Care and service implementation

A critical incident is something that happens, either positively or negatively, that may cause someone to reflect on what has happened and maybe rethink the events. Critical Incident Analysis can help to facilitate reflective practice or reflective learning by enabling nurses to explore their feelings on a certain subject. [1-2] It is a valuable learning tool that can be used as a starting point for evidence based practice. It can also be included within a professional portfolio. [3]

A critical incident could be a medication error, an interaction between a patient and staff member, or the circumstances surrounding a patient’s death. The critical incident may only be significant for the individual(s) involved or it may affect the whole team.

Critical incident analysis involves focusing on an event, including analysing the circumstances surrounding it, the actions of those involved, responses to the event and the outcomes. The result should be a better understanding of how practice can be improved. [4]

References

1. Mulligan A. Should dying patients be monitored? A reflective analysis of a critical incident. Nurs Crit Care. 2005 May-Jun;10(3):122-6; discussion 127-8.
2. Alphonso C. Reflection on a critical incident. Contemp Nurse. 2007 Feb;24(1):89-92.
3. Hilliard C. Using structured reflection on a critical incident to develop a professional portfolio. Nurs Stand. 2006 Sep 20-26;21(2):35-40.
4. Vachon B, LeBlanc J. Effectiveness of past and current critical incident analysis on reflective learning and practice change. Med Educ. 2011 Sep:45(9):894-904.

Evidence Based Practice (EBP), Quality Improvement (QI) and Research are tools for problem solving and inform each other. [1]

• QI analyses existing data to improve systems related to business processes and outcomes (ie, cost, productivity, quality). Audit is a QI activity.
• EBP analyses existing data for purposes of ranking evidence that will be used to answer questions that guide practice.
• Research validates and refines existing data or generates new knowledge to influence nursing practice, systems and policies. [2]

Clinical audit has been defined as a quality improvement strategy that intends to measure and improve the care and outcomes patients experience. [3] It is a proven and effective process for measuring quality and driving improvement. [4] An audit is a snapshot of current practice against best practice, target performance. This is done by the selection of aspects of patient care and the evaluation of the performance of a service against an agreed set of criteria or standards to answer the following questions:

• What is happening now? (baseline)
• What should be happening? (according to evidence, best practice, other agreed standards, which provide the criteria for the audit)
• How can we improve? (changes and interventions required)
• Have our improvements resulted in a change? (repeated audits as part of the cycle to close the gap).

For audit and feedback the choice of comparator impacts on quality improvement outcomes, with no single comparator suited to all recipients and contexts. [5] As a result of these activities a change in practice is often indicated, with appropriate change management strategies required for effective implementation.

References

1. Cepero J. Differences among quality improvement, evidence-based practice, and research. J Neurosci Nurs. 2011 Aug;43(4):230-2.
2. Shirey MR, Hauck SL, Embree JL, Kinner TJ, Schaar GL, Phillips LA, et al. Showcasing differences between quality improvement, evidence-based practice, and research. J Contin Educ Nurs. 2011 Feb;42(2):57-68; quiz 69-70. Epub 2010 Jul 6.
3. National Institute for Clinical Excellence. Principles for best practice in clinical audit. Abingdon: Radcliffe Medical Press; 2002.
4. Burgess R, editor. New principles of best practice in clinical audit. 2nd ed. Oxford(GB): Radcliffe publishing; 2011.
5. Gude WT, Brown B, van der Veer SN, et al. Clinical performance comparators in audit and feedback: a review of theory and evidence. Implement Sci. 2019;14(1):39. Published 2019 Apr 24. doi:10.1186/s13012-019-0887-1

The term evidence is used frequently in clinical practice and in research. Evidence is most commonly thought of as the proof that supports a claim or belief. In healthcare for example, this could be the effectiveness of an intervention.

It can be confusing when there are different levels and sources of evidence. There are resources here that can help to explain the types and levels of evidence.

Evidence-based practice is an approach to care that encourages clinicians to use the best available evidence and critically apply it to the individual patient’s circumstances and preferences in clinical practice.

There is a large quantity of information and resources within CareSearch that can help nurses in addressing the issue of evidence based practice.

In the era of evidenced-based practice, research is a vital component of current and future nursing practice. All nurses, regardless of their role or workplace will encounter research throughout their career. Their involvement will vary.

While some nurses will be involved in conceptualising and initiating research, others will be putting into practice the outcomes of research so as to deliver the best possible care to the patient.

Nurses can sometimes be unsure about the ethics of conducting research in vulnerable patient populations, such as those at the end-of-life. However, it has been shown that studies in this population are appropriate. Patients are often rewarded in knowing that their participation will benefit those who will follow in the future. If patients have all the information they need to make an informed choice and decide to go ahead, nurses are in the best position to support them.

Having easy access to up to date resources regarding research is important no matter what your role.