Using GRADE to reduce the theory-practice gap

One of the most enduring problems in nursing and nurse education is what has been referred to as the ‘theory-practice gap’. This paper aims to demonstrate that the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) Evidence to Decision Frameworks can be used to explain the complex link between evidence and other influencing factors on one side of the equation, and the clinical recommendations and decisions that are made by clinicians and patients on the other. It further argues for the development of GRADE specifically for this purpose among the educational community

Does the Use of Dihydroartemisinin-Piperaquine in Treating Patients with Uncomplicated falciparum Malaria Reduce the Risk for Recurrent New falciparum Infection More Than Artemether-Lumefantrine?

Malaria contributes significantly to the global disease burden. The World Health Organization recommended the use of artemisinin-based combination therapies (ACTs) for treatment of uncomplicated falciparum malaria a decade ago in response to problems of drug resistance. This review compared two of the ACTs-Dihydroartemisinin-Piperaquine (DP) and Artemether-Lumefantrine (AL) to provide evidence which one has the ability to offer superior posttreatment prophylaxis at 28 and 42 days posttreatment. Four databases (MEDLINE, EMBASE, Cochrane Database and Global Health) were searched on June 2, 2013 and a total of seven randomized controlled trials conducted in sub-Sahara Africa were included. Results involving 2, 340 participants indicates that reduction in risk for recurrent new falciparum infections (RNIs) was 79% at day 28 in favour of DP [RR, 0.21; 95% CI: 0.14 to 0.32, P < 0.001], and at day 42 was 44% favouring DP [RR, 0.56; 95% CI: 0.34 to 0.90; P = 0.02]. No significant difference was seen in treatment failure rates between the two drugs at days 28 and 42. It is concluded that use of DP offers superior posttreatment prophylaxis compared to AL in the study areas. Hence DP can help reduce malaria cases in such areas more than AL

“Barriers to” and “Recommendations for” providing care and support for children living as AIDS orphans in township communities in the Eastern Cape South Africa: A cluster analysis

Background: Orphan-hood is a major consequence of the Acquired Immune Deficiency Syndrome (AIDS) pandemic globally. In South Africa most children who are AIDS orphans live in township communities. They are often uncared for and unsupported by the community, and experience recurrent psychological trauma and much personal suffering. Identifying the “barriers to” and “recommendations for” providing care and support to these vulnerable children is vital to enable the development of comprehensive implementations to meet these children's unique care and support needs. Objective: Using empirical data from health and social care professionals and cluster analysis to identify “barriers to” and “recommendations for” providing care and support to children living as AIDS orphans in township communities in Nelson Mandela Bay South Africa. Design: Data was collected using a descriptive phenomenology research design incorporated an exploratory, contextual and descriptive approach. In-depth unstructured interviews were used to collect data from participants. Participants: The primary health care nurses (PN) (n = 10) and social workers (SW) (n = 8) were selected using criterion-based purposive sampling, whilst snowball sampling was used to select psychologists (Psy) (n = 6). Participants are referred to as health and social care professionals. Setting: Participants were selected using purposive sampling (nurses and social workers) and snowball sampling (psychologists) from four primary health care clinics and twelve satellite health care clinics, all located in township communities in Nelson Mandela Bay, South Africa. The participants were all caring for and supporting children who are AIDS orphans living in these communities. Methods: In-depth individual interviews occurred between April and Nov 2013 which were recorded and transcribed verbatim. All data was then analysed using cluster analysis to identify “barriers to” and “recommendations for” providing care and support to these vulnerable children as identified by these research participants. Results: All “barriers to” and “recommendation for” are represented in this cluster analysis. There were six identified clusters illustrating “Barriers to” and four visualised clusters illustrating “Recommendations for”. The barriers can be identified using the following broad themes; B1, fundamental barriers; B2, primarily related to legislative and policy frameworks, B3, lack of human and financial resources also included stigma and communication. B4, grief, high risk behaviours and cumbersome bureaucratic processes and included loss of trust in adults; B5, barriers related to poverty B6, barriers related to poverty also included non-disclosure of HIV status. Regarding the “recommendations for” these can be identified using the following broad themes; R1, developing the resilience of health and social care professionals. R2, developing interventions, to meet the unique needs of these AIDS orphans. R3, developing, empowering and capacitating professionals and R4, facilitating an empowering working environment for professionals. Conclusions: Significant clusters emerged and the “barriers to” and “recommendations for” were identified in this research which could be used to inform the development of an intervention to provide “best practice” care and support to these vulnerable children living in these township communities

Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis

Objective To systematically review the literature exploring impact of isolation on hospitalised patients who are infectious: psychological and non-psychological outcomes Design Systematic review with meta-analysis Data Sources Embase, Medline and Psychinfo were searched from inception until December 2018. Reference lists and Google Scholar were also handsearched. Results Twenty six papers published from database inception until December 2018 were reviewed. A wide range of psychological and non-psychological outcomes were reported. There was a marked trend for isolated patients to exhibit higher levels of depression, the pooled standardised mean difference being 1.28 (95% CI: 0.47 to 2.09) and anxiety 1.45 (95% CI: 0.56 to 2.34), although both had high levels of heterogeneity; and worse outcomes for a range of care-related factors but with significant variation. Conclusion The review indicates that isolation to contain risk of infection has negative consequences for segregated patients. Although strength of the evidence is weak, comprising primarily single centre convenience samples, consistency of the effects may strengthen this conclusion. More research needs to be undertaken to examine this relationship and develop and test interventions to reduce the negative effects of isolation. Strengths and limitations of this study • This review covers a wide variety of literature from a range of different clinical areas. • Data collected and the methods of collecting data on the impact of isolation is varied across studies. • These data do not show if these effects are temporary, or in most cases if they are clinically significant. Funding statement This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors Competing interests statement No authors have any competing interests to declar

Electronic hand hygiene monitoring: accuracy, impact on the Hawthorne effect and efficiency

Objectives: To evaluate a type five electronic monitoring system (EMS) for hand hygiene (HH) adherence with respect to accuracy and ability to avoid the Hawthorne effect. Design: HH events were observed manually and electronically. The agreement between the two observation methods was evaluated. Continuous electronic measurement was made throughout the study. Setting: An acute 31-bed medical ward in a National Health Service trust in London, United Kingdom. Participants: Staff working or attached to the ward. Intervention: A newly developed type five EMS that can measure disinfectant dispenser usage as well as continuous movements of health workers throughout the ward with arm-length precision and analyse HH adherence was installed at the ward. Results: A total of 294 HH events were observed in five sessions by an observer previously unknown to the ward. There was concordance between HH adherence assessed by manual observer and the EMS on 84% (79.1%–89.9%) of the occasions. During the five observation sessions, the observed HH adherence increased from 24% to 76% while the EMS measurements immediately before the arrival of the observer remained constant for all sessions. Conclusion: The 84% agreement between the EMS and the manual observation suggest a high level of precision for the evaluated system. The Hawthorne effect (higher rate of HH performance) was clearly seen in the increase by a factor of three in the manually observed adherence from session to session as the health workers became more aware of them being observed. The EMS was able to avoid the Hawthorne effect when the observer was not present

Teaching health care students hand hygiene theory and skills: a systematic review

Hand hygiene is the cornerstone of infection prevention but is poorly undertaken and under-appreciated by medical, nursing, and other health care students. This systematic review aimed to identify and describe strategies used to teach the theory and practice of hand hygiene, determine impact on knowledge and practice, and identify need for future education and research. Ten studies met the criteria for review. Health care students' theoretical knowledge of hand hygiene and their ability to practise are suboptimal and should be improved before they have contact with vulnerable patients. Educational input can increase knowledge and practice but the methodological heterogeneity of the studies and lack of rigour make it impossible to determine which interventions are most likely to be successful. The literature provides little evidence upon which to base educational practice in this area. There is a need for multi-centred longitudinal studies to measure effectiveness of teaching methods over time

Changing the paradigm: messages for hand hygiene education and audit from cluster analysis

BACKGROUND: Hand hygiene is considered to be the foremost infection prevention measure. How healthcare workers accept and make sense of the hand hygiene message is likely to contribute to the success and sustainability of initiatives to improve performance, which is often poor. METHODS: A survey of nurses in critical care units in three National Health Service trusts in England was undertaken to explore opinions about hand hygiene, use of alcohol hand rubs, audit with performance feedback, and other key hand-hygiene-related issues. Data were analysed descriptively and subjected to cluster analysis. RESULTS: Three main clusters of opinion were visualized, each forming a significant group: positive attitudes, pragmatism and scepticism. A smaller cluster suggested possible guilt about ability to perform hand hygiene. CONCLUSION: Cluster analysis identified previously unsuspected constellations of beliefs about hand hygiene that offer a plausible explanation for behaviour. Healthcare workers might respond to education and audit differently according to these beliefs. Those holding predominantly positive opinions might comply with hand hygiene policy and perform well as infection prevention link nurses and champions. Those holding pragmatic attitudes are likely to respond favourably to the need for professional behaviour and need to protect themselves from infection. Greater persuasion may be needed to encourage those who are sceptical about the importance of hand hygiene to comply with guidelines. Interventions to increase compliance should be sufficiently broad in scope to tackle different beliefs. Alternatively, cluster analysis of hand hygiene beliefs could be used to identify the most effective educational and monitoring strategies for a particular clinical setting

Should automated electronic hand hygiene monitoring systems be implemented in routine patient care? Systematic review and appraisal with Medical Research Council Framework for Complex Interventions

Manual hand-hygiene audit is time-consuming, labour-intensive and inaccurate. Automated hand-hygiene monitoring systems (AHHMSs) offer advantages (generation of standardized data, avoidance of the Hawthorne effect). World Health Organization Guidelines for Hand Hygiene published in 2009 suggest that AHHMSs are a possible alternative. The objective of this review was to assess the current state of the literature for AHHMSs and offer recommendations for use in real-world settings. This was a systematic literature review, and publications included were from the time that PubMed commenced until 19th November 2023. Forty-three publications met the criteria. Using the Medical Research Council's Framework for Developing and Evaluating Complex Interventions, two were categorized as intervention development studies. Thirty-nine were evaluations. Two described implementation in real-world settings. Most were small scale and short duration. AHHMSs in conjunction with additional intervention (visual or auditory cue, performance feedback) could increase hand hygiene compliance in the short term. Impact on infection rates was difficult to determine. In the few publications where costs and resources were considered, time devoted to improving hand hygiene compliance increased when an AHHMS was in use. Health workers' opinions about AHHMSs were mixed. In conclusion, at present too little is known about the longer-term advantages of AHHMSs to recommend uptake in routine patient care. Until more longer-term accounts of implementation (over 12 months) become available, efforts should be made to improve direct observation of hand hygiene compliance to improve its accuracy and credibility. The Medical Research Council Framework could be used to categorize other complex interventions involving use of technology to prevent infection to help establish readiness for implementation