Nsg 7100-Theoretical Framework Research Proposal Paper
-
Upload
muhammad-arsyad-subu -
Category
Documents
-
view
105 -
download
0
Transcript of Nsg 7100-Theoretical Framework Research Proposal Paper
NSG 71020 Theoretical Framework Research
CONCEPTUAL FRAMEWORK
Integration of the RNAO Best Practice Guidelines (BPGs) Into an Undergraduate Nursing
Curriculum
NSG 7100 – Theoretical and Philosophical Perspectives in Nursing
Muhammad Arsyad Subu
PhD of Nursing Student University of Ottawa
University of Ottawa, School of Nursing
December, 2011
1
NSG 71020 Theoretical Framework Research
INTRODUCTION (1-2 Pages)
In November 1999, the Registered Nurses Association of Ontario (RNAO) launched the
Best Practice Guidelines (BPGs) program. The RNAO BPGs program is a program with funding
from the Government of Ontario. The purpose of this multi-year program is to support Ontario
Nurses by providing them with Guidelines for client care. There are currently 44 published
guidelines as well as a Toolkit and Educator's Resource to support implementation. To date, 16
of these publications are available in French and continue to translate materials on an ongoing
basis (RNAO, 2011). BPGs are systematically developed statements (based on best available
evidence) to assist practitioner and patient decisions about appropriate health care for specific
clinical (practice) circumstances" (Field & Lohr, 1990). The BPGs are based on a review of a
large body of research findings and recommend the most current and evidence-based information
about concerns of nursing issues.
The main purpose of BPGs is to support nurses by providing guidelines for client care.
BPGs have emerged as an important tool to facilitate knowledge transfer of credible research
evidence (Thompson, et al, 2006). The BPGs program aims to bridge the gap between research
and practice and ensure that the most current available knowledge is put to use for the benefit of
the public who receive nursing care (RNAO, 2005). BPG should be thought of as decision
making tools within the context of patient preferences, wishes, ethics and feasibility (RNAO,
2002). The mandate of the BPG is the commitment to improve and maintain the highest
standards of evidence based practice (EBP). This will be achieved through the: 1)
implementation, evaluation and dissemination of BPGs; 2) assessment, implementation and
evaluation of care pathways; 3) continued evaluation of community nursing standards; and 4)
ensuring sustainability of the above actions.
2
NSG 71020 Theoretical Framework Research
RATIONALE FOR STUDY
Excellent Care for All Act, Bill 46 (Chapter 14 Statutes of Ontario, 2010) point (12.c.)
mentions that…“the functions of the council are to promote healthcare that is supported by the
best available scientific evidence by making recommendations to healthcare organizations and
other entities on standards of care in the health system, based on or respecting clinical practice
guidelines and protocols, making recommendations, based on evidence and with consideration of
the recommendations “(The Legislative Assembly of Ontario, 2010).
Since it was launched, the BPGs proliferation of has promises in clinical practice, improves
patient care and outcomes as well as offers potential cost savings. Some researchers mentioned
that BPGs implementations in some clinical settings facilitate better sustainable practices and
improve patient outcomes. Therefore, attention needs to be given to better understanding the use
of BPGs by nurse educators where they provide teaching-learning process. Furthermore, BPGs
implementation by nurse educators needs to be explored in the context of the educational settings
in order to derive the maximum benefits for the students, clients, and organization.
Understanding these variations will lead to establish better methods for introducing and
transferring the BPGs to the educational settings and facilitate organizational learning that lead
to better teaching-learning process and the best students’ outcomes.
For the past decade, the nursing discipline has embraced evidence based practice to optimize
patient care. The main purpose of BPGs is to support nurses by providing guidelines for client
care. BPGs have emerged as an important tool to facilitate knowledge transfer of credible
research evidence (Thompson, et al, 2006). The BPGs program aims to bridge the gap between
research and practice and ensure that the most current available knowledge is put to use for the
benefit of the public who receive nursing care (RNAO, 2005). Important points for learners
3
NSG 71020 Theoretical Framework Research
include: 1) Systematic development; 2) Best available evidence; and 3) BPG as decision tools.
BPG should be thought of as decision making tools within the context of patient preferences,
wishes, ethics and feasibility (RNAO, 2003). The mandate of the BPG is the commitment to
improve and maintain the highest standards of evidence based practice. This will be achieved
through the: 1) implementation, evaluation and dissemination of BPGs, 2) assessment,
implementation and evaluation of care pathways, 3) continued evaluation of Community Nursing
Standards, and 4) ensuring sustainability of the above actions.
Nursing programs require the ability to transfer knowledge to the students for their
learning with the best evidence. It is important to consider that the courses being taught in
classrooms, clinical, and laboratory settings are based on the best available evidence. The
integration of evidence based practice (EBP) in nursing undergraduate nursing curriculum will
explore the potency of available educational resources. The integration of BPGs throughout
curricula will promote student acceptance of the philosophy and underlying BPGs values as a
natural part of their approach to the nursing profession. These values include having an evidence
base for practice, integrating systematic reviews of evidence into recommendations for practice,
critical selection of appropriate recommendations for the client and the context, and transferring
knowledge to the real world of nursing care (RNAO, 2005).
In clinical settings, many studies showed that BPGs improves patient outcomes, impacts
patient referrals, creates partnership & offers cost savings (i.e. Brouwers, et al, 2004; Campbell,
et al, 2010; Coutts, 2003; Delvin, et al, 2002); Ellis, et al, 2007; Higuchi, et al, 2011; Hogan &
Logan, 2004; & Ploeg, 2004). In addition, many studies described knowledge translation (KT)
& Knowledge Utilization (KU) of evidence-based strategies in nursing disciplines. For example
KT was described (Davis et al., 2003; Glasgow, et al., 2003; Jacobson, et al., 2003; Nutley, et
4
NSG 71020 Theoretical Framework Research
al, 2003; Ohlsson, 2002) and KU was mentioned by (Backer, 1991; Greenhalgh, et al, 2005;
Grol, 2000; Grol & Grimshaw, 2003; Rogers, 2005). However, little is known how these
strategies are used in nursing curriculum development.
STATEMENT OF THE PROBLEM (8-10 Pages)
For the past decade, the nursing discipline has embraced evidence based practice (EBP)
to optimize patient care. There is also a growing recognition of the importance of EBP in nursing
curriculum to ensure that students' learning needs are provided as effectively and efficiently as
possible. Addressing deficiencies in the dissemination and transfer of research-based knowledge
into routine nursing practice is high in nursing discipline internationally.
The Best Practice Guidelines have been piloted in some Best Practice Spotlight
Organization (BPSOs). BPSOs are health care and academic organizations selected by the
Registered Nurses' Association of Ontario (RNAO) through a request for proposals process to
implement and evaluate the RNAO's best practice guidelines. Some selected nursing programs as
BPSOs in Canada and the United States implement BPGs in undergraduate nursing curricula
(RNAO, 2011).
It is essential that sustainability of BPGs implementation needs to be maintained in order
to achieve a high level in a nursing education program. Some studies have been conducted to
investigate the integration of BPGs in clinical settings and these studies show that BPGs
improves patient outcomes, impacts patient referrals, creates partnership & offers cost savings.
However, after an intensive literature search, little has been said that BPGs are systematically
integrated in an undergraduate nursing curriculum. In addition, the barriers and facilitators in
integrating the Best Practice Guidelines in clinical practice have been mentioned in some
5
NSG 71020 Theoretical Framework Research
articles. But, very little is discussed related to the barriers and facilitators of BPGs
implementation in an undergraduate nursing program.
LITERATURE REVIEW
Today, Evidence Based Practice (EBP) has a popular movement in influencing
knowledge development in educational and clinical nursing practice. Nursing discipline exists in
a world in which an evidence-base for professional practice is essential. EBP is in the forefront
of many contemporary discussions of nursing education and nursing practice. The impetus for
EBP in nursing comes from payor and healthcare facility pressures for cost containment, greater
availability of information, and greater consumer savvy about treatment and care options
(Youngblut & Brooten, 2001). EBP has gained momentum in nursing, and definitions vary
widely. The term "best practice" has been used to describe "what works" in a particular situation
or environment. When data support the success of a practice, it is referred to as a research-based
practice or scientifically based practice. It is important to keep in mind that a particular practice
that has worked for someone within a given set of variables may or may not yield the same
results across educational environments. EBP is a collection of facts that are believed to be true.
EBP in nursing is important because it promises to provide a research base that is directly
relevant to practice. Evidence should be generated and validated in multiple forms (Melnyk &
Fineout-Overholt, 2011).
Nursing must be the discipline that uses knowledge and evidence generated from multiple
sources as an integral part of evidence-based nursing recommendations (Carper, 1978). EBP will
integrate research findings into decision making in nursing practice. One of the goals of EBP is
to reduce practice pattern variation (Melnyk & Fineout-Overholt, 2011). EBP demands changes
in educating students, more practice-relevant research, and closer working relationships between
6
NSG 71020 Theoretical Framework Research
clinicians and researchers. EBP also provides opportunities for nursing care to be more
individualized, effective, streamlined, dynamic, and to maximize effects of clinical judgment.
EBP encompasses multiple types of evidence such as research findings, research reviews and
evidence-based theory and the integration of that evidence with clinical expertise and client
preferences and values (Melnyk & Fineout-Overholt, 2011). With the current emphasis on
evidence-based practice in health care and the explosive growth in practice guidelines, it is
critical that careful planning be given to strategies for successful implementation (Ploeg, et al,
2007).
Development of a nursing curriculum needs to be put in serious attention if the nursing
profession is expected to be progressive. The rapid global transcendence of nursing degrees over
other health-care professions triggered most nursing schools to adopt more progressive evidence
based approach to the nursing curriculum. The term nursing curriculum is defined as the total of
philosophical approaches, curriculum outcome statements, overall design, courses, teaching
learning strategies, delivery methods, interaction, learning climate, evaluation methods,
curriculum policies, and resources (Iwasiw et al, 2009). The curriculum, whether in the academic
setting or as the learning strategy for a practice setting, is the overall plan for the education of
learners in the institution or program.
Many authors have called for changes to the curriculum to ensure a levelled building of
EBP competencies over the course of a baccalaureate program (Ciliska, 2005, Fineout-Overholt
et al., 2005, Fineout-Overholt & Johnston, 2005; Mazurek- Melnyk, 2011; Miner Ross, et al.,
2009). It has been my observation that this is not happening in a systematic way at this time,
though it simply may not be evident due to a lack of description or mapping of concepts and EBP
activities in the curriculum. According to Iwasiw, et al (2009), faculty support for curriculum
7
NSG 71020 Theoretical Framework Research
development is mandatory for the process to begin and for a successful outcome to be achieved.
This is gained through open and thoughtful consideration of the reasons for curriculum
development and honest attention to factors that could be limiting. Attention to the values of
individual and collective faculties, an extent curriculum development might be necessary, and
the timeframe for the undertaking will influence whether approval is gained. The impetus and
decision to proceed must be thoughtfully reviewed since curriculum development is intensive,
extensive, and requires ongoing faculty dedication and involvement.
The gap between research evidence on interprofessional collaboration and nursing
practice is wide and well documented. However, among nurse educators, there is a growing
commitment to infuse their nursing curriculum with evidence-based practice. Whitehurst (2003)
defined evidence-based education as "the integration of professional wisdom with the best
available empirical evidence in making decisions about how to deliver instruction. The Canadian
Nurses Association, CNA (2010) released a position statement indicating that educators must
support those graduating from basic and continuing nursing education programs to acquire
competencies to provide evidence-informed nursing.
The turn to evidence over the past decade has far reaching implications for the study of
knowledge translation within the nursing discipline. This distinction in the context of practice
shifts the focus of knowledge translation from understanding a knowledge-to-action process to
an overwhelming emphasis on adherence to evidence-based practice guidelines. It is in the
forefront of many contemporary discussions of nursing research and nursing practice. The
practice of effective nursing, which is mediated through the contact and relationship between
individual practitioner and client, can only be achieved by using several sources of evidence.
The multiple bases of evidence are those from more acknowledged research and clinical
8
NSG 71020 Theoretical Framework Research
experiences, and less informed clients, clients and providers, and local context and environment
(Rycroft-Malone, et al., 2004).
Curriculum implementation begins when the first course is introduced and continues for
the life of the curriculum. Successful implementation is dependent on faculty adoption of the
curriculum tenets and congruent teaching-learning approaches. Also, successful implementation
of the curriculum is dependent on forethought as the curriculum is being designed. The essential
aspects of preparing for the implementation are informing stakeholders; marketing; attending to
contextual agreement and logistics; and planning on going faculty development (Iwasiw, et al.,
2009).
Undergraduate nursing programs require the ability to transfer knowledge to the students
for their learning with the best evidence based practice. It is also important to consider the
courses being taught in classrooms, clinical, and laboratory settings are based on best available
evidence. Integration of EBP in an undergraduate nursing curriculum will explore the potency of
available educational resources. For nurses (educators and clinical instructors), the integration of
best research evidence is important with educational and clinical expertise, and students or client
values. EBP helps nurses provide high-quality client care based on research and knowledge. It is
important that nurses with the most current and comprehensive resources translate the best
evidence into the best nursing research, education, administration, policy and practice (Rycroft-
Malone, Bucknall, Melnyk, 2004).
RNAO BPGs are congruent with the practice standards and provide the best available
knowledge for practice. It has provided an Educator's Resource and a Toolkit for integrating the
Best Practice Guidelines for educational purposes. This guideline has been developed to assist
educators in both academic and practice settings to incorporate BPG into learning events, to
9
NSG 71020 Theoretical Framework Research
promote evidence-based practice to nurse students and faculties in academic settings, and to help
nurses in practice settings (RNAO, 2005). Both the Educator's Resource and the Toolkit to be
used to plan and implement as well as to evaluate a comprehensive strategy for BPG
implementation in both academic and practice settings. The integration of BPG throughout
curricula will promote student acceptance of the philosophy and underlying BPG values as a
natural part of their approach to nursing. These values include: having an evidence base for
practice; integrating systematic reviews of evidence into recommendations for practice; critical
selection of appropriate recommendations for the client and the context; and transferring
knowledge to the real world of nursing care (RNAO, 2005). Strategies to integrate BPG content
into the practice setting will be different from approaches for the academic setting. In the
practice setting, it is important to recognize that some nurses have learned about EBP in their
undergraduate education; however, they may not have had recent exposure to BPGs. For others,
client care based on evidence may be a new concept. Implementing BPGs recommendations may
require that these nurses change their approach and EBP has not been a key in the delivery of
nursing care. Nurses rated knowledge of the client as an individual, and their own experience,
more highly than research as the basis for decision making related to client care (Gerrish &
Clayton, 2004; RNAO, 2006).
The knowledge translation and knowledge utilization concepts have gained popularity as
a viable solution to address the "research-practice gap." The discussion around knowledge
translation is on the transfer or dissemination of research findings into education and nursing
practice. Reviews of dissemination, implementation, and impact of practice guidelines in nursing
show the following factors might influence implementation: a combined strategy of opinion
leaders and in-service lectures, group culture or belief systems, time and resources, computerized
10
NSG 71020 Theoretical Framework Research
reminders of recommendations, documentation systems, inter-professional partnerships, and
strategic commitment (Cheater & Closs 1997; Thomas et al, 1998; Thomas et al, 1999).
However, these conclusions are based on a small number of studies; some with significant
methodological limitations.
Attention to the sustainability of BPGs programs is increasing. Sustainability of
application of BPGs in an undergraduate nursing curriculum needs to be maintained in order to
achieve a high level in a nursing education program. Planning for BPGs sustainability requires a
clear understanding of the concept of sustainability and operational indicators that may be used
in monitoring sustainability over time. The reason for consistency to sustain of BPGs
implementation is that it leads to the highest quality of care and clients outcomes. The literature
provides descriptions of a number of strategies to promote the integration of evidence-based
practice in nursing clinical education (de Cordova, et. al., 2008, Eaton, et. al., 2007, Higuchi et.
al., 2006, Miner-Ross et. al., 2010, Ritchie, et. al., 2010, and Stone & Rowles, 2007). Examples
of these strategies described include: workshops for clinical instructors and/or students to
promote critical appraisal and the use of BPGs in education; clinical practices; and having the
students conduct evidence-based projects during their clinical rotations.
Many authors have discussed the potential barriers to research utilization. Some of the
articles report the results of data-based surveys on the perceptions of nurses in clinical,
administrative, or academic positions. Others are firsthand reports of informal or formal
utilization experiences. The numbers of barriers are identified and the consistency among the
reports is striking. Several papers have also discussed the barriers and facilitators to the
implementation of evidence based practice in nursing education (Ciliska, 2005, Mazurek
Melnyk, 2008, Schoales Lada, 2006). EBP must be consistently threaded throughout both
11
NSG 71020 Theoretical Framework Research
didactic and clinical courses where real life case examples provide the framework for the EBP
process and continual reinforcement through the professional program leads to lifelong learning
skills to improve practice (Fineout-Overholt & Melnyk & Shultz, 2005). Newton (2009) stated
that the challenge of translating research findings into clinical practice has been an explicit
concern to the discipline and profession of nursing for decades. Barriers to effective use of
research include the gap between research and practice goals; the relevance or perceived
relevance of research; poor access to research or not having time to absorb it; and research-
unfriendly organizational settings (Hemsley-Brown, 2004). It is helpful to draw on Rogers'
seminal work diffusion on innovation. Rogers (2005) defined diffusion as "the process by which
an innovation is communicated through certain channels over time among the members of a
social system."
The barriers and facilitators in integrating Best Practice Guidelines in clinical settings
have been mentioned also in some articles. Few researchers have examined barriers and
facilitators experienced by other health care providers including nurses, administrators, or project
leaders who have implemented clinical guidelines (Ploeg, et al., 2007). The RNAO (2005)
predicted some facilitators that may influence the integration of BPGs in any setting: 1)
accreditation expectations; 2) professional practice standards: 3) changes to entry practice
requirements; 4) increased awareness and appreciation of evidence-based practice (EBP); social
accountability for quality outcomes; and fiscal accountability for quality outcomes. In acute,
long-term, community, extended care and home care settings. The most commonly reported
barriers were staff time, workload and resource constraints; lack of access to equipment and
resources; and; staff resistance to change (Ploeg, et al., (2007). The four most commonly
reported facilitators were: (1) presence of change champions, local facilitators, local leaders
12
NSG 71020 Theoretical Framework Research
and/or specialist nurses; (2) staff training, education, and problem solving related to guidelines;
(3) strong unit or organizational leadership; and (4) collaboration with multidisciplinary teams
(Ploeg, et al., 2007).
In summary, nursing programs require the ability to transfer knowledge to the students
for their learning with the EBP. It is important to consider that the courses being taught in
classroom, clinical, and laboratory are based on EBP. The integration of BPGs throughout
curricula will promote student acceptance of the philosophy and underlying BPGs values as a
natural part of their approach to nursing profession. These values include having an evidence
base for practice; integrating systematic reviews of evidence into recommendations for practice;
critical selection of appropriate recommendations for the client and the context; and transferring
knowledge to the real world of nursing care (RNAO, 2005). In clinical settings, many studies
showed that BPGs have benefits for patients and organizations (i.e. Brouwers, et al, 2004;
Campbell, et al, 2010; Coutts, 2003; Delvin, et al, 2002); Ellis, et al, 2007; Higuchi, et al, 2011;
Hogan & Logan, 2004; & Ploeg, 2004). Little has been said that BPGs benefits in nursing
programs. Also, many authors mentioned the barriers and facilitators in integrating Best Practice
Guidelines in clinical practice. In nursing program, very little is discussed related to the barriers
and facilitators of BPGs implementation. In addition, many studies described knowledge
translation (KT) & Knowledge Utilization (KU) of evidence-based practice strategies in nursing
disciplines. For example KT was described by (Davis et al., 2003; Jacobson, et al., 2003;
Nutley, et al, 2003; Ohlsson, 2002) and KU was mentioned by (Backer, 1991; Greenhalgh, et
al, 2005; Grol, 2000; Grol & Grimshaw, 2003; Rogers, 2005). However, little is known how
these KT and KU strategies are used in nursing curriculum development. It is important that
these phenomena need to be explored.
13
NSG 71020 Theoretical Framework Research
RESEARCH QUESTIONS
It is essential that sustainability of BPGs implementation needs to be maintained in order
to achieve a high level nursing education program. This study has three questions:
1. How the BPGs recommendations are integrated in overall curriculum design (theory and
clinical courses) in undergraduate nursing program?
2. What are the barriers and facilitators of BPGs implementation in undergraduate nursing
curriculum?
3. How the curriculum changes have been sustained based on BPGs recommendations?
A qualitative case study method will be used in this study. A Case study is one approach that
supports deeper and more detailed investigation of the type that is normally necessary to answer
(how, what and why) questions (Yin, 2004, 2008; Clardy, 1997; Shavelson & Townes, 2002).
Process in conducting a case study follows the same general process as other research: plan,
develop instruments, train data collectors (if necessary), collect data, analyze data, and
disseminate findings (Neale, Thapa & Boyce, 2006, Yin, 2008).
14
NSG 71020 Theoretical Framework Research
CONCEPTUAL FRAMEWORK (15-20 Pages)
Quantitative Methods Paradigm
Qualitative and quantitative approaches are rooted in philosophical traditions with different
epistemological and ontological assumptions.
Epistemology- is the theory of knowledge and the assumptions and beliefs that we have about
the nature of knowledge. How do we know the world? What is the relationship between the
inquirer and the known?
Ontology- concerns the philosophy of existence and the assumptions and beliefs that we hold
about the nature of being and existence.
Paradigms- models or frameworks that are derived from a worldview or belief system about the
nature of knowledge and existence. Paradigms are shared by a scientific community and guide
how a community of researchers act with regard to inquiry.
Methodology- how we gain knowledge about the world or "an articulated, theoretically
informed approach to the production of data" (Ellen, 1984, p. 9).
Most qualitative research emerges from the 'interpretivist' paradigm. While we describe the
epistemological, ontological and methodological underpinnings of a variety of paradigms, one
need not identify with a paradigm when doing qualitative research.
As Bryman (2004) articulates (see chapter 1) the tension between interpretivist and positivist approaches in a political debate about the nature, importance and capacity of different research methods.
Up until the 1960s, the 'scientific method' was the predominant approach to social inquiry, with little attention given to qualitative approaches such as participant observation.
In response to this, a number of scholars across disciplines began to argue against the centrality of the scientific method. They argued that quantitiative approaches might be appropriate for studying the physical and natural world, they were not appropriate when the object of study was people. Qualitative approaches were better suited to social inquiry.
15
NSG 71020 Theoretical Framework Research
To understand the tension between paradigms one must understand that this tension - the either or approach that emerged in the context of a debate about the capacity and importance of qualitative methods.
Byrman and others, most recently Morgan (2007), argue for a more pragmatic approach; one that is disentrangled from the entrapments of this paradigm debate, one that recognizes the ties or themes that connect quantitative and qualitative research, and one that sees the benefits of blending quantitative and qualitative methods.
Bryman, A. (2004). Quantity and Quality in Social Research. London: Routledge. First published in 1988.
Ellen, RF. (1984). Introduction. In RF Ellen (Ed.), Ethnographic Research: A guide to general conduct (research methods in social anthropology) (pp. 1-12). London: Academic Press
Morgan, DL. (2007). Paradigms lost and paradigms regained. Journal of Mixed Methods Research. 1(1), 48-76.
The Interpretivist Paradigm
Interpretivist views have different origins in different disciplines. Schultz, Cicourel and
Garfinkel (phenomenology/sociology), the "Chicago School of Sociology" (sociology), and Boas
and Malinowski (anthropology) are often connected with the origin the interpretivist paradigm.
The interpretivist paradigm developed as a critique of positivism in the social sciences. In
general, interpretivists share the following beliefs about the nature of knowing and reality.
Relativist ontology - assumes that reality as we know it is constructed intersubjectively through the meanings and understandings developed socially and experientially.
Transactional or subjectivist epistemology - assumes that we cannot separate ourselves from what we know. The investigator and the object of investigation are linked such that who we are and how we understand the world is a central part of how we understand ourselves, others and the world.
By positing a reality that cannot be separate from our knowlege of it (no separation of subject and object), the interpretivist paradigm posits that researchers' values are inherent in all phases of the research process. Truth is negotiated through dialogue.
Findings or knowledge claims are created as an investigation proceeds. That is, findings emerge through dialogue in which conflicting interpretions are negotiated among members of a community.
Pragmatic and moral concerns are important considerations when evaluting interpretive science. Fostering a dialogue between researchers and respondents is critical. It is through
16
NSG 71020 Theoretical Framework Research
this dialectial process that a more informed and sophisticated understanding of the social world can be created.
All interpretations are based in a particular moment. That is, they are located in a particular context or situation and time. They are open to re-interpretation and negotiation through conversation.
Methodology
Interpretive approaches rely heavily on naturalistic methods (interviewing and observation and analysis of existing texts).
These methods ensure an adequate dialog between the researchers and those with whom they interact in order to collaboratively construct a reality.
Generally, meanings are emergent from the research process.
Typically, qualitative methods are used.
View of Criteria for 'Good' Research
Interpretivist positions are founded on the theoretical belief that reality is socially constructed and fluid. Thus, what we know is always negotiated within cultures, social settings, and relationship with other people.
From this perspective, validity or truth cannot be grounded in an objective reality.
What is taken to be valid or true is negotiated and there can be multiple, valid claims to knowledge.
Angen (2000) offers some criteria for evaluating research from an interpretivist perspective:
Careful consideration and articulation of the research question
carrying out inquiry in a respectful manner
awareness and articulation of the choices and interpretations the researcher makes during the inquiry process and evidence of taking responsibility for those choices
a written account that develops persuasive arguments
evaluation of how widely results are disseminated
validity becomes a moral question for Angen and must be located in the 'discourse of the research community'
ethical validity - recognition that the choices we make through the research process have political and ethical consideration.
17
NSG 71020 Theoretical Framework Research
o Researchers need to ask if research is helpful to the target population
o seek out alternative explanations than those the researcher constructs
o ask if we've really learned something from our work
substantive validity - evaluting the substance or content of an interpretive work
o need to see evidence of the interpretive choices the researcher made
o an assessment of the biases inherent in the work over the lifespan of a research project
o self-reflect to understand our own transformation in the research process
Resources
Angen, MJ. (2000). Evaluating interpretive inquiry: Reviewing the validity debate and opening the dialogue. Qualitative Health Research. 10(3) pp. 378-395.
Blumer, H. (1969). Symbolic Interactionism. Englewood Cliffs, NJ: Prentice-Hall.
Berger, PL & Luckmann, T. (1967) The Social Construction of Reality. Garden City, NY: Doubleday and Company.
Blumer, M. (1984). The Chicago School of Sociology: Institutionalization, Diversity, and the Rise of Sociological Research. Chicago: University of Chicago Press.
Cicourel, AV. (1964). Method and Measurement in Sociology. New York: Free Press.
Garfinkel, H. (1967). Enthnomethodology. Englewood Cliffs, NJ: Prentice-Hall.
Glaser, B. & Strauss, A. (1967). The Discovery of Grounded Theory: Stragegies for Qualitative Research. Chicago: Aldine.
Guba, EG and Lincoln, YS. (1994). "Competing paradigms in qualitative research." In NK Denzin and YS Lincoln (eds.) Handbook of Qualitative Research. pp. 105-117.
Lyotard, J. (1979). The Postmodern Condition: A report on Knowledge. Theory and History of Literature. Volume 10. Minneapolis, MN: University of Minnesota Press.
Malinowski, B. (1967). A Diary in the Strict sense of the Term. New York: Harcourt, Brace & World.
Schutz, A. (1962). Collect Papers, Volume 1, The Hague, Martinus Nijhoff. See in particular: "Commonsense and scientific interpretations of human action" pp. 3-47; "Concept and theory formation in the social sciences" pp. 48-66; "On multiple realities" pp. 207-259.
Wittgenstein, L. (1958). Philosophical Investigations (GEM Anscome transl). Third Edition. Englewood Cliffs, NJ. Prentice-Hall.
18
NSG 71020 Theoretical Framework Research
Interpretive Case Studies
It is recognised that case studies can follow either quantitative or qualitative approaches
(Doolin, 1996; Stake, 1994) or any mix of both (Yin, 2003). Walsham (1995b) goes one step
further and highlights the value of interpretive case studies. In qualitative and interpretive case
studies the researcher is directly involved in the process of data collection and analysis
(Creswell, 1998; Klein & Myers, 1999; Morgan & Smircich, 1980; Morse, 1994); however, in
the latter, the researcher, through a close interaction with the actors, becomes a “passionate
participant” (Guba & Lincoln, 1994, p. 115). Even though this aspect might be regarded as a
pitfall, I contend that it is one of this approach’s advantages. It provides an opportunity to get a
deep insight into the problem under study because “[a]n interpretive explanation documents the
[participant’s] point of view and translates it into a form that is intelligible to readers” (Neuman,
1997, p. 72).
Indeed, interpretive research makes it possible to present the researcher’s own
constructions as well as those of all the participants (Guba & Lincoln, 1994; Neuman; Walsham,
1995a). This trait of interpretive case studies, however, puts an additional onus on the researcher,
as the scenario described in the next paragraph illustrates. If the interpretive researcher wants to
create an integral and persuasive piece of research around this phenomenon, each participant’s
different perspectives should be included.
The conceptual framework serves as an anchor for the study and is referred at the stage of
data interpretation (Yin, 2008). The conceptual framework serves several purposes: (1)
identifying who will and will not be included in the study; (2) describing what relationships may
be present based on logic, theory and/or experience; and (3) providing the researcher with the
opportunity to gather general constructs into intellectual “bins (Miles & Huberman, 1994). A
19
NSG 71020 Theoretical Framework Research
conceptual framework will include all the themes that emerged from data analysis. Yin (2008)
suggested that returning to the propositions that initially formed the conceptual framework
ensures that the analysis is reasonable in scope and that it also provides structure for the final
report.
The scope of the case study is bounded and the findings can rarely be generalized, but the
case study can provide rich and significant insights into events and behaviours. It can “contribute
uniquely to our knowledge of individual, organizational, social, and political phenomena” (Yin,
1984, p. 14). This approach serves my constructivist/feminist research paradigm and the theoretical
framework of organizational culture and change (Schein, 2004; Wheatley, 2007) embedded in that
paradigm. Qualitative case study research is supported by the pragmatic approach of Merriam,
informed by the rigour of Yin and enriched by the creative interpretation described by Stake.
Case study provides descriptive details about how our workplaces function, and can increase
understanding of a particular phenomenon. Examples of case study research might include the
exploration of how a class of students learns a new language, the study of how a group of coworkers
accepts new technology or the investigation of how women leaders in higher education function as
the assumptions of the organizational culture are challenged by globalization. The in-depth focus on
the particular within a bounded system can help provide a holistic view of a situation. It is a view that
includes the context as well as the details of an individual. Case studies do provide a humanistic,
holistic understanding of complex situations, and as such are valuable research tools. However,
unless the researcher fully understands case study and its place in the research process, and is
confident in the research paradigm from whence s/he works, the debates on its merits will obscure
the strength and direction of the research endeavor.
Stake is an interpretivist
20
NSG 71020 Theoretical Framework Research
In his early work on case study methodology, Stake (1978/2000) maintained that “case
studies are useful in the study of human affairs because they are down-to-earth and attention-
holding” (p. 19). This approach to research makes sense to readers because it resembles our
understanding of the naturalistic world through our personal experiences. Stake commented that
“case studies will often be the preferred method of research because they may be epistemologically
in harmony with the reader’s experience and thus to that person a natural basis for generalization” (p.
20). However, Stake also acknowledged a negative bias towards case study. He observed, “The more
episodic, subjective procedures, common to the case study, have been considered weaker than the
experimental or co-relational studies for explaining things” (p. 20). Stake concluded that when the
purpose of the research is to provide “explanation, propositional knowledge, and law … the case
study will often be at a disadvantage. When the aims are understanding, extension of experience, and
increase in conviction in that which is known, the disadvantage disappears” (p. 21).
Stake (1995) believed that the most important role of the case study researcher was that of
interpreter. His vision of this role was not as the discoverer of an external reality, but as the builder of
a clearer view of the phenomenon under study through explanation and descriptions, “not only
commonplace description, but ‘thick description’” (p. 102), and provision of integrated
interpretations of situations and contexts. This constructivist position, Stake claimed, “encourages
providing readers with good raw material for their own generalizing” (p.102).
In recent discussions of case study, Stake (2005, 2008) continued to focus on the importance
of the role of researcher as interpreter, and he commented that if the case is “more human or in some
ways transcendent, it is because the researchers are so, not because of the methods” (2005, p. 443).
He acknowledged that the case itself may be studied qualitatively or quantitatively, analytically or
holistically, through measures or by interpretation, but the critical factor is that the case is a system
with boundaries, and with certain features inside those boundaries. The work of the researcher is to
21
NSG 71020 Theoretical Framework Research
identify “coherence and sequence” (2005, p. 444) of the activities within the boundaries of the case
as patterns. The case needs to be organized around issues – complex, situated, problematic
relationships – and questions around these issues will help deepen the theme of the case. Stake
(2005) noted that the contexts of the case, whether they are social, economic, political, ethical, or
aesthetic, are important to consider, and they “go a long way toward making relationships
understandable” (p. 449). The researcher must be “ever-reflective”, considering impressions, and
deliberating on materials and recollections. He furthered, “The researcher digs into meanings,
working to relate them to contexts and experience. In each instance, the work is reflective” (p. 450).
He confirmed his earlier views on the significance of the concept of generalizability of case study
research, when he noted, “The purpose of case study is not to represent the world, but to represent the
case … the utility of case research to practitioners and policy makers is in its extension of
experience” (1994, p. 245).
While he agreed that both qualitative and quantitative research could be undertaken through
case study, Stake (1978/2000, 1994, 1995, 2005, 2008) is clearly grounded in an interpretivist
paradigm. His creative discussion of the characteristics of case study has informed many qualitative
researchers in the meaning making of their experiences and observations within a bounded context.
Sustainability Model
In order to achieve a high level in a nursing education program, one important thing needs to
be considered is sustainability of BPGs implementation in nursing curriculums. Sustainability is
the result of effective preparation and implementation and it needs to be planned. In addition,
improvement programs will only succeed if the same effort is put into their sustainability as their
launch. The NHS Institute for Innovation and Improvement (2005) described sustainability as
‘when new ways of working and improved outcomes become the norm’. A more detailed
description, which includes the notion of ‘steady state’, in addition to promoting the desirability
22
NSG 71020 Theoretical Framework Research
of continued improvement, is as follows: ‘Not only have the process and outcome changed, but
the thinking and attitudes behind them are fundamentally altered and the systems surrounding
them are transformed as well. In other words the change has become an integrated or mainstream
way of working rather than something ‘added on’. As a result, when you look at the process or
outcome one year from now or longer; you can see that at a minimum it has not reverted to the
old way or old level of performance. Further, it has been able to withstand challenge and
variation; it has evolved alongside other changes and perhaps has continued to improve over
time. Sustainability means holding the gains and evolving as required - definitely not going
back”.
Sustainability is continued use of an idea (Ackerlund, 2000). Sustainability needs to be
planned, to be builds on implementation activities, and to be influenced by factors at an
individual, organizational and external level. According to Shediac-Rizkallah & Bone (1998),
underlying concepts of sustainability is behavioural and organizational change that includes
project design (duration, financing, training, and type); organization (strength, integration with
programs, champions and leaders); and community (socio-economic infl uences and community
participation). In addition, there are five themes were identified that impact on guideline
sustainability: change factors, organizational factors, implementation factors, leaders, and
passion.
In an attempt to substantially increase the sustainability of improvements for patients and
healthcare services, NHS Institute for Innovation and Improvement (2010) developed
sustainability model and guide ha for use by individuals and teams who are involved in local
improvement initiatives. The development of the model based on the premise that the changes
individual and teams wish to make fulfill the fundamental principle of improving the patient
23
NSG 71020 Theoretical Framework Research
experience of health services. Another important impact that can be gained by using this model
is the effective achievement of change which creates a platform for continual improvement. This
sustainability model consists of ten factors relating to process, staff and organization that play a
very important role in sustaining change in healthcare.
The conceptual framework serves as an anchor for the study and is referred at the stage of
data interpretation (Yin, 2008). Further, he suggested that returning to the propositions that
initially formed the conceptual framework ensures that the analysis is reasonable in scope and
that it also provides structure for the final report. This section will discuss NHS Sustainability
Model as framework that will guide the study.
In order to achieve a high level in a nursing education program, one important thing
needs to be considered is sustainability of BPGs implementation in nursing curriculum. In an
attempt to substantially increase the sustainability of improvements for patients and healthcare
services, NHS Institute for Innovation and Improvement (2010) developed sustainability model
and guide for use by individuals and teams who are involved in local improvement initiatives.
Many authors have defined concept of “sustainability”. For example, Rogers (2005) defined
sustainability as “the degree to which an innovation continues to be used after initial efforts to
secure adoption is completed”. The NHS Institute for Innovation and Improvement (2005)
described sustainability as ‘when new ways of working and improved outcomes become the
norm’. The concept of sustainability refers to the continuation of programs (Shediac-Rizkallah
& Bone, 1998). Sustainability is the result of effective preparation and implementation and it
needs to be planned. A sustained program is a set of durable activities and resources aimed at
program-related objectives (Scheirer, 1994). The NHS Sustainability Model consists of ten
factors relating to process, staff and organizational issues, which play a very important role in
24
NSG 71020 Theoretical Framework Research
sustaining change in healthcare. The Model has been developed with and for the NHS using a
co-production approach.
Recently, sustainability model is used worldwide. It is implemented inter professional
shared decision making, patient decision aids, and diversity in nursing in Australia, Chile, Italy,
Jamaica, Malta, South Africa, UK and the USA (RNAO, 2011). Sustainability is continued use
of an idea (Ackerlund, 2000). Sustainability needs to be planned, to be builds on implementation
activities, and to be influenced by factors at an individual, organizational and external level.
According to Shediac-Rizkallah & Bone (1998), underlying concepts of sustainability is
behavioural and organizational change that includes project design (duration, financing, training,
and type); organization (strength, integration with programs, champions and leaders); and
community (socio-economic infl uences and community participation). In addition, there are
five themes were identified that impact on guideline sustainability: change factors, organizational
factors, implementation factors, leaders, and passion (Shediac-Rizkallah & Bone, 1998).
The goal for using the NHS Sustainability Model is to develop an easy-to-use tool to help
improvement teams: self-assess against a number of key criterion for sustaining change,
recognize and understand key barriers for sustainability, relating to their specific local context,
identify strengths in sustaining improvement, plan for sustainability of improvement efforts, and
monitor progress over time.
Sustainability Model (Maher et al, 2007; 2010)
25
NSG 71020 Theoretical Framework Research
NHS SUSTAINABILITY FACTORS
The development of the NHS sustainability model based on the premise that the changes
individual and teams wish to make fulfill the fundamental principle of improving the patient
experience of health services. Another important impact that can be gained by using this model
is the effective achievement of change which creates a platform for continual improvement. By
holding the gains, resources - including financial and most importantly human resources - are
effectively employed rather than being wasted because processes that were improved have
reverted to the old way or old level of performance. Sustainability model consists of ten factors
relating to process, staff and organization that play a very important role in sustaining change in
healthcare. Addressing sustainability requires planning for “scaling up” knowledge use,
including adequate human capacity, supportive financial, organizational, governance, and
regulatory structures. Issue of “boutique Interventions” designed for a specific setting but not
feasible or applicable in a large scale due to resources or relevance (Simmons et al., 2006;
26
NSG 71020 Theoretical Framework Research
Hanson et al., 2003). It is intended to provide a user-friendly practice-based guide to the key
factors that need to be considered for sustained organizational change (NHS, 2010). There are
some factors to consider in the development of a sustainability action plan. The following is
NHS sustainability model that consists of ten factors (Higuchi, et al, 201; Maher et al, 2007,
2010) related to process, staff and organizational issues, which play a very important role in
sustaining change in healthcare.
Process Sustainability Factors
1. Benefits
The focus on improving the students’ experience and journey through care is essential.
The sustainability of a change will be greatly enhanced if, in addition to this, the staff can
also recognise a benefit in their own role which may manifest itself in certain tasks becoming
easier or making their role feel more rewarding. The likelihood of sustaining the change is
reduced if jobs become harder, processes are less efficient or work flow becomes more
complex. Even if the reality is that none of this happens, it may never the less be perceived to
do so.
This section suggests some techniques to help recognise if the staff feel that the change is
making their jobs more difficult (real or perceived) and suggests some actions to improve
roles and efficiency of the process. Benefits beyond helping patients ensure that the change
does bring benefits to staff, patients and the organisation. It is important because it will raise
awareness of the impact on staff roles and responsibilities. It will illustrate areas of concern
and areas for celebration. It is essential to consider that it needs to be clear about the purpose
of the change. Also, need to ask staffs for their input ideas and opinions in order to get
Benefits beyond helping patients. The benefit of guidelines implementation such as
27
NSG 71020 Theoretical Framework Research
classroom courses (research/theory courses) and clinical/lab courses and making the faculty
workloads easier have been communicated to staff.
2. Credibility of evidence
Credibility of evidence and benefits is about ensuring that there is evidence that the
change will produce benefits that are obvious to all key stakeholders. It is important because
evidence of benefits above and beyond those gained through the existing process will give
people reason to support, accept and participate in the change. It illustrates the differences
between the existing and new process. It also identifies the benefits for patients, staff and the
organisation and communicates those benefits in a way that meets the needs of these different
audiences.
New processes are more likely to be sustained if there is evidence to support their advantages
over the existing or old processes. Staffs need to be able to understand and believe that the
new process has benefits and are more likely to support the change if at least some of these
are immediately obvious. The material that follows offers suggestions on what you can do if
the benefits are not immediately obvious or if there is limited evidence supporting the
advantages and value of the change. Put yourself into the position of the organisation or staff
who will be affected by the change. Why would they support the proposed change initiative?
It is important to be able to identify the beneficial impact of the intended change otherwise
there is little or no incentive for participation and involvement. The harder it is for people to
see the benefits for the patients, themselves and the organisation, the harder it will be to
convince them to accept the proposed or new change. There are two key elements, which will
help to demonstrate the evidence and benefits for this change. The first is identifying the
benefits and the second is being able to effectively communicate the evidence. The more
28
NSG 71020 Theoretical Framework Research
difficult it is to appreciate the benefits of a new or revised process, even if there is evidence
to support it, the less likely staff will be to engage in the process of change. The more the
benefits are immediately obvious, the more likely that staff will support the new change.
Benefits of the change related to guideline implementation are credible, widely
communicated, immediately obvious, supported by evidence, and believed by stakeholders.
Credibility and beliefs concerning knowledge gained from guideline recommendations or
other related evidence. The monitoring of new evidence and its incorporation into practice.
3. Adaptability
Adaptability of improved process refers to the extent that the changes from guideline
implementation process can adapt to link with and even support other organizational change,
and whether the changes that are occurring during guidelines adoption will continue even if
specific individuals or groups leave the project.
Adaptability is about ensuring that the change can continue in the face of ongoing changes in
staff, leadership, organisation structures, etc. it is important in ensuring that your
improvement is flexible to the surrounding systems will help make it sustainable and become
a platform for continuous improvement. Need to be aware of potential organisational or staff
changes and look for the opportunities these could bring and be prepared to change the
original improvement plans. Adaptability can be very important in determining whether a
new or improved process will be sustained over the long run. There are three situations where
this adaptability can be very important: during the design stage when you want to use an idea
from outside the organisation but must adapt it to fit within your organisation; during a
period when your organisation changes (e.g. changes in people, location, structure) and the
29
NSG 71020 Theoretical Framework Research
relevance of the new or improved process is being questioned; and over time as the new
process itself becomes a candidate for further improvement.
Changes from guideline implementation process link with existing organizational processes
(e.g. permanent agenda item on key committees). Creating synergy within multiple change
processes.
4. Monitoring Progress
Monitoring progress refers the development of new systems or the revision of current
systems to measure improvement as a result of guideline implementation and whether
organizations also ensure that mechanisms are in place to continue monitoring progress
beyond the guideline implementation project, and whether the results of guideline
implementation are communicated to staffs and the organization.
Effectiveness of the system to monitor progress is about Ensuring that a system is in
place to continually and effectively monitor the progress of change. It is important in
measuring keeps us informed about success and identifies further areas for improvement. In
the absence of feedback, serious flaws or ‘slipping back’ may go unnoticed. In order to get it,
need to find out what is already being collected by others and to build measurement into
current reporting systems. Communicate the impact and benefits widely.
When the improvement has completed its pilot testing and begins full-scale
implementation, a baseline will have been established that will allow determining whether
the desired level of improvement has occurred. The message within this section is that both
measurement and communication must continue if need to sustain or ‘hold the gains’. If staff
are not able to identify and document either ongoing improvement or slippage they will be
unable to either take corrective action or think about how the process could be improved
30
NSG 71020 Theoretical Framework Research
even more. There is a resonance in the saying ‘we manage what we measure’. More than just
maintaining position, measurement and communication help the team to look toward ongoing
improvement of their processes beyond the point when the change is implemented.
In order to increase the likelihood of sustainability, measures should be routinely
collected in order to illustrate what is happening (e.g. are we continuing to achieve the
reduction in waiting time?). Reviewing the measures that were used during the design and
testing phases of the project is a good place to start when deciding what to measure to
support the improvement beyond the formal end of the project or initiative. However, you
should aim to collect data that will give you the best picture and keep things simple and
minimal. Think about which measures were most useful during the implementation phase;
which was the best measure in terms of identifying overall improvement; which measure did
the team relate to most; and which measure would give the senior leadership team the best
information overall.
The development of new system or the revision of currents system to measure
improvement as a result of guideline implementation and whether organization also ensure
that mechanisms are in place to continue monitoring progress beyond the guidelines
implementation project, and whether the result of guideline implementation are
communicated to client, staff, the organization, and wider healthcare community.
Staff Sustainability Factors
1. Staff involvement and training to sustain the process
Training and involvement is about ensuring that key staff at all levels are affected by
change, can contribute by being involved from the outset and trained in any new skills
needed. Staffs who feel valued are more likely to be motivated to make change work and an
31
NSG 71020 Theoretical Framework Research
aggressive resistance can be detrimental. It is essential to work as a multi-level team, ask,
listen, value and act on staff comments and concerns, and regularly communicate in ways
that will meet the needs of multiple audiences.
Giving front line staff the opportunity to think and work differently to solve old problems
in new ways is the only way to deliver the improvements set out in the NHS Plan. Staffs need
to be involved in decisions which affect service delivery. Individual employees within your
organisation play a crucial role in healthcare improvement whether they accept and
participate in the change, resist it or simply ignore it. Having a team of staff who willingly
take on change and do all they can to make it work is key for success and continuous
improvement, but unfortunately this ideal is often absent from many organisations. One of
the main reasons cited for hesitancy and resistance by staff is lack of involvement.
Involvement can be defined as motivating, training, informing and enabling staff to
contribute to the improvement process. ‘Employees improve their performance through
experiencing more control over and involvement in their work, leading to an increase in
personal commitment to management aims’ (Cunningham, Hyman & Baldry, 1996).
Meaningfully involving frontline healthcare staff is considered one of the biggest
challenges facing healthcare organisations looking to make improvements. Staffs are
involved in the guidelines implementation project, and whether staffs help to identify any
knowledge or skill gaps that will inform the guideline implementation process, and any
required changes to the introduction of the guidelines. This factor also includes whether there
are staff development initiatives to ensure that the staff members are confident and
competent in new way of working as a result of guideline implementation.
2. Staff behaviours toward the change process
32
NSG 71020 Theoretical Framework Research
An important first step towards understanding scepticism about sustainability is to try to
understand why staffs believe the change will not sustain. There may be many potential
reasons and these need to be understood at the level of the individual and can relate to
complex personal, organisational and social reasons. One very important fact to remember is
that sceptics often have a very good reason why they believe the change will not sustain and
these should be considered constructively. Some scepticism about sustainability of the
change may originate from staff involvement during the change itself and the points listed
below should be considered.
Behaviours is all about reducing scepticism by increasing belief in the change and
helping staff to feel empowered in their work. It is important to consider that negative beliefs
lead to negative outcomes. It is also important to meet regularly with staff to identify barriers
and concerns, as well as to use data and stories to demonstrate the positive impact of the
improvement. The staffs, their feelings, attitudes and beliefs are central to any effort to
achieve and sustain a change. One important aspect is the extent to which the staffs
themselves believe that the change will actually be sustained. ‘Scepticism at any level is
important in practical terms because it may manifest itself as resistance’ (Modernisation
Agency, 2002).
The staffs, their feelings, attitudes and beliefs are central to any effort to achieve and
sustain a change. One important aspect is the extent to which the staffs themselves believe
that the change will actually be sustained. ‘Scepticism at any level is important in practical
terms because it may manifest itself as resistance’ (Modernisation Agency, 2002).
Staff members are encouraged to share their ideas about the change process and whether
the change process is modified based on staff feedback. In addition, staffs believe that the
33
NSG 71020 Theoretical Framework Research
changes from guidelines implementation will result in a better way to do things, and whether
staff are trained and empowered to see if additional improvements should be recommended.
3. Senior Leaders
Senior administrator leadership is about engaging senior leaders and encouraging them to
engage in mutually - respectful interactions with staff and take responsibility for sustaining
change. Engaging senior administrative leaders is needed to ensure responsibility and their
interaction with staff. It is it important that a respected leader who has invested in the
improvement will be influential and help overcome barriers. It is essential to: identify the
significance of the leader’s involvement, identify the benefits of the improvement, and
regularly communicate these in a meaningful way. Countless change programmes have
faltered despite well-argued logic because people in positions of power and authority
wavered in their support.
Roles and actions of organizational leaders (e.g. school’s senior administrators such as
school’s chief Executive Officer) are highly involved and visible in their support of guideline
implementation, use their influence to communicate the impact of the work and breakdown
any barriers and the extent that open communication exists between leaders and staff.
4. Faculty and Clinical Leaders
It is about academic faculty and clinical leaders or stakeholders who engage and
encourage involvement in the project’s success. An important factor in ensuring sustainable
change is the engagement of faculty, clinicians, and stakeholders in the redesign and
improvement of services. While evidence suggests that many clinicians are committed to
improving services in principle, present levels of engagement within the clinical field could
still be improved. Clinician scepticism and the relative scarcity of clinicians willing to take
34
NSG 71020 Theoretical Framework Research
on the challenges and responsibility of clinical leadership for improvement are significant
risks to sustaining improvement. Redesigned systems of healthcare delivery almost always
require clinicians to change the way they work, both at an individual level and collectively
within their professional groups. It is therefore vital to engage clinicians in the redesign
process, ensuring that new ways of working take account of clinicians’ priorities and needs
(Kilo, 1999).
Because any profession is most likely to listen to advocates who understand their values
and challenges, a faculty and clinical leaders will be very important in gaining the support of
other faculties or clinicians. Faculties and clinicians are powerful actors in change; without
their support, sustainability will be difficult. Their engagement for individuals or groups of
faculties, clinicians and stakeholders could be described as developing along a range or
continuum.
Roles and actions of faculty and clinical leaders such as nursing faculty, nursing
professional practice leaders, inter-professional leaders, advanced practice nurses, are highly
involved and visible in their support of guideline implementation. It is about faculty and
clinical leaders or stakeholders who engage and encourage involvement in the project’s
success.
Organizational Sustainability Factors
1. Fit with goal and Culture
Fit with organisational strategic goal and culture is about ensuring that there is synergy
between the improvement and organisational goals and vision. It is important that a clear
links with the organisational goals and vision support long-term success for the
improvement. It is important to; identify the relationship between the organisational goals
35
NSG 71020 Theoretical Framework Research
and the improvement; demonstrate the impact of the improvement, and communicate widely
but especially to the senior leadership team.
Individual employees within organisation play a crucial role in healthcare improvement
whether they accept and participate in the change, resist it or simply ignore it. Having a team
of staff who willingly take on change and do all they can to make it work is key for success
and continuous improvement, but unfortunately this ideal is often absent from many
organisations.
Improvement of healthcare services to achieve better quality for patients and better
working lives for staff is a major theme for the sustainability.
In order to achieve improvements change is inevitable and this will include people and
their behaviours, clinical and managerial processes and organisational vision and culture.
Culture includes the values, beliefs and norms of an organisation, all of which influence the
actions and behaviours of the people within that organisation. A helpful way of looking at it
is through these three short statements: culture is about how things are done within
workplace; the way things are done within your team is heavily influenced by shared but
unwritten rules, and cultures reflect what has worked well in the past.
One of the reasons often cited for change initiatives that do not sustain is that there is no
clear vision or strategy which identifies how the change ‘fits’ into the organisation. Therefore
the culture of the organisation is not receptive to the change and the culture does not support
staff to be receptive to change. Every organisation should have a clear stated vision for the
future and goals, which will enable movement from the current state towards the vision state.
The goal of guideline implementation are clear and have been shared widely with staff,
and whether the goals of change are consistent with and support the organizational vision and
36
NSG 71020 Theoretical Framework Research
mission for improvement. Description of organizational culture, strategic goals and aims
related to guideline implementation.
Finally, fit with goal and culture is about ensuring that there is synergy between the
improvement and organisational goals and vision. It is important that a clear links with the
organisational goals and vision support long-term success for the improvement. It is
important to; identify the relationship between the organisational goals and the improvement;
demonstrate the impact of the improvement, and communicate widely but especially to the
senior leadership team.
2. Infrastructure for sustainability
Infrastructure is about ensuring the improvement effort is supported during and beyond
the formal life of the project (i.e Job roles, equipment, funding, and communication). it is
important in order to reinforce the improvement as, ‘the way we do things around here’. The
staffs, their feelings, attitudes and beliefs are central to any effort to achieve and sustain a
change. One important aspect is the extent to which the staffs themselves believe that the
change will actually be sustained. ‘Skepticism at any level is important in practical terms
because it may manifest itself as resistance’ (Modernisation Agency, 2002).
Whether changes have been made to existing policies and procedures, and whether chart
documents and forms are developed or revised to incorporate the newly adopted guideline
recommendation. Infrastructure also refers to whether organisation reviewed the adequacy of
existing resources and communication systems required to support the implementation of
guideline recommendations and have acquired necessary resources or made changes to
existing system.
Barriers and facilitator of Sustainability
37
NSG 71020 Theoretical Framework Research
According to Wakerman et al., (2005), the same factors can be both facilitator and barriers of
sustainability:
1. Relevance of the topic: Is there a well-defined need and priority for the knowledge that is
being implemented? Is there consensus about what knowledge needs to be sustained and
what is needed to create conditions for sustainability? How does the new knowledge fit with
current priorities?
2. Benefits: What are the anticipated outcomes of knowledge implementation from a biological,
economic, psychological, organizational, social, political, or other perspective? How
meaningful are these benefits to the various stakeholders?
3. Attitudes: What are the attitudes of the patient/ client, their family, the public, health care
providers, and relevant decision-makers toward the innovation?
4. Networks: What team or groups can be engaged to facilitate the sustainability of knowledge
use? Are there people who can be engaged to cross disciplines, settings, or sectors of the
health care system?
5. Leadership: What actions might leaders and managers at all levels of involvement take to
support the sustainability of knowledge use? Are there champions for the change? Who is
responsible for continued implementation of the innovation and making modifications as new
knowledge is brought forward? Who will be responsible for ensuring that relevant outcomes
are met?
6. Policy articulation and integration: How will the fit between new knowledge and existing
policies are assessed? How might the knowledge be integrated in relevant policies,
procedures, regulatory and documentation systems?
7. Financial: What funding is required to implement, sustain, and scale up knowledge? What
38
NSG 71020 Theoretical Framework Research
flexibility in funding is necessary and available for reimbursement? Can cost-effective
strategies be used?
8. Political: Who are the stakeholders and what power or support might be leveraged? Who will
initiate scaling up processes? (Buchanan et al., 2007 Davies et al., 2006; Lomas; Maher et al.,
2007; Nolan et al., 2005; Shediac- Rizkallah & Bone, 1998; Sibthorpe & Glasgow, 2005).
Monitoring Sustainability
Monitoring systems and data feedback mechanisms are needed to determine relevant
process and outcome factors to assess sustainability. Four degrees of sustainability are absent,
precarious, weak, and routinization (Pluye, et al., 2004).
RESEARCH METHODS
A qualitative case study approach will be used in this study. The selection of a proper
methodology for the study is driven by coming to understand my research questions. Although
case study method has been described clearly by several authors (i.e. Stake, 1995; Yin, 2004,
2008; Merriem, 1998; Silvermean, 2005) but I do not determine yet to follow one of these
authors to follow or use in this study. Furthermore, I need to make sure that the selection of a
proper case study methodology is driven by coming to understand my research questions: (1)
How the BPGs recommendations are integrated in overall curriculum design (theory and clinical
courses) in undergraduate nursing program?; (2) What are the barriers and facilitators of BPGs
implementation in undergraduate nursing curriculum?; and (3) How the curriculum changes have
been sustained based on BPGs recommendations?
A case study may be considered a methodology, or 'the case' may be considered an object
of the study (Creswell 1998; Stake, 1995). Yin (2004) defined case study as an empirical inquiry
that "investigates a contemporary phenomenon within its real-life context; when the boundaries
39
NSG 71020 Theoretical Framework Research
between phenomenon and context are not clearly evident; and in which multiple sources of
evidence are used". It investigates phenomena within its real life context, especially when the
boundaries between phenomenon and context are not clearly evident (Merriem, 1998).
Components of a case study research according to Yin (2008) are: 1) a study’s questions; 2) its
proposition (if any); 3) its unit(s) of analysis; 4) the logic linking the data to the propositions; &
5) the criteria for interpreting the findings. Components (1, 2 and 3) refer to what data are to be
collected; components (4, and 5) refer to what is to be done after the data have been collected
(Yin, 2008).
Case study focuses on the idea of a bounded unit which is examined, observed, described
and analysed in order to capture key components of the 'case'. The case might be a person, a
group of particular professionals, an institution, a local authority etc. Stake (1995) described this
kind of case study as 'holistic', it captures the essentials of what constitutes this person/this role
etc. In addition, he also offered an alternative form of case study, and this is the model which is
used most frequently by those in education: an instrumental or delimited case study (Stake,
1995).
One of the advantages of case study approach is the close collaboration between the
researcher and the participant, while enabling participants to tell their stories (Crabtree & Miller,
1999). Through these stories the participants are able to describe their views of reality and this
enables the researcher to better understand the participants' actions (Robottom & Hart, 1993). A
case study enables the researcher to answer "how" and "why" type questions, while taking into
consideration how a phenomenon is influenced by the context within which it is situated Yin
(2008). Another unique strength of a case study is its ability to deal with a variety of evidence
collected from documents, interviews, and observations (Stoecker, 1991). Study procedure will
40
NSG 71020 Theoretical Framework Research
be to: (a) describe what will happen in integrating the BPGs in a nursing school, (b) interpret
participants experiences (individually and collectively), and (c) describe the experiences that
participants have within their everyday lives that may have affected their BPG's curriculum
implementation.
Settings and Participants
This study will be conducted at one nursing school that has implemented BPGs in
Ontario. For inclusion criteria, site or setting is a nursing program that integrates or implements
the BPGs recommendation in undergraduate curriculum (theory and clinical courses). This long
inquiry is the case, and it will be a context-sensitive exploration which includes significant
periods of reflection and data collected from a variety of sources.
Participants in this study will be the school's faculty, program leaders (administrative
leaders), clinical partner representatives, and students. In selecting research participant, it is
important to conduct a formal case study screening procedure. The screening can be based on
reviewing documents or querying of people knowledgeable about each candidate. Useful
screening criteria include: the willingness of key persons in the case to participate in your study,
the likely richness of the available data, and preliminary evidence that the case has had the
experience or situation (Yin, 2004).
Data Collection
Data collection is emergent in case study research (Olson, 2009). According to Yin
(2008), rigorous data collection follows carefully articulated steps: the use of multiple sources of
evidence, the creation of a case study database, and the maintenance of a chain of evidence. The
use of multiple sources of data enables the researcher to cover a broader range of issues, and to
develop converging lines of inquiry by the process of triangulation. A case study allows to
41
NSG 71020 Theoretical Framework Research
present data collected from multiple methods (i.e., surveys, interviews, document review, and
observation) to provide the complete story or information (Neale, Thapa, & Boyce, 2006). Tools
used in this type of data collection are usually surveys, interviews, document analysis, and
observation, although standard quantitative measures such as questionnaires are also used.
For data collection procedure, it is important that the researcher use specific tools for
specific data collection. A key demand of the case study method is the investigator's skill and
expertise at pursuing an entire (and sometimes subtle) line of inquiry at the same time as (and not
after) data are being collected. In fact, good case studies benefit from having multiple sources of
evidence (Yin, 2004). A key strength of the case study method involves using multiple sources
and techniques in the data gathering process. Stake, 1995) mentioned that a hallmark of case
study research is the use of multiple data sources, and a strategy which also enhances data
credibility (Yin, 2008). Data will be collected using in-depth case study data collection methods
with participants (lecturers, students, and administrators). There are three data collection tools
and approaches of a case study method that will be used in this study: interview, document
review and observation.
Firstly, a semi-structured interview will be used as a method of data collection. A semi
structured interview provides a clear set of instructions for interviewers and can provide reliable,
comparable qualitative data. It can provide a clear set of instructions for interviewers and can
provide reliable, comparable qualitative data. Questions can be prepared ahead of time (allows
the interviewer to be prepared and appear competent during the interview). Many researchers
like to use semi-structured interviews because questions can be prepared ahead of time. This
allows the interviewer to be prepared and appear competent during the interview. According to
Bernard (1988), semi structured interview allows participants the freedom to express their views
42
NSG 71020 Theoretical Framework Research
in their own terms. Semi-structured interviews also allow informants the freedom to express their
views in their own terms. Semi-structure interviews can provide reliable, comparable qualitative
data (Bernard (1988). It will be used to collect data from faculty, program leaders (administrative
leaders), clinical partner representatives, and students.
Secondly, documents review is also used for data collection. Documents comprise a
variety of written, visual, and physical material those are by-products of human activity that
"document" their activity over time (Merriam, 1998). According to Olson (2009), documents is
a record of human activity, provide a valuable source of data in case study research. Documents
can also provide historical information that lead to a better understanding of the case in question
and can provide a diverse wealth of information from a wide variety of sources. This wealth of
possibilities creates several issues of which researchers need to be aware. Researchers need to be
cognizant that because different documents were created for different purposes, they will present
different points of view. To limit bias, researchers need to have a wide enough variety of
documentary sources to provide a reliable research report. On the other hand, much of the
documentary data may be irrelevant to the present research purpose, and the sheer volume of
documentary data can become overwhelming. Merriam (1998) suggested several things
researcher might need to know about the authenticity of a document: the history of the
document; the document complete, as originally constructed; the circumstances and the purpose
of it is produced; the maker's sources of information; the document represent an eyewitness
account, a second hand account, a reconstruction of an event long prior to the writing, an
interpretation. In this study, documents review will include syllabus (theory, clinical/lab),
assignments, minutes meeting, and report to the RNAO.
43
NSG 71020 Theoretical Framework Research
Thirdly, in order to address the research questions effectively, observation is also used as
forms of data collection. It is required particularly as sustainable development involves the
interaction between the participants and their environment. Observation allows the researcher to
get an in-depth understanding of the social reality and to "see as others see (Bryman, 2008).
Observation involves looking and listening carefully that allow studying people in their natural
setting without their behaviour being influenced by the presence of a researcher. During the data
collection, observation will be focused on teaching-learning processes (during classes, clinical
meetings, and lab sessions).
Data Analysis
According to Miles & Huberman (1994), qualitative data analysis is a continuous
process. The process, including data collection, analysis, and interpretation resulting in the
drawing of conclusions, is both interactive and cyclical in nature. Stake (1995) recognized the
importance of effectively organizing data. It will improve the reliability as it enables the
researcher to track and organize data sources including notes, key documents, tabular materials,
narratives, photographs. Data analysis should be independently conducted for each case study,
both relating back to the objectives and drawing out policy implications. Close familiarity with
each case is required to allow the investigator to draw out its unique patterns and the basis for
rich cross-case comparison (Eisenhardt, 1989).
In case study research, there are two popular types of analysis: structural analysis and
reflective analysis. Structural analysis is the process of examining case study data for the purpose
of identifying patterns inherent in discourse, text, events, or other phenomena. It is used in
conversation analysis, ethno-science, and other qualitative research methods. Yin (2008)
encouraged researchers to make every effort to produce an analysis of the highest quality. In
44
NSG 71020 Theoretical Framework Research
order to accomplish this, he presented four principles that should attract the researcher's
attention: show that the analysis relied on all the relevant evidence, include all major rival
interpretations in the analysis, address the most significant aspect of the case study, and use the
researcher's prior, expert knowledge to further the analysis. Stake (1995) recommended
categorical aggregation as another means of analysis and also suggested developing protocols for
this phase of the case study to enhance the quality of the research. He also presented ideas on
pattern-matching along the lines that Yin (2008). Runkel (1990) used aggregated measures to
obtain relative frequencies in a multiple-case study. Stake (1995) favoured coding the data and
identifying the issues more clearly at the analysis stage. Eisner & Peshkin (1990) placed a high
priority on direct interpretation of events, and lower on interpretation of measurement data,
which is another viable alternative to be considered.
In this research, each data source will be treated independently and the findings reported
separately. Data collected will be analyzed using NVivo software qualitative data analysis. The
software is a new generation qualitative data analysis package that can be used to analyze
interviews, field notes, textual sources, and other types of qualitative or text-based data. It allows
researchers to classify, sort and arrange information; examine relationships in the data; and
combine analysis with linking, shaping, searching, and modeling.
Rigor in case study research
The most influential model used to ensure the rigor of case study research adheres to
what is commonly called the "natural science model" (Eisenhardt & Graebner, 2007). The
natural science model groups a number of research actions under four criteria: construct validity,
internal validity, external validity and reliability (Behling, 1980; Cook & Campbell, 1979).
45
NSG 71020 Theoretical Framework Research
Construct validity is about appropriate definitions and operational measures for the
theoretical propositions being studied. Using several ways to measure the key variables
(constructs) in the study is an important way to overcome possible problems of inaccuracy. The
construct validity of a procedure refers to the extent to which a study investigates what it claims
to investigate, i.e. to the extent to which a procedure leads to an accurate observation of reality
(Denzin & Lincoln, 2005).
Internal validity is about establishing credible causal relationships. Yin (2008) stated that
internal validity or "logical validity" is the presence of causal relationships between variables and
results. Whereas construct validity is relevant mainly during the data collection phase, internal
validity applies also to the data analysis phase, even though many decisions regarding internal
validity are made in the design phase (Yin, 2008).
External validity concerns convincingly specifying the domain to which the findings can
be generalised. This requires carefully choosing the cases and explaining why each case has been
chosen, and its similarities and differences to other cases, in terms of the research questions
guiding the study. External validity or “generalizability” is grounded in the intuitive belief that
theories must be shown to account for phenomena not only in the setting in which they are
studied, but also in other settings. Neither single nor multiple case studies allow for statistical
generalization, i.e. inferring conclusions about a population (Yin, 2008; Lee, 2003).
Finally, reliability refers to the absence of random error, enabling subsequent researchers
to arrive at the same insights if they conducted the study along the same steps again (Denzin &
Lincoln, 2005). According to Silverman (2005), reliability is the degree of consistency with
which instances are assigned to the same category by different observers or different occasions.
According to Yin (2008), it is important to make reference to a case study database, in which
46
NSG 71020 Theoretical Framework Research
data such as interview transcripts, preliminary conclusions, and the narratives collected during
the study are organized in such a way as to facilitate retrieval for later investigators; and to
facilitate the replication of the case study (Leonard-Barton, 1990).
References
Backer, T. (1991). Knowledge utilization: The third wave. Knowledge, 225-240.
Behling, O. (1980). The case for the natural science model for research in organizational
behavior and organization theory. Academy of Management Review, 5(4), 483-490.
Bernard, H. R. (1988). Research Methods in Cultural Anthropology. Newbury Park,
California: Sage.
Brouwers, M., Graham, I.D., Hanna, S.E., Cameron, D.A., & Browman, G.P. (2004).
Clinician’s assessments of practice guidelines in oncology: the CAPGO survey. International
Journal of Technology Assessment in Health Care, 20(4), 421-426.
Bryman, A. (2008). Social Research Methods (3rd ed). Oxford: Oxford University Press.
Campbell, K.E., Woodbury, M.G. & Houghton, P.E. (2010). Implementation of best
practice prevention of heel pressure ulcers in the acute orthopedic population. International
Journal of Wound Care, 7 (1), 28–40.
Carper, B. A. (1978). Fundamental Patterns of Knowing in Nursing. Advances in Nursing
Science, 1(1), 13-23.
Cheater, F.M. & Closs, S. J. (1997). The effectiveness of methods of dissemination and
implementation of clinical guidelines for nursing practice: a selective review. Clinical
Effectiveness in Nursing, 1, 4-15.
Ciliska, D. (2005). Educating for evidence-based practice. Journal of professional
nursing, 21 (3), 345-350.
47
NSG 71020 Theoretical Framework Research
Clardy, A. (1997). Studying your workforce: Applied research methods and tools for
training and development practitioners. Thousand Oaks, CA: Sage.
Coutts, P. (2003). Overview of the development process for the BPG Venous Leg Ulcers.
Wound Care Canada, 1(1), 38-39.
Crabtree, B.F., & Miller, W.L. (1999). Doing Qualitative Research in Primary Care:
Multiple Strategies. (2nd ed). Newbury Park, CA: Sage Publications.
Davis, D., Evans, M., Jadad, A., Perrier, L., Rath, D., Ryan, D., et al. (2003). The case for
knowledge translation: Shortening the journey from evidence to effect. British Medical Journal,
327 (7405), 33-35.
De Cordova, P.B., Collins, S., Peppard, L., Currie, L.M., Hughes, R., Walsh, M., &
Stone, P.W.(2008). Implementing evidence-based nursing with student nurses and clinicians:
Uniting the strengths. Applied Nursing Research, 2, 242.
Delvin, R., Czaus, M., & Santos, J. (2002). Registered Nurses Association of Ontario's
best practice guideline as a tool for creating partnerships. Hospital Quarterly, 5(3), 62-65.
Denzin, N.K. & Lincoln, Y.S. (2005). The Sage Handbook of Qualitative Research. (3rd
ed.). Thousand Oaks, CA: Sage.
Eaton, E., Henderson, A., & Winch, S. (2007). Enhancing nurses’ capacity to facilitate
learning in nursing students: Effective dissemination and uptake of best practice guidelines.
International Journal of Nursing Practice, 13, 316-320.
Eisenhardt, K. M. (1989). Building theories from case study research. Academy of
Management Review, 14(4), 532-550.
Eisenhardt K. M. & Graebner M. E. (2007). Theory building from cases: opportunities
and challenges. Academy of Management Journal, 50(1), 25-32.
48
NSG 71020 Theoretical Framework Research
Eisner, E., & Peshkin, A. (1990). Qualitative inquiry in education. New York: Teachers
College Press.
Ellis, J., McCleary, L., Blouin, R., Dube, K., Rowley, B., McNeil, M., Cook, C. (2007).
Implementing best practice pain management in a pediatric hospital. Journal of Specialists in
Pediatric Nursing, 12(4), 264-277.
Field, M.J. & Lohr, K.N. (1990). Guidelines for clinical practice: Directions for a new
program. Institute of Medicine, National Academy Press, Washington, DC.
Finout-Overholt, E., Mazurek Melnyk, B. & Shultz, A. (2005). Transforming health care
from the inside out: Advancing evidence-based practice in the 21st century. Journal of
Professional Nursing, 21 (6), 335-344.
Gerrish, K., & Clayton, J. (2004). Promoting evidence-based practice: an organizational
approach. Journal of Nursing Management, 12, (2), 114-123.
Greenhalgh, T., Robert, G., Bate, P., Macfarlane, F., & Kyriakidou, O. (2005). Diffusion
of innovations in health service organizations. Malden, Massachusetts: Blackwell Publishing
Ltd.
Grol, R. (2000). Twenty years of implementation research. Family Practice, 17, S32-S35.
Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective
implementation of change in patients' care. Lancet, 362(9391), 1225-1230.
Hemsley-Brown, J.( 2004). Facilitating research utilization: A cross-sector review of
research evidence. The International Journal of Public Sector Management, 17(6): 534-552.
Higuchi, K.S., Cragg, C.E., Diem, E., Molnar, J., & O’Donohue, M. (2006). Integrating
clinical guidelines in to nursing education. International Journal of Nursing Education
Scholarship, 3(1).
49
NSG 71020 Theoretical Framework Research
Higuchi, K.S., et al. (2011). Implementation of Best Practice Guidelines: The Pioneer
Best Practice Spotlight Organization, Final Report. International Affairs and Best Practice
Guidelines Program, RNAO.
Hogan, D., & Logan, J. (2004). The Ottawa Model of Research Use: A guide to Clinical
Innovation in the NICU. Clinical Nurse Specialist Journal, 18(5), 255-261.
Iwasiw, C.L, Goldenberg, D., Andrusyszyn, M. (2009). Curriculum development in
Nursing Education. (2nd ed.). Sudbury, MA: Jones and Bartlett Publisher.
Jacobson, N., Butterill, D., & Goering, P. (2003). Development of a framework for
knowledge translation: Understanding user context. Journal of Health Services Research &
Policy, 8(2), 94-99.
Leonard-Barton, D. (1990). A dual methodology for case studies: Synergistic use of a
longitudinal single site with replicated multi sites. Organization Science, 1(3), 248-266.
Maher, L., Gustafson, D., Evans, A. (2007). Sustainability model and guide. NHS
Institute for Innovation and Improvement. Retrieved from: URL
www.institute.nhs.uk/sustainability
Maher, L (2010). Sustainability of Improvement. (Ppt Presentation). NHS Institute for
Innovation and Improvement.
Mazurek-Melnyk, B. (2011). Integrating Evidence-Based Practice in Your Curriculum.
Retrieved from: http://www.aacn.nche.edu/Faculty/FacultyLink/pdf/2Feb11handout.pdf
Melnyk, B.M., & Fineout-Overhold, E. (2011). Evidenc-Based Practice in Nursing &
Healthcare. A Guide to Best Practice. (2nd ed). Philadelphia: Lippincott William & Wilkins.
Merriam, S. B. (1998). Qualitative research and case study applications in education.
San Francisco: Jossey-Bass Publisher.
50
NSG 71020 Theoretical Framework Research
Miles, M. B., & Huberman, A. M. (1994). An expanded sourcebook: Qualitative data
analysis. Thousand Oaks, CA: Sage.
Miner-Ross, A. Noone, J., Luce, L.L., & Sideras, S.A. (2009). Spiraling evidence-based
practice and outcomes management concepts in an undergraduate curriculum: A systematic
approach. Journal of Nursing Education, 48(6), 319-326.
Neale, P., Thapa, S., & Boyce, C. (2006). Preparing a Case Study: A Guide for Designing
and Conducting a Case Study for Evaluation Input. Pathfinder International. Retrieved from:
http://www.pathfind.org/site/DocServer/m_e_tool_series_case_study.pdf
Newton, L. (2009). Knowledge Translation and nursing: What are we translating? In
conference proceedings of Building Connections for the Scholarship of Practice. Victoria, BC:
University of Victoria.
Nutley, S., Walter, I., & Davies, H. T. O. (2003). From knowing to doing: A framework
for understanding the evidence-into-practice agenda. Evaluation, 9(2), 125-148.
Olson, M. (2009). Document Analysis. In Mills, A. J. Durepos, G. & Wiebe, E. (Eds.).
The Encyclopedia of Case Study Research. California: Sage Publications.
Ploeg, J. (2004). Nursing best practice guidelines: Ensuring optimal care for older
persons. Aging, Health and Society: News and Views.
Ploeg, J., Davies, B., Edwards, N., Gifford, W., & Miller, P.E. (2007). Factors
Influencing Best-Practice Guideline Implementation: Lessons Learned from Administrators,
Nursing Staff, and Project Leaders. Worldviews on Evidence-Based Nursing, 4(4):210-219.
Ritchie, L., Evans, M.K., & Matthews, J. (2010). Nursing students’ and clinical
instructors’ perceptions on the implementation of a best practice guideline. Journal of Nursing
Education, 49(4), 223-227.
51
NSG 71020 Theoretical Framework Research
Robottom, I. & Hart, P. (1993). Research in Environmental Education: Engaging the
debate. Geelong: Deakin University Press.
Rogers, E.M. (2005). Diffusion of Innovations. 5th ed. New York: Free Press.
Rycroft-Malone, J. (2004). The PARIHS framework-A framework for guiding the
implementation of evidence-based practice. Journal of Nursing Care Quality, 19 (4), 297-304.
Rycroft-Malone, J., Bucknall, T., Melnyk, B.M., (2004). Editorial. Worldviews on
Evidence-Based Nursing. 1(1), 1-2. Retrieved from: www.blackwellpublishing.com/wvn.\
Runkel, P. (1990). Casting nets and testing specimens: Two grand methods of
psychology. New York: Praeger.
Scheirer, M. A. (1994). Designing and using process evaluation. In J. S. Wholey, H. P.
Hatry, & K. E. Newcomer (Eds.). Handbook of practical program evaluation. San Francisco:
Jossey-Bass.
Schoales-Lada, N. (2006). Making the connections: Using health care research in
nursing clinical teaching practice. (Unpublished master’s thesis). University of Ottawa, Ottawa,
ON.
Shavelson, R.J., & Lisa Townes, L. (2002). Scientific Research in Education.
Washington, DC: National Academy Press.
Shediac-Rizkallah, M. C., & Bone, L. R. (1998). Planning for the sustainability of
community-based health programs: conceptual frameworks and future directions for research,
practice and policy. Health Education Research, 13, 87–108.
Silverman, D. (2005). Doing qualitative research. London: Sage.
Stake, R. E. (1995). The art of case study research. Thousand Oaks, CA: Sage.
52
NSG 71020 Theoretical Framework Research
Stake, R. E. (2000). The case study method in social inquiry. In R. Gomm, M. Hammersley,
& P. Foster (Eds.), Case study method: Key issues, key texts (pp. 20-26). London: Sage. (Original
work published 1978 Educational Researcher (7), 5-8).
Stake, R. E. (2005). Qualitative case studies. In N. K. Denzin, & Y.S. Lincoln (Eds.), The
Sage handbook of qualitative research (3rd ed., pp. 443-466). Thousand Oaks, CA: Sage.
Stoecker, R. (1991). "Evaluating and Rethinking the Case Study."The Sociological
Review, 39, 88-112.
Stone, C. & Rowles, C.J. (2007). Nursing students can help support evidence-based
practice on clinical nursing units. Journal of Nursing Management, 15 (3), 367-370.
The NHS Institute for Innovation and Improvement (2010). Sustainability Guide. NHS
Institute for Innovation and Improvement.
The Registered Nurses' Association of Ontario (2002). Toolkit: Implementation of
Clinical Practice Guidelines. Retrieved online from RNAO website:
http://www.rnao.org/Storage/12/668_BPG_Toolkit.pdf
The Registered Nurses' Association of Ontario (2005). Enrichment Materials Nursing,
Chapter 6: Best Practice Guideline Program. Toronto, ON, Canada: Registered Nurses’
Association of Ontario.
The Registered Nurses' Association of Ontario (2005). Educator’s Resource. Best
Practice Guideline Program. Toronto, ON, Canada: Registered Nurses’ Association of Ontario.
The Registered Nurses' Association of Ontario (2011). Nursing Best Practice Guidelines.
Retrieved online from RNAO website: http://www.rnao.org/Page.asp?
PageID=861&SiteNodeID=133.
53
NSG 71020 Theoretical Framework Research
Thomas, L.H., McColl, E., Cullum, N., Rousseau, N., Soutter J. & Steen, N. (1998).
Effect of clinical guidelines in nursing, midwifery and the therapies: a systematic review of
evaluations. Quality in Health Care (7), 183-191.
Thomas, L.H., McColl, E., Cullum N., Rousseau N., & Soutter J. (1999). Clinical
guidelines in nursing, midwifery and the therapies: a systematic review. Journal of Advanced
Nursing 30, 40-50.
Thompson, G.N., Estabrooks, C.A., & Degner, L.F. (2006). Clarifying the concepts in
knowledge transfer: A literature review. Journal of Advanced Nursing, 53, 691-701
Yin, R.K (2004). The Case Study Anthology. Sage Publication.
Yin, R. K. (2008). Case study research: Design and methods. (4th ed.). Thousand Oaks,
CA: Sage Publications.
Youngblut, J. M., & Brooten, D. (2001). Evidence-based nursing practice: why is it
important? AACN Clinical Issues, 12(4):468-76.
Allen-Meares, P. (1995). Applications of qualitative research: Let the work begin. Social WorkResearch, 19(1), 5-7.Bennett, A., & Elman, C. (2006). Qualitative research: Recent developments in case studymethods. Annual Review of Political Science, 9(1), 455-476.Chaffee, E. E., & Tierney, W. G. (1988). Collegiate culture and leadership strategies. NewYork: Macmillan.Corcoran, P. B., Walker, K. E., & Wals, A. E. J. (2004). Case studies, make-your-case studies,and case stories: A critique of case-study methodology in sustainability in highereducation. Environmental Education Research, 10(1), 7-21.Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among fivetraditions. Thousand Oaks, CA: Sage.Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed methodsapproaches (2nd ed.). Thousand Oaks, CA: Sage.Crotty, M. (1998). The foundations of social science research: Meaning and perspective in theresearch process. London: SageCutler, A. (2004). Methodical failure: The use of case study method by public relationsresearchers. Public Relations Review, 30(2004), 365-375.Denzin, N. K., & Lincoln, Y. S. (2005). Introduction: The discipline and practice of qualitativeresearch. In N. K. Denzin, & Y. S. Lincoln (Eds.), The Sage handbook of qualitativeresearch (3rd ed., pp. 1-32). Thousand Oaks, CA: Sage.Denzin, N. K., & Lincoln, Y. S. (2008). Introduction: The discipline and practice of qualitative
54
NSG 71020 Theoretical Framework Research
research. In N. K. Denzin, and Y. S. Lincoln (Eds.), Strategies of qualitative inquiry (pp.1-44). Thousand Oaks, CA: Sage.Feagin, J. R., Orum, A. M., & Sjoberg, G. (1991). Preface. In J. R. Feagin, A. M. Orum, & G.Sjoberg (Eds.), A case for the case study (pp. vii-viii). Chapel Hill: the University ofNorth Carolina.Fraser, M. W. (1995). Rich, relevant, and rigorous: Do qualitative methods measure up? SocialWork Research, 19(1), 25-27.Gilgun, J. F. (1994). A case for case studies in social work research. Social Work, 39(4), 371-380Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In N. K.Denzin, & Y.S. Lincoln (Eds.), Handbook of qualitative research (pp. 105-117).Thousand Oaks, CA: Sage.Hamel, J. (1992). The case method in sociology. Current Sociology, 40, 1-7.Hammersley, M. (1992). What’s wrong with ethnography? Methodological explorations. London: Routledge.Hammersley, M., & Gomm, R. (2000). Introduction. In R. Gomm, M. Hammersley, & P. Foster(Eds.), Case study method: Key issues, key texts (pp. 1-16). London: Sage.Hatch, J. A. (2002). Doing qualitative research in education settings. Albany: State University ofNew York.Heck, R. H. (2006). Conceptualizing and conducting meaningful research studies in education.In C. F. Conrad, & R.C. Serlin (Eds.), The Sage handbook for research in education:Engaging ideas and enriching inquiry (pp. 373-392). Thousand Oaks, CA: Sage.Jones, C., & Lyons, C. (2004). Case study: Design? Method? Or comprehensive strategy? NurseResearcher, 11(3), 70-76.Kanter, R. M. (1977). Men and women of the corporation. New York: Basic Books.Kanter, R. M., & Stein, B. A. (1979). Life in organizations: Workplaces as people experiencethem. New York: Basic Books.Lloyd-Jones, G. (2003). Design and control issues in qualitative case study research.International Journal of Qualitative Methods, 2(2), Article 4. Retrieved September 9,2006, from, http://www.ualberta.ca/~iiqm/backissues/2002_2002/pdf/lloydjones.pdfLuck, L., Jackson, D., & Usher, K. (2006). Case study: A bridge across the paradigms. NursingInquiry, 13(2), 103-109.MacNealy, M. S. (1997). Toward better case study research. IEEE Transactions on ProfessionalCommunication, 40(3), 182-196.Mertens, D. M. (2005). Research and evaluation in education and psychology: Integratingdiversity with quantitative, qualitative, and mixed methods (2nd ed.). Thousand Oaks,CA: Sage.Meyer, C. B. (2001). A case in case study methodology. Field Methods, 13(4), 329- 352.Mitchell, J. C. (2000). Case and situational analysis. In R. Gomm, M. Hammersley, & P. Foster(Eds.), Case study method: Key issues, key texts (pp. 165-186). London: Sage. (Originallypublished 1983 Sociological Review, 31(20), pp. 187- 211).Mo, L. (1978). An adventure in exploratory research. Acta Sociologica, 21(2), 165- 177.Patton, M. Q. (1990). Qualitative evaluation and research methods. Newbury Park, CA: Sage.Platt, J. (1992). “Case study” in American methodological thought. Current Sociology, 40(1), 17-48.Ragin, C. C. (1992). Introduction: Cases of "what is a case?" In C. C. Ragin, & H.S. Becker(Eds.), What is a case? Exploring the foundations of social inquiry (pp. 1-17). New York:Cambridge University Press.Rolfe, G. (2006). Validity, trustworthiness and rigour: Quality and the idea of qualitativeresearch. Journal of Advanced Nursing, 53(3), 304-310.
55
NSG 71020 Theoretical Framework Research
Schein, E. H. (2004). Organizational culture and leadership. San Francisco: Jossey-Bass.Simons, H. (1996). The paradox of case study. Cambridge Journal of Education, 26(2), 225-240.Smith, D. E. (1987). The everyday world as problematic: A feminist sociology. Toronto:University of Toronto Press.Stake, R. E. (1994). Case studies. In N. K. Denzin, & Y.S Lincoln (Eds.), Handbook ofqualitative research (pp. 236-247). Thousand Oaks, CA: Sage.Stake, R. E. (1995). The art of case study research. Thousand Oaks, CA: Sage.Stake, R. E. (2000). The case study method in social inquiry. In R. Gomm, M. Hammersley, & P.Foster (Eds.), Case study method: Key issues, key texts (pp. 20-26). London: Sage.(Original work published 1978 Educational Researcher (7), 5-8).Stake, R. E. (2005). Qualitative case studies. In N. K. Denzin, & Y.S. Lincoln (Eds.), The Sage handbook of qualitative research (3rd ed., pp. 443-466). Thousand Oaks, CA: Sage.Stake, R. E. (200). Qualitative case studies. In N. K. Denzin, & Lincoln, Y. S. (Eds.), Strategies of qualitative inquiry (pp. 119-149). Los Angeles: Sage.
Verschuren, P. J. M. (2003). Case study as a research strategy: Some ambiguities andopportunities. International Journal of Social Research Methodology, 6(2), 121-139.Wheatley, M. J. (2007). Finding our way: Leadership for an uncertain time. San Francisco:Berrett-Koehler.Yin, R. K. (1981). The case study crisis: Some answers. Administrative Science Quarterly, 26(1), 58 65.Yin, R.. K. (1984). Case study research: Design and methods. Beverly Hills, CA: Sage.Yin, R. K. (1994). Case study research: Design and methods (2nd ed.). Thousand Oaks, CA: Sage.Yin, R. K. (1999). Enhancing the quality of case studies in health services research. HealthServices Research, 34(5), 1209-1224.Yin, R. K. (2003a). Applications of case study research (2nd ed.). Thousand Oaks, CA: Sage.Yin, R. K. (2003b). Case study research: Design and methods (3rd ed.). Thousand Oaks, CA: Sage.Yin, R. K. (2005). Introduction. In R. K. Yin (Ed.), Introducing the world of education: A case study reader (pp. xiii-xxii). Thousand Oaks, CA: Sage.
56