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 msubu061@uottawa.ca
University of Ottawa, School of Nursing December, 2011
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.
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 thatthe 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 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 al,
NSG 71020 Theoretical Framework Research 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 articles. But, very little is
NSG 71020 Theoretical Framework Research 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 & FineoutOverholt, 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
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 evidencebased 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 development is mandatory for the process to begin and for a successful outcome to be achieved. This is gained
NSG 71020 Theoretical Framework Research 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 evidencebased 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 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 (RycroftMalone, 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
NSG 71020 Theoretical Framework Research promote evidence-based practice to nurse students and faculties in academic settings, and to help
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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 reminders of recommendations, documentation systems, inter-professional partnerships, and
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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 didactic and clinical courses where real life case examples provide the framework for the EBP process and continual
NSG 71020 Theoretical Framework Research reinforcement through the professional program leads to lifelong learning skills to improve
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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 (HemsleyBrown, 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 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).
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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.
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:
NSG 71020 Theoretical Framework Research 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?
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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).
CONCEPTUAL FRAMEWORK (15-20 Pages) Quantitative Methods Paradigm Qualitative and quantitative approaches are rooted in philosophical traditions with different epistemological and ontological assumptions.
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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. 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.
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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 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
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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.
o o o
Researchers need to ask if research is helpful to the target population seek out alternative explanations than those the researcher constructs ask if we've really learned something from our work
substantive validity - evaluting the substance or content of an interpretive work

o o
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need to see evidence of the interpretive choices the researcher made an assessment of the biases inherent in the work over the lifespan of a research project 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. 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
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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 approachs advantages. It provides an opportunity to get a deep insight into the problem under study because [a]n interpretive explanation documents the [participants] 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 researchers 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 participants 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 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
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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 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 readers 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-
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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 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
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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 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.
NSG 71020 Theoretical Framework Research Sustainability is continued use of an idea (Ackerlund, 2000). Sustainability needs to be
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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 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.
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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 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
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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)
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
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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; 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.
NSG 71020 Theoretical Framework Research This section suggests some techniques to help recognise if the staff feel that the change is
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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 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
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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 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
NSG 71020 Theoretical Framework Research 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
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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 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.
NSG 71020 Theoretical Framework Research When the improvement has completed its pilot testing and begins full-scale
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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 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.
NSG 71020 Theoretical Framework Research 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
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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 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
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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 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
NSG 71020 Theoretical Framework Research 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 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
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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 leaders 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. schools senior administrators such as schools 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 projects success. An important factor in ensuring sustainable change is the
NSG 71020 Theoretical Framework Research engagement of faculty, clinicians, and stakeholders in the redesign and improvement of
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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 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 projects success. Organizational Sustainability Factors 1. Fit with goal and Culture
NSG 71020 Theoretical Framework Research Fit with organisational strategic goal and culture is about ensuring that there is synergy
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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. 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
NSG 71020 Theoretical Framework Research staff to be receptive to change. Every organisation should have a clear stated vision for the
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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 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
NSG 71020 Theoretical Framework Research existing resources and communication systems required to support the implementation of
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guideline recommendations and have acquired necessary resources or made changes to existing system. Barriers and facilitator of Sustainability 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?
NSG 71020 Theoretical Framework Research 6. Policy articulation and integration: How will the fit between new knowledge and existing
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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 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
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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 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 studys 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
NSG 71020 Theoretical Framework Research 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
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collected from documents, interviews, and observations (Stoecker, 1991). Study procedure will 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
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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 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
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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 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
NSG 71020 Theoretical Framework Research 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
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review will include syllabus (theory, clinical/lab), assignments, minutes meeting, and report to the RNAO. 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).
NSG 71020 Theoretical Framework Research In case study research, there are two popular types of analysis: structural analysis and
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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 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
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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). 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).
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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 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). Clinicians 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), 2840. Carper, B. A. (1978). Fundamental Patterns of Knowing in Nursing. Advances in Nursing Science, 1(1), 13-23.
NSG 71020 Theoretical Framework Research 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. Clardy, A. (1997). Studying your workforce: Applied research methods and tools for training and development practitioners. Thousand Oaks, CA: Sage.
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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.
NSG 71020 Theoretical Framework Research 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.
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Eisenhardt K. M. & Graebner M. E. (2007). Theory building from cases: opportunities and challenges. Academy of Management Journal, 50(1), 25-32. 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.
NSG 71020 Theoretical Framework Research 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., & ODonohue, M. (2006). Integrating clinical guidelines in to nursing education. International Journal of Nursing Education Scholarship, 3(1).
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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.
NSG 71020 Theoretical Framework Research 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.
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Merriam, S. B. (1998). Qualitative research and case study applications in education. San Francisco: Jossey-Bass Publisher. 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.
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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. 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 masters thesis). University of Ottawa, Ottawa, ON. Shavelson, R.J., & Lisa Townes, L. (2002). Scientific Research in Education. Washington, DC: National Academy Press.
NSG 71020 Theoretical Framework Research 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, 87108. Silverman, D. (2005). Doing qualitative research. London: Sage. Stake, R. E. (1995). The art of case study research. Thousand Oaks, CA: Sage.
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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). Educators Resource. Best Practice Guideline Program. Toronto, ON, Canada: Registered Nurses Association of Ontario.
NSG 71020 Theoretical Framework Research 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.
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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.
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NSG 71020 Theoretical Framework Research

NSG 7100 Theoretical and Philosophical Perspectives in Nursing

Muhammad Arsyad Subu PhD of Nursing Student University of Ottawa msubu061@uottawa.ca

University of Ottawa, School of Nursing December, 2011

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

substantive validity - evaluting the substance or content of an interpretive work

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

NSG 71020 Theoretical Framework Research

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