Leading Evidence-Based Practice in Finnish Healthcare
7.3 Framework for Evidence-Based Practice in Finnish Healthcare
Two Finnish organizations focus on improving evidence-based healthcare on national level. Current Care supports evidence-based decision-making by produc- ing and disseminating evidence-based clinical guidelines, particularly for physi- cians (www.kaypahoito.fi) [26]. The Nursing Research Foundation (NRF) has the same purpose, but the target group is nurses (www.hotus.fi) [27]. Both
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organizations publish the clinical guidelines on their websites, available free of charge. Most of the work is publicly financed by the government. A milestone for evidence-based nursing was 2017 when the Nursing Research Foundation’s activity of producing and disseminating guidelines became permanently funded from the national budget, in the same way as medical guidelines. The clinical guidelines include evidence-based recommendations for professionals about the care of patients with specific conditions, helping professionals to make informed clinical decisions [28, 29]. Care should not vary between healthcare organizations or health- care professionals without justification [29–31]. Clinical guidelines are intended to improve the quality of care and safety, and they can inform patients and clients about the best available options concerning their care and services [29].
Although clinical guidelines as well as systematic reviews are important in applying the best available evidence to clinical settings [28], they are not enough.
Furthermore, it is crucial to incorporate the evidence into decision-making in prac- tice [32]. Therefore, healthcare organizations should have structures and processes in place for disseminating and implementing the evidence. For example, through information dissemination infrastructures (e.g. library resources), the organization can ensure that clinical guidelines are available for professionals [32, 33]. In addi- tion, it is essential that processes for implementation are in order because they help to realize what should be done so that evidence-based consistent practices are pos- sible [30, 33]. For example, it is important to understand whether a clinical guide- line is feasible and sustainable in a specific context and what are the procedures to ensure it [34]. The role and structural commitment of directors, managers and lead- ers (including all other professionals) are particularly crucial when creating struc- tures and processes for the organization to ensure evidence-based practices in healthcare facilities [28, 30].
7.3.1 Special Positions and Roles to Support Evidence-Based Practice
In addition to directors, managers, other professionals and leaders, one driving force behind the implementation of evidence-based nursing practice is expert nurses in clinical nurse specialists’ (CNS) roles and, more generally, advanced practice nurs- ing. The role of the CNS was first established within hospital care in Finland in the beginning of the 2000s [35]. Many larger hospitals, especially university hospitals and their catchment areas and regions, have established special advanced practice nursing (APN) positions, such as CNS positions. Such positions are mainly held by individual nurses having master’s degree education from universities. In 2009, the Ministry of Social Affairs and Health developed a four-category model to define the different expert roles of nurses in Finland (see [36], Suutarla and the Finnish Nurses Association’s APN expert group): (1) nurses in clinical care, (2) specialized nurses in clinical care, (3) clinical nurse specialists and (4) specialists in clinical nursing science. However, some recent studies from the Nordic countries have shown that no consensus exists on the definition of APN [37, 38]. Wisur-Hokkanen and
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colleagues [39] suggested that the role of APN could be strengthened by strategic leadership and support from organizations on all management levels, including nursing organizations and unions. As Jokiniemi and colleagues have stated [40],
“Despite the history of specialist level practice and existing APN educational pro- grams, advanced-level nursing roles have not been nationally conceptualized in a Finnish context, authorized by the National Supervisory Authority for Welfare and Health, or regulated by the government” (p. 79), still more work needs to be done in this field.
One major area of expertise of these CNSs is supporting evidence-based prac- tice [40] through mentoring, especially in the areas of research, development and educational activities and expertise. CNS roles are more common in specialized healthcare than in primary healthcare. At the moment, only a few such roles exist in primary healthcare. A total of 78 clinical nurse specialists form a network (updated statistics 3.1.2018); two of them are clearly working in primary health- care, while 2–3 are working broadly in the hospital district, also including pri- mary healthcare. The majority of them work in specialized healthcare, in hospital settings. Therefore, there has been a need in primary healthcare organizations to include the leadership in evidence-based nursing practice into formal leader posi- tions. In addition to these roles, a large number of nurses having masters’ degree in health sciences and nursing science work in the leadership roles in healthcare organizations. The APN and different roles of nurses have also been clarified in 2016 [41]. In addition, the Finnish professors in nursing science may also have cross-appointments, as they work at a nursing science department at the university and have a part-time position of director of nursing or a head nurse. These posi- tions are clearly focused on supporting leadership, management and development activities in the healthcare systems based on research, especially evidence-based practice. Such cross-appointment positions are bound to almost all professorships in nursing science in the four Finnish-speaking universities offering nursing science.
7.3.2 National-Level Support for Evidence-Based Nursing
The NRF supports the dissemination and implementation of evidence by developing structures on national level for effective, meaningful, appropriate and feasible evidence- based practices in collaboration with its stakeholders. The two models generally used for dissemination and implementation are the Action Model of Expertise (AME) and the Operational Model for Evidence-Based Consistent Practices (OMCP). The first model (AME) includes the roles of four different types of experts and their core competencies with emphasis on EBP and actions for its implementation. These experts have their own strengths and duties in clinical prac- tice. Together they can ensure that clinical practices are based on evidence and thus support the quality of healthcare and the expected patient outcomes [33].
The second model (OMCP) describes the development process of evidence- based consistent practices. The process begins when professionals compare their
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practices, for example, to the clinical guideline or the systematic review and identify potential development needs of the current practices. The next phase is to plan what kinds of changes are needed and what kind of strengths and barriers there are to the change. After that, the professionals develop a new consistent practice which is based on evidence (e.g. clinical guidelines). In the individual decision-making situ- ation with a patient, consistent practice provides evidence-based information which together with the patient’s preferences, information about resources and care con- text as well as the professional’s expertise supports the best possible decision for the patient. The process of evidence-based consistent practices continues, and the next phase includes monitoring and evaluation. It is important that professionals monitor and evaluate outcomes before a new practice is established as a new consis- tent practice [42].
7.3.3 Operational Model for Evidence-Based Consistent Practices (OMCP)
The development of evidence-based practice needs clear processes and protocols.
The OMCP model for evidence-based practices is increasingly being adopted. Here are some examples of how evidence-based consistent practices are developed by using the OMCP model. The NRF and Oulu University Hospital developed a model for monitoring professionals’ hand hygiene performance in a hospital setting. The aim was to develop consistent evidence-based hand hygiene practices and thus decrease healthcare-associated infections [43]. This model for monitoring profes- sionals’ hand hygiene is disseminated almost nationwide; several healthcare organi- zations in primary and specialized healthcare as well as in the private sector have adopted it in their practice. An outcome study investigating the impact of the model for monitoring professionals’ hand hygiene has already provided some preliminary results showing that, e.g. the number of catheterization-related infections has decreased.
Another example concerns pressure ulcer prevention. The University of Turku, the Satakunta Hospital District and the NRF used the model of the OMCP when they developed a new consistent practice for pressure ulcer prevention in primary healthcare. The project is ongoing in the year 2018. The studies around the project indicate that the results of the project are promising and the model of OMCP is usable in projects of this kind.
One of the challenges in healthcare has been to ensure that evidence-based prac- tices are consistent across the entire care chain so that the continuity of care is ensured and practices do not vary without justification. For this reason, projects are needed where consistent practices are developed throughout the care chain, not just in a single work unit or organization. However, local conditions should always be considered when using consistent practices in a new context [34]. For example, if a practice has been developed in a hospital environment, the different requirements of the environment must be considered before it is disseminated into primary care settings.
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