist to guide and inform practice, and began this by focusing on Clinical Practice Guidelines (CPG). This column builds on that knowledge to highlight how educators can use CPGs in practice and change situations whilst also raising awareness of the limitations of these tools in terms of their impact on practice.

Using meta-synthesis to facilitate evidence-based practice

In a previous column, Fineout-Overholt et al. (2008) discussed the use of systematic reviews in decision making for clinical practice, focusing primarily on the quantitative studies, such as randomised controlled trials. Narrative reviews were included but in less detail; this was intentional because the synthesis of qualitative evidence is a complex process and has evoked significant discussion over the past 5 years. Consequently, this column addresses some of the process issues surrounding qualitative evidence synthesis, or meta-synthesis as it is more commonly known, and offers ideas for how evidence arising from these can be used to inform education, teaching, and practice.

How systematic reviews can foster evidence-based clinical decisions : part II

In the prior issue, we spoke about what a systematic review is and where a clinician can find this important evidence for decision making (Fineout-Overholt et al. 2008). In this column, we will address what is involved in conducting a systematic review, and how critically appraising a systematic review informs clinicians of the best evidence available to make decisions that impact outcomes.

Supervisors are central to work characteristics affecting nurse outcomes

Purpose: To examine the predictive capability of the demand-control-support (DCS) model, augmented by organizational justice variables, on attitudinal- and health-related outcomes for nurses caring for elderly patients.

Design: The study is based on a cross-sectional survey design and involved 168 nurses working with elderly patients in facilities of a medium to large Australian organization.

Method: Participants were asked to complete a questionnaire consisting of scales designed for measuring independent (e.g., demand, control, support, organizational justice) and dependent (e.g., job satisfaction, organizational commitment, wellbeing and psychological distress) variables. Multiple regression analyses were undertaken to identify significant predictors of the outcome variables.

Findings: The DCS model explains the largest amount of variance across both the attitudinal and health outcomes with 27% of job satisfaction and 49% of organizational commitment, and 33% of psychological distress and 35% of wellbeing, respectively. Additional variance was explained by the justice variables for job satisfaction (5%), organizational commitment (4%), and psychological distress (23%).

Conclusions: Using organizational justice variables to augment the DCS model was valuable in better understanding the work conditions experienced by nurses caring for elderly patients. Inclusion of curvilinear effects added clarity to the potentially artifactual nature of certain interaction variables.

Clinical Relevance: The results indicated practical implications for managers of nurses caring for elderly patients in terms of developing and maintaining levels of job control, support, and fairness, as well as monitoring levels of job demands. The results particularly show the importance of nurses' immediate supervisors.

Moving beyond resistance to restraint minimization : a case study of change management in aged care

Aim: This case study describes a quality initiative to minimize restraint in an Australian residential aged care facility.

Approach: The process of improving practice is examined with reference to the literature on implementation of research into practice and change management. The differences between planned and emergent approaches to change management are discussed. The concepts of resistance and attractors are explored in relation to our experiences of managing the change process in this initiative. The importance of the interpersonal interactions that were involved in facilitating the change process is highlighted.

Implications: Recommendations are offered for dealing with change management processes in clinical environments, particularly the need to move beyond an individual mind-set to a systems-based approach for quality initiatives in residential aged care.

Information-based regulation of high-velocity foot-targeting tasks

Judging time-to-contact with a target is an important criterion for avoiding harm in everyday walking and running tasks, and maximizing performance in high-velocity sporting tasks. The information-based regulation of step length and duration during target-directed locomotion was examined in relation to gait mode, approach velocity, target task, expertise, and sporting performance during a series of four experiments. The first three experiments examined novice performers (Each n=12, 6 males, 6 females), whilst the last experiment examined expert gymnasts (n=5). Two reference strips with alternating 50cm black and white intervals were placed on either side of the approach strip for all of the experiments. One 50Hz-panning video camera filmed the approach from an elevated position. In Experiment 4, two stationary 250Hz cameras filmed the post-flight performance of the gymnastic vaults and, in addition, two qualified judges provided a performance score for each vaulting trial. The panning video footage in each experiment was digitized to deduce the gait characteristics. In Experiment 4, the high-speed video footage was analyzed three-dimensionally to obtain the performance measures such as post-flight height. The utilization of visual stimulus in target-directed locomotion is affected by the observer's state of motion as characterized by the mode of locomotion and also often the speed of locomotion. In addition, experience plays an important role in the capacity of the observer to utilize visual stimulus to control the muscular action of locomotion when either maintaining or adjusting the step mechanics. The characteristics of the terrain and the target also affect the observer's movement. Visual regulation of step length decreases at higher approach speeds in novice performers, where as expert performers are capable of increasing visual regulation at higher approach speeds. Conservatism in final foot placement by female participants accounts for the observed increase in distance from the critical boundary of the obstacle relative to toe placement. Behavioural effects of gender thus affect the control of final foot placement in obstacle-directed locomotion. The visual control of braking in target-directed locomotion is described by a tau-dot of-0.54. When tau-dot is below -0.54 a hard collision with the obstacle will occur, however, when tau-dot is above -0.54, a soft collision with the target will occur. It is suggested that the tau-dot margin defining the control of braking reveals the braking capacity of the system. In the target-directed locomotion examined a tau-dot greater than -0.70 would possibly exceed the braking capacity of the system, thus, leading to injury if performed. The approach towards the take-off board and vaulting horse in gymnastics is an example of target-directed locomotion in sport. Increased visual regulation of the timing and length of each step is a requirement for a fast running approach, a fundamental building block for the execution of complex vaults in gymnastics. The successful performance of complex vaults in gymnastics leads towards a higher judge's score. Future research suggestions include an investigation of visual regulation of step length in curved target-directed locomotion.

Diverse fibrillar peptides directly bind the Alzheimer’s amyloid precursor protein and amyloid precursor-like protein 2 resulting in cellular accumulation

The Alzheimer’s disease Aβ peptide can increase the levels of cell-associated amyloid precursor protein (APP) in vitro. To determine the specificity of this response for Aβ and whether it is related to cytotoxicity, we tested a diverse range of fibrillar peptides including amyloid-β (Aβ), the fibrillar prion peptides PrP106–126 and PrP178–193 and human islet-cell amylin. All these peptides increased the levels of APP and amyloid precursor-like protein 2 (APLP2) in primary cultures of astrocytes and neurons. Specificity was shown by a lack of change to amyloid precursor-like protein 1, τ-1 and cellular prion protein (PrPc) levels. APP and APLP2 levels were elevated only in cultures exposed to fibrillar peptides as assessed by electron microscopy and not in cultures treated with non-fibrillogenic peptide variants or aggregated lipoprotein. We found that PrP106–126 and the non-toxic but fibril-forming PrP178–193 increased APP levels in cultures derived from both wild-type and PrPc-deficient mice indicating that fibrillar peptides up-regulate APP through a non-cytotoxic mechanism and irrespective of parental protein expression. Fibrillar PrP106–126 and Aβ peptides bound recombinant APP and APLP2 suggesting the accumulation of these proteins was mediated by direct binding to the fibrillated peptide. This was supported by decreased APP accumulation following extensive washing of the cultures to remove fibrillar aggregates. Pre-incubation of fibrillar peptide with recombinant APP18–146, the putative fibril binding site, also abrogated the accumulation of APP. These findings show that diverse fibrillogenic peptides can induce accumulation of APP and APLP2 and this mechanism could contribute to pathogenesis in neurodegenerative disorders.