Intensive and Critical Care Nursing (2014) 30, 159—166

Available online at www.sciencedirect.com

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ORIGINAL ARTICLE

Sources of knowledge used by intensive care nurses in Norway: An exploratory study Heidi B. Bringsvor a,c,∗, Signe Berit Bentsen b, Astrid Berland c a

Department of Research, Haugesund Hospital, Helse Fonna, Norway Faculty of Social Sciences, Department of Health Studies, University of Stavanger, Stavanger, Norway c Department of Health Education, Stord/Haugesund University College, Haugesund, Norway b

Accepted 1 December 2013

KEYWORDS Evidence-based practice; Focus groups; Intensive care; Knowledge; Nursing

Summary This study explored the sources of knowledge that intensive care nurses used in their daily nursing practice. It used a qualitative design based on four focus group interviews with 20 intensive care nurses, from four intensive care units in Norway. Data were analysed using systematic text condensation. The following condensed meaning units were identified: research, theoretical knowledge, experiential knowledge, work place culture, clinical expertise and patient participation. This study illustrates the complexity and variety of the knowledge bases of intensive care nurses. Despite some variation in nurses’ familiarity with research literature, nursing interventions found by research to be useful were given priority, and research affected daily practice through changes in guidelines and procedures. © 2013 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice • This study indicates that there is a complex and multifaceted knowledge base for intensive care nursing practice, which should be recognised when initiatives for implementing evidence-based practice (EBP) are developed. Hence, this study suggests that further efforts should be made to ensure that nursing practice is based on the best available evidence. Educating ICU nurses in EBP is essential to achieve this. • Research findings were stressed by the ICU nurses in this study as important, and as being more important today than some years ago, but they also described uncertainty about whether research conducted within the nursing profession was used as a basis for actual nursing practice, indicating a need for both the educational system and organisational management to assist them in applying nursing research in practice. • Personal and cultural differences might influence nursing decisions, suggesting that attention needs to be paid to the social and cultural aspects of ICU units when research findings and EBP are implemented.

∗

Corresponding author at: Department of Research, Helse Fonna, P.Boks 2170, 5540 Haugesund, Norway. Tel.: +47 52732770. E-mail address: [email protected] (H.B. Bringsvor).

0964-3397/$ — see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.iccn.2013.12.001

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Introduction Evidence is one of the most fashionable concepts in health care (Rycroft-Malone et al., 2004) and health care environments increasingly demand nurses to be able to solve patient problems by utilising the best available evidence (Shorten et al., 2001). Despite some criticism of evidencebased practice (EBP) (Porter and O’Halloran, 2008), there is a strong international desire for EBP in nursing (Forsman et al., 2010; Sherriff et al., 2007). Evidence-based practice is defined in different ways. Sackett et al.’s (1996, p. 71) definition of EBP in medicine states that EBP is ‘‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’’. According to this definition practising EBP means ‘‘integrating individual, clinical expertise with the best available external clinical evidence from systematic research’’ (Sackett et al., 1996, p. 71). Evidence-based practice has also been described as the optimal use of research evidence in nursing (van Achterberg et al., 2008). Others have emphasised the process of making clinical decisions using the best available research evidence, clinical expertise and patient preferences within the context of available resources (DiCenso et al., 1998). Evidence-based practice has evolved in definition and scope, and requires that decisions about health care are based on the most current, valid and relevant evidence available. The decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources (Dawes et al., 2005). In Norway, EBP has sometimes been considered synonymous to knowledge-based practice (Nortvedt et al., 2007). The Norwegian Nurses Organisation (NNO) states that ‘‘nursing practice shall be knowledge-based and shall be founded on research and empirical knowledge as well as on the patient’s/user’s choices and value preferences’’ (NNO, 2008, p. 12). Recently, there has been significant growth in the field of knowledge utilisation in nursing (Scott et al., 2010). The literature includes research on how knowledge is built up and expanded in the health care system. For example, studies show that social interactions and experience are two important sources of practice knowledge for nurses (Estabrooks et al., 2005; Marshall et al., 2011; Thompson et al., 2008), and that, when faced with uncertainty, nurses tend to rely on these sources of information, rather than evidence-based resources, for their clinical decisionmaking (McCaughan et al., 2005). Regardless of efforts to implement EBP in nursing, and nurses’ positive attitudes concerning the use of scientific evidence to guide practice (Adib-Hajbaghery, 2009; Majid et al., 2011), both individual and organisational barriers to research utilisation and EBP have been described (Brown et al., 2009; Estabrooks et al., 2003, 2007). In a previous study, we explored the knowledge nurses used in their clinical practice of primary care and found that although they used different sources of knowledge, they seldom used research (Berland et al., 2012). Other studies have also found that few nurses use research in their clinical practice (AdibHajbaghery, 2009; Bonner and Sando, 2008; Boström et al., 2006).

H.B. Bringsvor et al. Fewer studies have examined the knowledge upon which nurses in intensive care units (ICUs) base their clinical practice. Aitken et al. (2008) described decision-making in ICU settings as a highly complex process. Marshall et al. (2011) found that nurses preferred to rely on information obtained from colleagues and that this was considered both the most useful and accessible source of knowledge in the clinical setting of ICUs, while text and electronic information were seen as less accessible. However, little is known, and further research is recommended. Therefore, the objective of this study was to explore the sources of knowledge used by ICU nurses, as described by the nurses themselves.

Methods A qualitative exploratory design was used, with focus group interviews. The study was approved by the Norwegian Social Science Data Service (No.: 25853), and was conducted according to the Declaration of Helsinki. Leaders in the administrations of the involved hospitals all gave informed written consent. Prior to participation, all participants received verbal and written information regarding the aims of the study and how the results were to be presented, and were told that participation was voluntary. Anonymity and confidentiality were guaranteed. Participants were recruited from ICUs located on the west coast of Norway. Four different ICUs, located at three different hospitals, were chosen. The hospitals varied in size; none was a university hospital. The selection criteria for participation in the study were being an ICU nurse and working at the bedside of patients in an ICU. This excluded ICU nurses in primarily administrative or management roles and nurses who were working outside ICUs. The ward management distributed information to ICU nurses who fulfilled the criteria, and made appointments for the interviews for those who wanted to participate. The participants in this study consisted of 17 female and three male ICU nurses. All participants had completed 18 months of postgraduate education to specialise as ICU nurses. Their experience levels as ICU nurses varied from three months to more than 30 years, with a mean of 10 years. The data collection was conducted during the spring of 2011. Four focus group interviews, one in each ICU, were conducted. The number of participants in each interview was respectively 7, 5, 6 and 2. The hospitals provided conference rooms, and the interviews lasted between 1.5 and 2 hours, which is a common duration for focus group interviews (Kitzinger, 1995). The interviews were led by the first author, who is an ICU nurse. This was based on recommendations that the moderator must have adequate background knowledge on the topic of discussion and be familiar with ‘inside language’, jargon and key issues (Krueger and Casey, 2009). An assistant moderator was also present and took notes on nonverbal communication. The moderator facilitated the discussion so that appropriate themes were discussed, and ensured that all participants were heard. Emphasis was placed on asking simple, open-ended and clear questions (Krueger and

Sources of knowledge used by intensive care nurses in Norway Casey, 2009). All the interviews started with a question concerning the understanding of the term ‘knowledge’, such as ‘how do you understand knowledge?’ or ‘what is knowledge?’ Later in the interviews, group discussion themes focused on the different sources of knowledge the nurses used in their daily practice. The order of different themes discussed varied depending on the participants’ answers. If not mentioned by participants during the interview, the following themes were addressed by the moderator: theoretical knowledge/research-based knowledge, experience-based knowledge and patient participation. The participants were actively engaged in the discussions and contributions were sometimes given in half sentences that were completed or followed up by other participants. The atmosphere was positive during the interviews, with both humour and laughter. At the end of each interview, there was a summary and an invitation for additional comments. All the interviews were audiotaped and transcribed verbatim by the first author. Data were analysed using systematic text condensation as described by Malterud (2012). The transcribed interviews were read several times to form a general impression. Secondly, meaningful units concerning the knowledge used by ICU nurses were separated and coded. Thirdly, information from each code-group defined in the second step was abstracted and further sorted into subgroups. Then the meaningful information was summarised and compared with its initial context. Finally, the results were validated by reading the material both horizontally; evaluating how descriptions and concepts corresponded across the material, and vertically; evaluating the correspondence in information given by different participants (Malterud, 2012). The authors discussed the meaning and interpretation of the text in collaboration during the analysis process.

Findings The following condensed meaning units were identified: research, theoretical knowledge, experiential knowledge, work place culture, clinical expertise and patient participation. The findings are schematically presented in Table 1.

Research Research, as a source of knowledge, was the first emerging theme in three of four focus groups. The ICU nurses described research-based knowledge as essential in their

Table 1

daily practice, and also pointed out that research findings are of greater importance today than they were some years ago. Nursing interventions found by research to be useful were given priority in their daily practices, as exemplified by the nurses giving priority to the writing of diaries for patients: ‘‘It’s like those diaries we write. Research was conducted. . .. It’s important [i.e., the research], because writing and following up a patient diary is a bit labour intensive. But if you know it’s for a good reason, that simplifies it. . .’’ (FG1-P5). Even so, participants pointed out that not everything referred to as research should automatically influence their nursing practice. Some participants questioned research conducted within the nursing profession. They emphasised that research findings must be evaluated with respect to the validity of the research methods, their scope and their representativeness. The following statements exemplify this: ‘‘You must be sceptical regarding research, the method and the scope. . .’’ (FG2-P4). ‘‘I assess the limitations of the nursing research. The size of it [i.e., the study] — how many participated? And of course, in a gold standard there are several studies, but I’m unsure to what degree that’s conducted within the field of nursing’’ (FG3-P6). Reading research directly was an activity that mainly took place when the nurses were off duty; lack of time was described as a large barrier to reading research within their working hours. Many of the participants stated that they read research journals, but they were selective in their choice of reading subjects. The use of Internet-based sources varied. Several participants described difficulties in locating research in general and in using search engines in particular, but some participants described their comfort with Internet use: ‘‘And then you have the Internet too, Medline and so on. I’ve shown it to many colleagues. It’s very simple’’ (FG1P2). In all the interviews, participants mentioned Practical Procedures in Nursing (PPS), a database used by all nursing schools in Norway. The nurses described the procedures in PPS as research based, but varied in their opinions about their wards’ specific procedures. Mostly, their wards’ own procedures were described as indirectly research based:

Systematic presentation of the code-groups and subgroups.

Code-groups Subgroups

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Research

Theoretical knowledge

Experiential knowledge

Scientific medical knowledge

Person- and context-specific knowledge Life experience

Nursing theories and concepts Laws, guidelines and directives

Nursing colleagues

Work place culture

Clinical expertise

Patient participation

162 ‘‘It [research] is in [our ward’s] procedures. We might implement new procedures because new research shows [benefits]. . .We haven’t necessarily read the research directly ourselves, but the development nurse introduces new procedures because research has shown that [there are benefits]. . .’’ (FG1-P3).

Theoretical knowledge Three subgroups were identified: scientific medical knowledge; nursing theories and concepts; and laws, guidelines and directives. Scientific medical knowledge was described by several ICU nurses as a particular category of theoretical knowledge, with both physiology and pathology as essential parts of the knowledge they used in their daily practice. Theories of nursing and concepts such as coping, care and hope were also mentioned in the interviews. Our findings indicate that this type of knowledge is not something the nurses consciously think about in their nursing practice; instead, it was mainly described as a background for their daily practice. Even so, several participants described how knowledge about different theories and concepts was more important in the ICU than in other settings: ‘‘Actually, I believe we must know more about this in the ICU, because here it is more critical. The patients are helpless and their relatives are helpless. So, often they need even more caring, and hope, and all these words that in reality are quite grandiose words. . .’’ (FG3-P5). Laws, guidelines and directives were also described as theoretical knowledge and, like theories of nursing, laws and guidelines were described as part of the background knowledge used in judgements and decision-making: ‘‘You also have laws and guidelines ticking in the back of your head. . .’’ (FG2-P5).

Experiential knowledge Subgroups identified under this code group were: knowledge as person- and context-specific; knowledge from life-experience; and nursing colleagues as a source of knowledge. Several participants described theoretical knowledge and experience-based knowledge as equally important, while some participants stated that practical and experiencebased knowledge play the leading part in their daily practice: ‘‘Theory is very important, but practical skills, to know your own limitations and practice knowledge [are even more important]. You could have a lot of research articles in your head, but if you don’t know nursing then you can’t work. . .’’ (FG3-P4). Experience-based knowledge was often linked to exercising judgement, tacit knowledge and a clinical gaze. The following quote exemplifies the latter: ‘‘Clinical gaze is something not definable; you just perceive — in addition to what you know. I believe that this

H.B. Bringsvor et al. trait brings you close to being an excellent nurse, but it takes time getting there. . .’’ (FG1-P7). A number of the ICU nurses pointed out that parts of their experience-based knowledge are individual, personal and context-specific, and arise from being in a specific context and connected to a particular patient group, rather than simply being experienced in general. One participant explained this by referring to her experience with patients with heart-attacks: ‘‘If I, myself, hadn’t seen a lot of patients with heartattacks, then I wouldn’t have thought about it. Instead I would have thought: ‘‘This is nothing. This isn’t a heartattack, because it’s so atypical’’. But because I have been here and seen a lot of patients with heart-attacks, I know that the most atypical symptoms might be a heartattack’’ (FG4-P2). Although some parts of the nurses’ knowledge were viewed as specifically related to work experience, several participants also described how experience and knowledge derived from their private life played a part in their work as ICU nurses: ‘‘Clearly, I also brought with me my experience from life before I became a nurse. You bring with yourself everything, well, from the moment you open your eyes. How you were brought up’’ (FG4-P1). In addition to their own knowledge base, the nurses also explained how the knowledge of others both affected their nursing directly and gradually became a part of their own knowledge base. Nursing colleagues were described as an available and useful source of knowledge. The participants described an atmosphere in which asking questions and sharing information were valued: ‘‘We ask each other a lot [of questions]. I think we use our colleagues more than in a regular hospital ward, even if we have long experience. Just to check if our thoughts are ‘‘on track’’. . .’’ (FG1-P1). Reflection was also emphasised during the interviews. Participants in one interview talked about how they found time for reflection in their ward, but most of the participants did not have this opportunity in their work: ‘‘. . .it would probably be better if we were able to discuss things — quite simply, to reflect. I think about that frequently, both for the new ones and for those of us who have been here for a long time’’ (FG3-P1).

Work place culture influences in clinical knowledge Several participants emphasised how they are influenced by, and have learned from, the ward culture itself. The participants referred to culture as a concept in general, as well as the explicit ward culture, and its influence on their daily nursing practice. One nurse described how the cultural differences between two different ICU wards in the same hospital resulted in differences in the priorities of the nurses, referring to the example of how long she stayed at the bedside of patients receiving non-invasive respiratory support:

Sources of knowledge used by intensive care nurses in Norway ‘‘I came from NN ward, and there we always stay in the room with the patients. There’s a culture of being [at the] bedside almost all the time. So I continued doing that [at my new ward], maybe a little too much in the beginning, but then it started like this: ‘‘Oh, so you are at work today?’’ when they [colleagues] saw me in the staffroom. And that was only because I had given priority to talking with my patients. So, it’s the culture as well. . .’’ (FG3-P6).

Clinical expertise Besides the nursing colleagues they worked with in their own ICU ward, the nurses had direct contact with other professionals and with other ICU nurses, both in other hospital wards and in other hospitals. Most of the knowledge exchanged was in the form of answers to specific questions with explicit relevance for practice: ‘‘It’s quite OK to ask the staff at NN ward [about a particular procedure] when it’s something we seldom do. They do these things every day . . . I get a lot of help there’’ (FG3-P3). Even though specific subjects and defined questions are important, other aspects were also highlighted. Some participants emphasised that the visits they made to other hospitals, and the presence of ICU nurses from temporary staff recruitment agencies, contributed to the knowledge exchange between ICUs: ‘‘Visiting other hospitals, or routinely having temporary staff here [represents opportunities to learn]. . .. We talk a lot, and get a lot from them. They travel everywhere. They are at all the hospitals in Norway, and abroad, and bring with themselves what they believe is the best’’ (FG1-P6). The nurses also collaborate with other professionals, and the knowledge gained through these interactions was described as a part of the knowledge base upon which they built their practice. Staff in anaesthesia, operating units, laboratories and radiology departments were mentioned, but in all the interviews, physical therapists and physicians in particular were discussed. Several participants pointed out that the physical therapists in their ward were enthusiastic and passionate, and that they had learned much from them. Participants also explained that much knowledge was exchanged between physicians and ICU nurses through daily interaction, but that this type of relationship and information exchange was more dependent on individual attributes than the professional roles. Participants in several interviews stated that they missed the interdisciplinary collaboration of working in larger ICUs, through which they had previously gained knowledge: ‘‘I must say, there is a big difference between how this ICU is and how it was working in an ICU in a larger hospital. There, we learned a lot from the physicians. As they [the physicians] did bedside checks and procedures, they explained both what [they were doing] and why, so we learned a lot. Here, that doesn’t exist at all. . .’’ (FG1-P3).

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Patient participation From the participants’ descriptions it appears that the patients are important as a source of knowledge, and influence on intensive care nurses’ daily practice, in two different respects. Directly; when the patient’s individual knowledge about himself and his own situation is expressed and used during the actual interaction and indirectly; when knowledge and experience from former patients and their relatives are communicated, through the nurses’ own encounters with patients and through various literature sources describing patient experiences. Regarding the direct influence, the nurses distinguish between awake intensive care patients and patients unable to express themselves. The participants call attention to the fact that, in this regard, the ICU differs from other wards, because in the ICU most patients are not capable of communicating their knowledge and influencing the judgements and decisions made by the health personnel, so patient participation is affected by each patient’s actual medical condition: ‘‘It depends on what phase they are in. So, it’s a bit different. But for awake patients I believe it’s [i.e., the level of patient participation] equal to [that of] other patients. . .’’ (FG2-P2). Simultaneously, the participants in several interviews discussed and expressed disagreement concerning the degree to which nurses actually listen to awake patients. Some participants point out that any adjustments often affect less important areas, such as the exact time for taking medication, or the times at which the patient would like to eat or get up. Some participants went even further, maintaining that no attention was paid to the patients’ knowledge when decisions were made: ‘‘How much influence does their [the patients’] knowledge have? — None!’’ (FG2-P3). Other participants emphasised that the knowledge of the patients and their relatives is of greater significance today than some years ago, and that attention is paid to both their knowledge and experience: ‘‘Twenty years ago, the patients were insignificant, [and] had no influence. Today, I see some patients, and especially some relatives, with some power, demanding things from the health care system, [and] using their knowledge. They might have been online, reading on the Internet about their diagnosis. I think they do that a lot more today, and then they ask very relevant questions. . .’’ (FG1-P6).

Discussion In this study, we explored the sources of knowledge used by ICU nurses in their daily nursing practice. Our findings show the complexity and variety of the knowledge bases of ICU nurses, which are similar to the descriptions given by Estabrooks et al. (2005). Grimen (2008) states that the knowledge base of nursing as a profession is integrated by a practical synthesis, in distinction to other professions’

164 knowledge bases, which are integrated by theoretical syntheses. Professional knowledge based on a practical synthesis is integrated by the demands made by the professional practice itself, and is not necessarily theoretically connected (Grimen, 2008). This may be congruent with our findings. The nurses described a broad and varied knowledge foundation, in which the nurses’ experience in daily nursing practice was essential to the impact of different knowledge. Great emphasis was placed on research-based knowledge by the participants. In three of the four focus groups, research was the first emerging theme in the group discussion. Many of the nurses described research findings as an important part of their knowledge, and as a factor that influenced their daily nursing practice, despite some variation in the nurses’ familiarity with research literature and search tools such as databases. Some previous studies have shown that nurses in other contexts seldom use research-based evidence when clinical decisions are made (Adib-Hajbaghery, 2009; Berland et al., 2012; McCaughan et al., 2005). Other studies describe the use of both written and Internetbased information (Estabrooks et al., 2005), consistent with the ICU nurses’ descriptions of sources of research-based knowledge. Profetto-McGrath et al. (2007) found that clinical nurse specialists (advanced practice nurses who hold a master’s or doctoral degree) used research literature as a primary source of evidence, and that research was used in their decision-making. None of the hospitals in this study was a university hospital and none of the participants had a master’s or doctoral degree, but all were specialised intensive care nurses and had completed postgraduate education. Some of the nurses had finished their specialisations several years prior to the study, when there was less emphasis on research and EBP; this might explain the variation in the nurses’ familiarity with research-based knowledge sources. Different studies also indicate that, despite growing opportunities to base intensive care nursing on EBP and research, knowledge from these sources is still not effectively put into practice in ICUs (Kahn, 2009; Vandijck et al., 2008; Wallin et al., 2006). The participants described barriers to acquiring researchbased knowledge. The barriers were attached to both organisational factors, such as opportunities to keep up to date with research literature during working hours, and individual factors, such as the ability to search for and locate the desired research-based literature. This corresponds with previous research findings describing barriers to research utilisation and EBP in nursing (Brown et al., 2009; McCaughan et al., 2002; Thompson et al., 2005). An interesting finding is the participants’ conscious evaluation of research findings and their descriptions of both national and local procedures as being based on research findings. Other studies show that ICU nurses did not always have knowledge about evidence based guidelines (Labeau et al., 2009; Vandijck et al., 2008), and that local clinical guidelines and procedures in ICUs have limited evidence on how they were attained (Eldh et al., 2013). Furthermore, when local guidelines undergo external evaluation only 25% are approved (Thaysen et al., 2008). Research-based knowledge is not the only type of theoretical knowledge important for nursing practice in ICUs.

H.B. Bringsvor et al. Although other studies indicate that ICU nurses have a low to intermediate level of knowledge of respiratory physiology (Pirret, 2007), knowledge about physiology and pathology was described as basic and important by the nurses in this study. The participants also viewed theories on themes such as nursing, caring, coping and hope as background influences on their practice, even though such theories were not necessarily being consciously and directly used. This might be seen as in line with Eraut’s (2004) statement that, particularly in professions involving direct contact with patients, there is a tendency to construct theories that are ideologically attractive, though difficult to align with actual practice. Laws concerning health care were described as a source of knowledge used by the ICU nurses; this finding is consistent with findings in a previous study related to nurses in primary care (Berland et al., 2012). The ICU nurses related this knowledge especially to ethical judgements, consistent with Wueste (2005) descriptions of the tendency of ethical and professional codes to be like laws. An interesting finding of this study is that experience and social interactions were important sources of knowledge. This finding is consistent with previous research findings concerning nursing in other contexts (Berland et al., 2012; Estabrooks et al., 2005; McCaughan et al., 2005). Concerning ICU nurses in particular, Marshall et al.’s (2011) findings show that colleagues are considered both useful and accessible information sources in the ICU setting. According to Benner et al. (2011), the development of a rich experiential base is essential for the critical care nurse to enter undetermined or ambiguous situations. Some of these skills can only be developed and enhanced when nurses collaborate and compare their own judgments in the actual practice of nursing (Benner, 1984). The participants in this study also pointed out the usefulness of consulting one another and discussing and reflecting upon their judgements and decisions. The participants used the term ‘culture’, describing the influence that work place culture might have on their knowledge base and clinical practice. The importance of cultural aspects is also described by Villa et al. (2012). They found that cultural unwritten rules are an important part of the decision-making processes of nurses in ICUs. According to Wenger, the term community of practice is a more tractable term than culture. Communities of practice are characterised by a mutual engagement, joint enterprise and a shared repertoire (Wenger, 1998). Our findings indicate that nursing colleagues are an important source of knowledge for ICU nurses, but that other types of clinical expertise are also viewed as sources of information and knowledge. Thompson et al. (2004) describe accessibility and usefulness as important aspects of nurses’ information seeking, and our finding that participants gave pragmatic reasons for seeking information and knowledge supports their descriptions. Even so, descriptions given by participants in our study indicate that the transmission of knowledge between physicians and nurses in particular might be dependent on both personal and structural factors. The presence of multidisciplinary teams has been shown to reduce patient mortality in ICUs (McHugh, 2010), but the interrelationship between knowledge and decisionmaking as nurses and doctors interact in ICUs is complex

Sources of knowledge used by intensive care nurses in Norway (Manias and Street, 2001). Some participants stated that they missed more interdisciplinary collaboration, consistent with Estabrooks et al.’s (2005) findings, indicating only minimal interactions or consultations between nurses and physicians. The ICU nurses also indicated that information obtained from patients and families was important in their daily practice. The participants distinguished between awake patients, who were able to articulate their wishes and needs, and those patients unable to do so. Indirectly, information from previous patient encounters was included as part of the nurses’ experiential knowledge, and patients’ written descriptions were also mentioned as sources of knowledge used in their nursing practice. For those patients who were able to communicate, the concept of patient participation was stressed, even though the participants varied in their descriptions of the weight this information was actually accorded in their daily practice. According to Estabrooks et al. (2005), nurses have strong positive views about patients as a routine source of information for nurses. Even so, patients were infrequently mentioned as a source of practice knowledge, and the information obtained from patients and families was typically nontechnical, and enabled the nurses merely to tailor their existing care plans to the patients’ individual preferences so as to optimise the care (Estabrooks et al., 2005), similar to some of the descriptions given by participants in this study. Patient empowerment in ICUs involves strengthening and stimulating the patients’ own inherent joy of life and will to fight (Wåhlin et al., 2006). Lewin and Piper (2007) conclude that empowerment issues involving the right of patients to be primary decision-makers and managers of their illness, treatment and care might be alien to most patients in acute settings, a finding supported by the discussion with the ICU nurses in this study. Transferability of findings refers to the receiver’s considerations of the extent to which findings can be transferred to other settings or groups (Polit and Beck, 2012). Data were obtained from a small sample and in a limited geographic region, and none of the hospitals was a university hospital. This could possibly limit transferability. The focus group method itself might also be a limitation of this study. As pointed out by Kitzinger (1995), participants may not feel free to express their opinion if the group dynamics are not open and free. The participants in this study consisted of 17 female and three male ICU nurses. Krueger and Casey (2009) state that sometimes it is unwise to mix genders in focus groups, because males tend to speak more often and this can have a negative effect on the female participants. We did not observe any negative effects as a result of including male participants, possibly because all participants had the same work responsibilities. The moderator’s own experience and understanding of intensive care nursing might have had an effect on the interpretation of the findings. However, the assistant moderator present during the interviews was not an intensive care nurse, and the analysis and interpretation were discussed among the authors until agreement was reached. Despite these possible limitations, the results provide insight into the sources of knowledge intensive care nurses use in their daily nursing practice.

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Conclusion Descriptions given in this study show the variety and complexity of ICU nurses base of knowledge. Participants described research, theoretical knowledge, experiential knowledge, work place culture and knowledge derived from interactions with others, including clinical expertise and patients, as knowledge used in daily nursing practice. The ICU nurses stressed research findings as important, despite some variation in the nurses’ familiarity with research literature. Evidence-based practice has been made a priority in health care in recent decades and this study’s findings imply that further effort needs to be made by the education system and nursing management to ensure that the best possible evidence is applied in practice.

Conflict of interest No conflict of interest relates to this work.

References Adib-Hajbaghery M. Evidence-based practice: Iranian nurses’ perceptions. Worldviews Evid Based Nurs 2009;6(2):93—101. Aitken LM, Marshall AP, Elliott R, McKinley S. Critical care nurses’ decision making: sedation assessment and management in intensive care. J Clin Nurs 2008;18(1):36—45, http://dx.doi.org/10.1111/j.1365-2702.2008.02318.x. Benner P. From novice to expert: excellence and power in clinical nursing practice. CA: Addison-Wesley Publishing Company Inc; 1984. Benner P, Kyriakidis HP, Stannard D. Clinical wisdom and interventions in acute and critical care: a thinking-in-action approach. 2nd ed. New York: Springer Publishing Company, LLC; 2011. Berland A, Gundersen D, Bentsen SB. Evidence-based practice in primary care: an explorative study of nurse practitioners in Norway. Nurse Educ Pract 2012;12(6):361—5, http://dx.doi.org/10.1016/j.nepr.2012.05.002. Bonner A, Sando J. Examining the knowledge, attitudes and use of research by nurses. J Nurs Manage 2008;16(3):334—43. Boström AM, Wallin L, Nordström G. Research use in the care of older people: a survey among healthcare staff. Int J Older People Nurs 2006;1(3):131—40. Brown CE, Wickline MA, Ecoff L, Glaser D. Nursing practice, knowledge, attitudes and perceived barriers to evidencebased practice at an academic medical center. J Adv Nurs 2009;65(2):371—81. Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, et al. Sicily statements on evidence-based practice. BMC Med Educ 2005;5(1):1, http://dx.doi.org/10.1186/1472-6920/5/1. DiCenso A, Cullum N, Ciliska D. Implementing evidence-based nursing: some misconceptions. Evid Based Nurs 1998;1:38—40. Eldh AC, Vogel G, Söderberg A, Blomqvist H, Wengström Y. Use of evidence in clinical guidelines and everyday practice for mechanical ventilation in Swedish intensive care units. WVN 2013;10(4):198—207, http://dx.doi.org/10.1111/wvn.12008. Eraut M. Transfer of knowledge between education and workplace settings. In: Rainbird H, Fuller A, Munro H, editors. Workplace learning in context. London: Routledge; 2004. Estabrooks CA, Floyd JA, Scott-Findlay S, O’Leary KA, Gushta M. Individual determinants of research utilization: a systematic review. J Adv Nurs 2003;43(5):506—20.

166 Estabrooks CA, Midodzi WK, Cummings GG, Wallin L. Predicting research use in nursing organizations: a multilevel analysis. Nurs Res 2007;56(Suppl. 4):7—23. Estabrooks CA, Rutakumwa W, O’Leary KA, Profetto-McGrath J, Milner M, Levers MJ, et al. Sources of practice knowledge among nurses. Qual Health Res 2005;15(4):460—76, http://dx.doi.org/10.1177/1049732304273702. Forsman H, Rudman A, Gustavsson P, Ehrenberg A, Wallin L. Use of research by nurses during their first two years after graduating. J Adv Nurs 2010;66(4):878—90, 10.1111/j.13652648.2009.05223.x. Grimen H. Profession and knowledge. In: Molander A, Terum LI, editors. Professional education. Oslo: Universitetsforlaget AS; 2008 [in Norwegian]. Kahn JM. Disseminating clinical trial results in critical care. Crit Care Med 2009;37(Suppl. 1):147—53, http://dx.doi.org/10.1097/CCM.0b013e318a31920. Kitzinger J. Qualitative research. Introducing focus groups. BMJ 1995;311(7000):299—302. Krueger RA, Casey MA. Focus groups: a practical guide for applied research. 4th ed. Thousand Oaks, CA: SAGE Publications Inc.; 2009. Labeau SO, Witdouck SS, Vandijck DM, Claes B, Rello J, Vandewoude KH, et al. Nurses knowledge of evidence-based guidelines for the prevention of surgical site infection. Worldviews Evid Based Nurs 2009;7(1):16—24. Lewin D, Piper S. Patient empowerment within a coronary care unit: insights for health professionals drawn from a patient satisfaction survey. Intensive Crit Care Nurs 2007;23(2):81—90, http://dx.doi.org/10.1016/j.iccn.2006.09.003. Majid S, Foo S, Luyt B, Zhang X, Theng YL, Chang YK, et al. Adopting evidence-based practice in clinical decision making: nurses’ perceptions, knowledge, and barriers. J Med Libr Assoc 2011;99(3):229—36, http://dx.doi.org/10.3163/1536-5050.99.3.010. Malterud K. Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health 2012;40(8):795—805. Manias E, Street A. The interplay of knowledge and decision making between nurses and doctors in critical care. Int J Nurs Stud 2001;38(2):129—40. Marshall AP, West SH, Aitken LM. Preferred information sources for clinical decision making: critical care nurses’ perceptions of information accessibility and usefulness. Worldviews Evid Based Nurs 2011;8(4):224—35, http://dx.doi.org/10.1111/j.1741-6787.2011.00221.x. McCaughan D, Thompson C, Cullum N, Sheldon T, Raynor P. Nurse practitioner and practice nurses’ use of research information in clinical decision making: findings from an exploratory study. Fam Prac 2005;22(5):490—7. McCaughan D, Thompson C, Cullum N, Sheldon TA, Thompson DR. Acute care nurses’ perceptions of barriers to using research information in clinical decision-making. J Adv Nurs 2002;39(1):46—60. McHugh MD. Daily multidisciplinary team rounds associated with reduced 30-day mortality in medical intensive care unit patients. Evid Based Nurs 2010;13(3):91—2, http://dx.doi.org/10.1136/ebn.13.3.91. Nortvedt MW, Jamtvedt G, Graverholt B, Reinar LM. To work and teach evidence-based: a work-book for nurses. Oslo: Norsk Sykepleierforbund; 2007 [in Norwegian]. The Norwegian Nurses Organisation’s (NNO’s). Constitution of principles; 2008, https://www.sykepleierforbundet.no/ Content/337222/NNOs%20Constitution%20of%20Principles6.pdf (derived from the internet 08.08.12.). AM. The level of knowledge of respiraPirret physiology articulated by intensive care tory nurses to provide rationale for their clinical

H.B. Bringsvor et al. decision-making. Intensive Crit Care Nurs 2007;23(3):145—55, http://dx.doi.org/10.1016/j.iccn.2006.11.004. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2012. Porter S, O’Halloran P. The postmodernist war on evidencebased practice. Int J Nurs Stud 2009;46(5):740—8, http://dx.doi.org/10.1016/j.ijnurstu.2008.11.002. Profetto-McGrath J, Smith KB, Hugo K, Taylor M, El-Hajj H. Clinical nurse specialists’ use of evidence in practice: a pilot study. Worldviews Evid Based Nurs 2007;4(2): 86—96. Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B. What counts as evidence in evidence-based practice? J Adv Nurs 2004;47(1):81—90. Sackett DL, Rosenberg WMC, Gray MJA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(7023):71—2. Scott SD, Profetto-McGrath J, Estabrooks CA, Winther C, Wallin L, Lavis JN. Mapping the knowledge utilization field in nursing from 1945 to 2004: a bibliometric analysis. Worldviews Evid Based Nurs 2010;7(4):226—37. Sherriff KL, Wallis M, Chaboyer W. Nurses’ attitudes to and perceptions of knowledge and skills regarding evidence-based practice. Int J Nurs Pract 2007;13(6):363—9, 10.1111/j.1440172X.2007.00651.x. Shorten A, Wallace MC, Crookes PA. Developing information literacy: a key to evidence-based nursing. Int Nurs Rev 2001;48(2):86—92. Thaysen HV, Mainz H, Bjørnshave B, Laustsen S, De Thurah A. Experiences with quality assessment of clinical guidelines. Sygeplejersken 2008;24:56—60 [in Danish]. Thompson C, Cullum N, McCaughan D, Sheldon T, Raynor P. Nurses, information use, and clinical decision making — the real world potential for evidence-based decisions in nursing. Evid Based Nurs 2004;7(3):68—72. Thompson C, McCaughan D, Cullum N, Sheldon TA, Raynor P. Barriers to evidence-based practice in primary care nursing — why viewing decision-making as context is helpful. J Adv Nurs 2005;52(4):432—44. Thompson DS, Moore KN, Estabrooks CA. Increasing research use in nursing: implications for clinical educators and managers. Evid Based Nurs 2008;11(2):35—9, http://dx.doi.org/10.1136/ebn.11.2.35. van Achterberg T, Schoonhoven L, Grol R. Nursing implementation science: how evidence-based nursing requires evidence-based implementation. J Nurs Scholarsh 2008;40(4): 302—10. Vandijck DM, Labeau SO, Blot SI. Level of knowledge articulated by intensive care nurses and clinical decisionIntensive Crit Care Nurs 2008;24(1):6—7, making. http://dx.doi.org/10.1016/j.iccn.2007.06.005. Villa G, Manara D, Palese A. Nurses’ near-decisionmaking process of postoperative patients’ cardiosurgical weaning and extubation in an Italian environIntensive Crit Care Nurs 2012;28(1):41—9, ment. http://dx.doi.org/10.1016/j.iccn.2011.10.007. Wallin L, Estabrooks CA, Midodzi WK, Cummings GG. Development and validation of a derived measure of research utilization by nurses. Nurs Res 2006;55(3):149—60. Wenger E. Communities of practice: learning, meaning and identity. New York: Cambridge University Press; 1998. Wueste DE. A philosophical yet user-friendly framework for ethical decision making in critical care nursing. Dimens Crit Care Nurs 2005;24(2):70—9. Wåhlin I, Ek AC, Idvall E. Patient empowerment in intensive care — an interview study. Intensive Crit Care Nurs 2006;22(6):370—7, http://dx.doi.org/10.1016/j.iccn.2006.05.003.