title: Implementing evidence-based practices in an emergency department: contradictions exposed when prioritising a flow culture.
abstract: BACKGROUND
  An emergency department is typically a place of high activity where practitioners care for unanticipated presentations, which yields a flow culture so that actions that secure available beds are prioritised by the practitioners.
  
  
  OBJECTIVE
  How does the flow culture in an emergency department influence nurses' use of a research-based clinical guideline and a nutrition screening routine.
  
  
  METHODS
  Ethnographic fieldwork was carried out over three months. The first author followed nurses, medical secretaries and doctors in the emergency department. Data were also collected by means of semi-structured interviews. An activity system analysis, as described in the Cultural Historical Activity Theory, was conducted to identify various contradictions that could exist between different parts of the activity system.
  
  
  RESULTS
  The main contradiction identified was that guidelines and screening routines provided a flow stop. Four associated contradictions were identified: insufficient time to implement guidelines; guilty conscience due to perceived nonadherence to evidence-based practices; newcomers having different priorities; and conflicting views of what constituted being a professional.
  
  
  CONCLUSIONS
  We found that research-supported guidelines and screening routines were not used if they were perceived to stop the patient flow, suggesting that the practice was not fully evidence based.
authors.affiliation: Optimed, Clinical Research Centre, Hvidovre, Denmark.|Department of Development and Quality, University Hospital Hvidovre, Hvidovre, Denmark.|Department of Education, Aarhus University, Emdrup, Denmark.
authors.forename: Jeanette W
authors.initials: JW
authors.lastname: Kirk
authors.affiliation: Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
authors.forename: Per
authors.initials: P
authors.lastname: Nilsen
mesh_terms: D019985:Benchmarking; D003718:Denmark; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000592:standards; D055317:Evidence-Based Practice; D006801:Humans; D057184:Practice Patterns, Nurses'; D010818:Practice Patterns, Physicians'; D016526:Workload
keywords: acute care; advanced practice; clinical guidelines; emergency care; emergency department; evidence-based practice
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