Module 2 Context of Practice considerations
1. Objectives
On completion of this module students will be able to:
Identify and articulate the components, both internal and external, that impact on their practice area.
Appraise, analyse and critically evaluate, evidence based practice foundations, legal aspects of care, cultural safety in health care and health policies that influence practice.
2. Key terms
Context of practice
Evidence Based Practice frameworks
Cultural Safety
Legal aspects of care
Health Policy
4. Context of Practice
‘What impacts on your practice contexts’?
When we discuss contexts of practice we are talking about where your area of health care or other professional practice, takes place. These are complex environments that reflect the history, socio-political, health policy, legal parameters of care, technological and knowledge advances, and the cultural influences on care. There is also the organisational structure you work in, your local community, and the local environment. Practice contexts are complex beasts!
Reading activity
Before you go any further read the following overview of the Australian health system.
Reading 2.1
Australian Institute of Health and Welfare (2020) The Australian health system overview. Retrieved December 16, 2022 from:
https://www.aihw.gov.au/reports/australia-health/health-system-overview
If you are an international student obtain access to an overview of your health care system. All might look at any State and/or Territory and regional systems that flow from the National perspective that in turn impact on your practice. If you are not from a health care background, conduct a literature search and you should be able to find readings that explain your professional context from a National or State perspective.
Learning activity 1
After completing the above reading or your own equivalent, reflect on the following:
Is your organisation government or privately owned?
How is it funded?
Are there adequate resources to provide quality care to clients/patients/staff?
Who are your main clientele? What are their socio-economic and cultural parameters?
How does the organisation’s structure affect your practice environment?
As we progress further you will undertake more comprehensive analysis of your practice context by way of a SPELT and SWOC analysis that will provide foundations for your final assessment. This overview is designed to assist you to begin to take a broader look at your practice context.
5. Health policy
After taking a broad look at the health care system, you need to also think about the impact of health policy on your context of practice. In Australia the Government has moved towards a national approach to health policy and planning to meet national and international health care contexts. This has occurred in response to finding funding solutions and to meet demands on the system as we care for an increasingly ageing population.
Historically health care employees such as nurses have had little involvement in policy development and review. As health care systems change and education for health care and other professions develops to meet the changes, there is a need for understanding and involvement in the policies that impact on practice and the politics behind policies.
Learning activity 1
Read the following article:
Turale, S. Kunaviktikul, W. (2019). The contribution of nurses to health policy and advocacy requires leaders to provide training and mentorship. International Nursing Review, 66(3), 302-4. https://doi.org/10.1111/inr.12550
Access the reading by clicking on the link above. Reflect and write down your responses to
the following questions:
Do you agree with the comment that health care workers and other professional employees have a responsibility to be involved in health policy development?
Is nursing represented on your organisations policy committee?
Is it your experience that nurses lack the confidence, experience and knowledge to engage in policy development and review?
Should the link between health policy and politics be included in undergraduate education?
Do you currently have an involvement in policy development and/or review?
Learning activity 2
Conduct a literature search for at least two articles related to health policy and your context of practice. These articles may contribute to your Assessment 3 content.
Ask yourself the following:
Are you aware of any nursing involvement in the development or review of these policies?
Does your organisation encourage employees to contribute to the critiquing of policies?
Do you feel listened to if you comment on deficiencies in policies that impact on your practice?
Health policy is a large area and this section is an introduction to start you thinking about how policy impacts on all levels of care. When you start with a ‘big picture’ view you can then begin to see the impact of the components of this picture has on your discreet context of practice. As we go about our day to day responsibilities we don’t always have or take the time to look at this ‘big picture’.
6. Legal aspects of care
Health care professionals as do other professionals, need to be fully cognisant of the relevant regulations that apply to their context of practice as they hold accountability and responsibility for their practice. Consumers of health care are more aware of their rights and expectations when accessing health care. The Charter of Aged Care Rights (2019) and the Australian Charter of Healthcare Rights (2020) are excellent examples of articulated consumer rights. Health care providers also need to be aware of the documentation surrounding Safety and Quality of Health Care (2020). You can access this information from the following link:
Reading activity 2.3
https://www.agedcarequality.gov.au/consumers/consumer-rights
Australian Charter of Healthcare Rights
When you view these documents you will see the links to your practice context and the standards of care and accountability for health care workers. Those of you not in the health care area will find similar documentation surrounding your practice. International students will also find similar standards of care available from their government sites.
Accountability
Nursing, has four main areas of legal accountability. According to Wiseman (2007) these are; accountability to the patient (civil law), accountability to the public (criminal law), accountability to the employer, and professional accountability as per nursing acts and legislation. There are also specific legal requirements for advanced practice nurses such as nurse practitioners.
Learning activity 3
At this point refresh your knowledge and understanding of the laws that impact on your context of practice. Look at your professional board’s responsibilities under the Health Practitioner Regulation National Law (2009). Once you have read about the responsibilities of your professional board, take a look at specific laws that impact on your practice context. You may hold endorsement for scheduled medicines for example and are expected to comply with the guidelines on obtaining, supplying and administering scheduled medicines.
Think about the following:
What accreditation and registration standards do members of your profession have to follow?
Are you required to hold professional Indemnity?
Do you require a specific endorsement for your professional practice?
What is required to gain this endorsement?
Is a Criminal History check a part of your mandatory professional documentation?
Reflect on the relationship between your practice context, your scope of practice, professional board guidelines and the legal and professional accountability of your role.
Next review the Code of Conduct applicable to your professional background. AHPRA in conjunction with the National Boards have developed A Code of Conduct for registered health practitioners which many health professions have adopted. Others such as nursing and midwifery have developed their own specific Codes and Standards of Practice.
Learning activity 4
Access the AHPRA website and search for your professional body’s Code and Standards
Does your profession use the ‘generic’ code or have they developed a profession specific code?
What are the differences between a specific code and the ‘generic’ code?
If you have a specific code, how do the differences impact on your context of practice?
You might like to post your comments on this section to the forum to generate discussion around codes and standards.
7. Cultural Safety
Cultural safety is an important element of your practice context. But what are the components behind our understanding of cultural safety? Let’s firstly take a look at what culture, ethnicity and race mean.
Culture
Andrews and Boyle (2007 as cited in Wilson 2010 p.98) have defined culture as:
‘…a shared system of beliefs, values and behavioural expectations that provide social structure for daily living. Culture defines roles and interactions with others as well as within families and communities, and is apparent in the attitudes and institutions unique to particular groups. Culture includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one’s family’.
While this is a long definition from a context perspective it is more comprehensive, as it includes the more personal aspects of culture which in the day to day of health care are the aspects that impact immediately. Wilson (2010) also notes that institutions such as health care are controlled by the dominant culture in a country and in Australia this is an early settler dominance of the white middle-class section of Australian society. There is an increased awareness and responsiveness to making sure all who live in Australia have access to culturally sensitive and safe care.
Ethnicity
This is sometimes confused with race and or culture. Wilson (2010) notes that ethnicity is about identifying with a cultural group based on a common heritage obtained either by birth or the adoption of the characteristics of a group. In Australia we have many societal groups who identify as Italian Australians, Greek Australians, Indian Australians, or Iranian Australians to name a few ethnic groups.
Race is based on physical characteristics such as skin pigmentation, body stature, facial features and hair texture. Wilson (2010) notes that while there has been racial blending around the world the major classifications of Caucasian, Negroid, Polynesian and Mongoloid still remain in use.
Cultural safety
What then is cultural safety? Is it cultural awareness? Is it cultural sensitivity?
In 2002 Ramsden developed a Cultural Safety Model for nursing and midwifery that subsumes these three elements and is identified as a professional process and outcome that is grounded in an awareness of your own power, prejudice and attitude. In health care it is client driven where the individual and family defines what cultural safety is and this gives power back to the client. According to Ramsden this removes barriers and inequities and social injustices.
Ramsden’s steps to cultural safety starts with cultural awareness as a beginning step to understanding that there is a difference and to acknowledge the emotional, social, economic and political context in which people exist rather than simply becoming sensitive to formal ritual. We all carry with us our cultural origins and beliefs and need to become aware of these and their influences on how we move within the health care context.
The next step is cultural sensitivity that alerts students to the legitimacy of difference and begins a journey of self exploration as the powerful bearers of their own life experiences and reality and how others may be affected by this.
The third step outlined by Ramsden is an achievement of cultural safety as an outcome of nursing and midwifery education that enables safe service to be defined by the recipients of the service. This means nurses acknowledging their own culture and ethnicity and that their care is of others is defined by their patients as culturally safe.
At this point access the Australian Human Rights Commission website and read their publication on cultural safety and security.
Chapter 4: Cultural safety and security: Tools to address lateral violence – Social Justice Report 2011 | Australian Human Rights Commission
Think about the following questions in relation to your clinical context:
What is the cultural, ethnic and racial mix of your practice context and your health care staff?
Are you cognisant with the differing health and health care beliefs of your patients and staff?
Are there any stereotypes and prejudices that you have observed that affect the health care within your context of practice?
What, if any adjustments to care processes and procedures have been made to reflect and provide culturally sensitive and safe care within your context?
Are staff in your area aware of the cultural safety guidelines that exist in Australia?
While our CALD communities are of importance we need to also look at Indigenous health issues and the provision of culturally sensitive and safe care for Indigenous clients. Shepherd, Li, and Zubrich (2012) have presented social indicators that show that the Indigenous population have a lower socio-economic and health status than non-Indigenous Australians. Other authors, such as Kendall, Milliken, Barnet and Marshall (2010) note that the health and welfare of Australia’s Indigenous population remains poor in comparison with the white population despite health policies that have been developed to address this. Kendall et al. (2010) comment that this is because the majority of the policies put in place have been developed without Indigenous input. The Australian government has attempted to bridge this gap in care for Indigenous Australians.
Reading activity 2.
Access the following website and read Overview of Aboriginal and Torres Strait Islander Health Status.
Learning activity 2
Do you think that assumptions and stereotypes about Indigenous people affect the health care approach used in your context?
Do you have Indigenous families within your practice area?
Reflect on an incident of health care you have experienced in your context that was culturally unsafe.
Wilson (2010 p.108) cites the writing of Caminha-Bacote (2007) on culturally safe and competent health care that suggests that health care employees ask themselves the following questions:
1. I am aware of my personal biases and prejudices towards cultural groups that differ from mine
2. Do I have the skill to conduct a cultural assessment in a sensitive manner?
3. Do I have knowledge of the person’s world view?
4. How many encounters have I had caring for people from diverse cultural backgrounds?
5. What is my genuine desire to be culturally safe?
These reflective questions link with Ramsden’s steps to cultural safety. Thinking your way through these questions and responding in a realistic manner is a way we can all understand or ‘know’ ourselves. It is our beliefs and our attitudes that influence how we interact with others and for us as health care workers, how we interact with the people we meet in a health care setting. It comes down to respecting ourselves and others.
Culturally sensitive and safe health care is a huge topic and we have just touched on it here. I hope you will look for further information around this important practice context.
8. Evidence Based Practice Foundations
The term ‘Evidence based Practice’ or EBP is a widely used concept in professions including health care. The question is ‘How do we judge the evidence that underpins clinical decisions? Who collects the data? In other words, what is EBP?
Hoffman, Bennett and Del Mar (2017) have defined EBP as: EBP = research evidence + clinical expertise + patient values and circumstance + practice context. At this point we suggest you read chapter one in the text book.
Reading activity 2.4
Learning activity 4
Think about the following:
Identify at least 10 interventions, procedures, and/or policies that are used every day in your practice context.
What evidence are they based on? Is it research, text books, experience and/or expert opinion?
Are there barriers to implementing EBP in your practice context?
What strategies would you put in place to facilitate better use of EBP in your practice area?
The literature around EBP makes it clear that in order to be able to provide the best evidence on which to base practice, health professionals need to know and be able to understand the research that underpins EBP. To do this health professionals need to be involved in research in order to be able to critique and evaluate evidence.
This leads nicely into the next reading which will revise your knowledge of research methodologies and their application to EBP.
Reading activity 2.5
Liamputtong, P. (2013) ‘The science of words and the science of numbers: research methods as foundations for evidence-based practice in health’. In P. Liamputtong (ed.) Research methods in health. Foundations for evidence-based practice (2nd ed, pp. 3-23) Australia: Oxford University Press.
While it is a long read it will refresh your knowledge of research approaches and research designs.
Learning activity 6
What factors should you consider to guide your choice of research approach?
Define, in your own words ontology and epistemology.
What is meant by research rigour?
I’m sure you agree that understanding the basic concepts of research is necessary for the development and application of EBP. We are introduced to research in our undergraduate programs however for many there is little opportunity to be involved in knowledge creation in our practice areas. You will no doubt be able to recall instances when you or a colleague has commented on how or why a particular intervention or procedure is being carried out. Or you will come across examples of health care professionals not following EBP guidelines for care and stating that their experience has shown them that another way of ‘doing’ is better. These are all opportunities to examine not just being part of a research project but also to think about ‘Where would I get the evidence to inform my practice?
By now some of you have identified an area of practice you would like to explore from an EBP perspective in assessment 3.
Learning activity 7
Identify a specific area of practice you are interested in and conduct a key word search for evidence-based research information related to your area of interest.
Do your current practice protocols and procedures reflect the research related to your area of interest?
If the answer is ‘no’, think of two strategies you could use to influence a change in the protocol/procedure to better reflect the application of current EBP.
How could you ensure that the patient voice and values are reflected in the procedure?
Reading activity 2.6
Chapter 2 of the text is a timely read at this stage
Learning activity 8
Once you have completed this chapter, write out your responses to the following points:
Think about a practice-based question you have asked in the past or one that you have been thinking about. The table on page 18 will assist you to determine if it is an EBP question.
Use the PICO steps outlined on page 22 to formulate your clinical question.
Think about the type(s) of information you need to look for to answer your question.
On the hierarchy of evidence what type of evidence should you search for first.
Justify your response to this last question.
As you read through the chapters in the text and the selected readings you are reminded that to understand and implement EBP in your practice context you need to understand the relevance of the research that supports practice. Do you think that a lack of understanding of the EBP process behind practice guidelines hinders the implementation of EBP in practice?
Now read the next chapter in the text.
Reading activity 2.7
This chapter provides practical advice on how to find reliable evidence sources. The following learning activity will set up your response to assessment item 3.
Learning activity 9
Revisit your PICO question and the types of evidence you would need to respond to your clinical question.
Undertake a search to find both quantitative and qualitative evidence as well as systematic reviews relevant to your question.
Critical appraisal
Once you have your evidence you need to be able to critically appraise it. This is an area that causes angst for many of us. What is a critical appraisal of the literature? It is not a literature review but a critical review using a systematic approach about the value of the research that has been undertaken in a given area. Chambers, Boath and Rogers (2004 cited in Kersten & Larmer, 2014, p. 239) define critical appraisal as ‘…the assessment of evidence by systematically reviewing its relevance, validity and results to specific situations’. We all read articles related to our practice context and patient/client care, and note if it is interesting or not. Reading with a critical eye takes on a different aspect as it is about engaging with the article.
Read the following:
Reading activity 2.8
This is a lengthy chapter but one that sets out the critical appraisal process in a clear and understandable manner. The authors of this chapter make it clear that there are no judgments made about the differing research designs. There is a different approach used for critical appraisal of a systematic review which is not included in this reading, however if you read chapter 12 of your text book you will have a clear understanding of what a systematic review is and how to conduct a critical appraisal of a systematic review.
Reading activity 2.9
The next short reading gives an example of a general appraisal template you might find useful.
Reading activity 2.10
Now work through the following:
Learning activity 10
Take just one of the articles you found related to your clinical question, and read and summarise the article, without using a critical appraisal tool (CAT).
Review the available JBI CATs (refer to the course readings – The Joanna Briggs Institute (JBI) CAT link) and select the appropriate CAT to critically appraise your article.
Next, conduct a critical appraisal of your article, by using the CAT you selected.
Compare the two reviews [your initial summary, without using a CAT and your formal critical appraisal, using an appropriate CAT]. What has the most impact for you after this exercise and say why?
Reflect on the clinical context reading you have done previously and relate the depth of understanding you have gained on the contemporary CAT approaches to generating knowledge and enquiry.
As noted earlier conducting a critical appraisal is vastly different to completing a review of the literature. Once you become familiar with critical appraisals, you will find yourself reading research articles or ‘evidence’ and asking yourself questions about the quality and applicability of the research to your practice context.
Now read chapter 4 of the text. This chapter looks at the different research designs that could be used when looking at the results of clinical interventions. We hear and read so much about EBP but this chapter asks us to examine the results of specific interventions. The initial intervention may have been based on evidence but what are the results of the actual care provided based on this evidence? In other words a systematic evaluation of the EBP.
Reading activity 2.11
Intervention research is of particular interest to nurses and other health care professionals in measuring the effectiveness of quality nursing care delivered. Zuzelo (2019) offers a number of examples, such as for pressure ulcer care and falls prevention management, where the scientific basis for the interventions used, is evaluated against patient outcomes. As health professionals, it is important to know what works and what doesn’t, so that care modalities can be refined, modified or removed from the list of practice interventions.
Learning activity 11
Respond to the following:
Was your PICO question related to a clinical intervention?
After reading chapter 4 in your text book what type of study would you need to conduct to answer your intervention question?
After the work and the readings you have undertaken to date, what are your thoughts about the intervention at this stage? Do you think the intervention outcomes outweigh any possible harm to the patient?
I’m sure by now if you were not familiar with the background to EBP or are revising your knowledge of EBP you have a much better understanding of the concept. It is certainly complex and highlights why it is essential that health care professionals know about, understand and be able to critique the evidence related to their practice areas. It is recommended that you read Chapters 5, 6, 7, 8 and 9 in your text and look specifically at the topics and appraisals relevant to your health care profession. You might also like to read some of the examples from other health professions as well. They are certainly interesting questions!
Think back to the definitions of EBP detailed at the beginning of this module. Both included the patient voice by including patient preferences, values and/or circumstances. Chapter 10 of your text is about listening to the patients’ voice in relation to their experiences.
Reading activity and learning activity 2.12
Have you been involved in a focus group or interview related to a research project? If you have you will understand the importance of being heard and having your opinion and thoughts noted.
Is there a clinical procedure undertaken in your practice area that you think would benefit from evidence collection related to the experiences of your patients?
Review the PICO question you wrote earlier and rewrite it to reflect an intervention evaluation approach.
When you have completed this exercise it is suggested that you read chapter 11 in your text which includes examples of questions and appraisals related to patients’ experiences from across a range of health professions. Read those related to your particular profession and then look at the examples from other health care areas. It certainly makes for interesting reading.
Chapter 14 is also of interest, as it discusses the importance of not only listening to and incorporating the patient voice into EBP but also the shared decision making that should take place in patient-centered care.
Reading activity 2.13
Translating research into practice
All of the reading and thinking you have done up to this point has focused on understanding the background to EBP. That is searching for and appraising the evidence related to an area of patient care. The next step is translating this research into health care practice. Zuzelo (2019) makes the point that applying research into practice is an important component of nursing leaders in contemporary health care. Unfortunately though, historical literature reveals that quality deficiencies have prevailed and exist even today. The reasons underpinning human thought, behavior and action, as highlighted by Zuzelo (2019, p.370), is “steeped in tradition and informed by habit, and too frequently associated with catastrophic errors”. A good example of this is offered by Crimmin (2013), in the treatment practice of scurvy for sailors back in 1601. British Sailor James Lancaster prevented scurvy on his ship by adding lemon juice to the daily diet of his sailors. However, due to well-formed traditions and ingrained habits adopted by navy leaders and medics at the time, it took from 1747 until 1795 for the scurvy treatment – lemon juice findings, to become standard practice in the Royal Navy!
To be able to translate research evidence into practice, health care professionals need to be able to access and evaluate the evidence, have the support of the organisation, have access to the resources needed to implement the interventions, champion and educate others involved in patient care, evaluate the outcomes and show that the EBP is cost effective. Read the following two chapters from your text (Chapters 15 and 16). This will assist you with assessment 3.
Reading activity 2.14
In Chapter 15 Turpin and Higgs (2017) remind us of the definition applied in this module, which includes the practice context, as an influencing factor. These authors clearly state that it is not just evidence alone that health care professionals use to guide their practice, but the ability to apply clinical reasoning to assess a range of different types of information into the implementation of health care.
Chapter 16 by McCluskey and O’Connor (2017) gives an excellent change management approach framework to the implementation of EBP into clinical practice. Have you seen such an approach used in your professional practice context? When you read this chapter and think about the introduction of practice changes that staff felt were imposed rather than collaboratively introduced, you can understand the barriers to EBP that exist in clinical areas.
Clinical guidelines
This has been included as a separate section as there is sometimes misunderstanding about what EBP procedures and what are clinical guidelines. The chapter by Hoffmann and Bennett (2017) in your text makes the distinction clear. Take the time to read this chapter. You should also search the literature available on the development of clinical guidelines. The International Journal of Evidence Based Health Care is a good place to start.
Reading activity 2.15
In this chapter the authors make note of the rise in the number of clinical guidelines in use in Australia and also point out that there are some guidelines for the same clinical condition that have conflicting recommendations for care. They comment that this is caused by a variety reasons.
Learning activity 2.13
Can you cite instances of differing clinical guidelines for the same clinical condition related to your practice area?
How does your practice handle comorbidities in the same patient when applying clinical guidelines?
Apply the AGREE 11 instrument (page 331) to a clinical guideline currently in use in your clinical practice area. What are your thoughts about the recommendations in the guideline?
As health professionals we are all aware of the importance of providing care that is based on the best available knowledge and is relevant to patient needs and values and the context of the practice area. However, we are also aware that it is more than recognising these concepts that determine if and how EBP is implemented and operationalised. The final chapter in your text book discuss the embedding of EBP from micro, meso and macro perspectives noting that the successful implementation of EBP is not just the responsibility of individuals but incorporates an organisational and systems approach as well.
Read the following:
Reading activity 2.16
Learning activity 2.14
Is EBP visibly supported by the culture, leadership and management in your organisation?
What policies and processes are in place that facilitate the implementation of EBP?
Do staff have access to the three data bases discussed in the chapter?
Read Box 17.3 on page 422 of your text and conduct an analysis of your organisation based on the components of the Box.
EBP based leadership and management
All health care professionals are leaders and managers in either an informal or formal capacity. To date there is not a lot of literature available on the topic of EBP in management or leadership however it is a significant and growing area that is worth mentioning at this point.
Read the following:
Reading activity 2.17
The above reading by Schaefer and Welton (2018, p. 626) offers insights concerning the importance of leadership in promoting a culture of EBP. In particular, these authors provide specific qualities and attributes of leaders that indicate whether leaders in a workplace actually supports an EB culture or not. These qualities and attributes include examples such as supporting/encouraging members of the health care team to ask lots of questions, to allocate regular time in their work schedule dedicated solely to investigating the literature, and time to plan for the implementation and evaluation of EBP in their workplace.
Can you think of examples of management or leadership decisions you have made or had involvement with, that were based on relevant evidence and supported EBP?
You might like to conduct a literature search yourself to identify EBP leadership and management research articles relevant to your practice context.
Conclusion
Returning to the definition of EBP that has been applied in this course, we have covered a lot of ground. Your knowledge and understanding of EBP will have been revised and refreshed as you worked your way through the readings and the text book, and looked at the literature you have searched out yourself. All of this will set up the groundwork for your final assessment piece in this course.