The role of nursing best practice champions in diffusing practice guidelines: a mixed methods study

The impact of a nurse's dual role on implementing an effectiveness study

BACKGROUND

Reorganizing the Approach to Diabetes through the Application of Registries (RADAR) improved diabetes care and outcomes for First Nations people in Alberta, Canada. The nurse involved in the implementation of RADAR performed two roles in this model of care: research nurse and care coordinator.

AIM

To describe the research nurse's dual role in the implementation and evaluation of RADAR.

DISCUSSION

The research nurse not only documented and collected data in hard-to-reach communities as part of effective research, she also provided remote care coordination to support community healthcare providers using a culturally tailored registry to facilitate population-level care. This dual role required many qualities of nursing leadership and transformation.

CONCLUSION

The research nurse's two roles contributed to the success of the intervention and were critical to the successful implementation of the model, creating valuable real-world evidence across diverse populations and settings.

IMPLICATIONS FOR PRACTICE

Nurses are well placed to perform research duties alongside engagement and implementation activities. This can enhance the effectiveness and evaluation of healthcare interventions, particularly in community-based interventions within First Nations communities.

[Impact of the implementation of the international best practice guidelines programme (BPSO®) on health outcomes in a public hospital]

OBJECTIVE

To analyze the impact on patient health outcomes after implementing 4 Good Practice Guidelines (GPG) in a level II public university hospital.

METHOD

A quasi-experimental pre-post study was carried out at the Hospital Universitario Fundación Alcorcón, belonging to the Servicio Madrileño de Salud (SERMAS) of the Community of Madrid. Anonymized patient health indicator data from February 2018 to December 2022 from a total of 4853 patient records were analyzed. Inclusion criteria all patients defined in the scope of each GBP. The sample analyzed was patients discharged in the last 5 working days of the month for all GBPs, except in Ostomy and Stroke, for which 100% of patients discharged during the month were included.

RESULTS

The main results were: incidence of pressure injury from 2.70% (2017) to 1.03% (2022); stoma marking from 66.67% (2017) to 75% (2022); exclusive breastfeeding from 50% (2017) to 61.54% (2022); neurological assessment on admission from 75.56% (2017) to 85.60% (2022).

CONCLUSIONS

The implementation of the GBPs led to an improvement in the health indicators of patients admitted to the target units. Improvements were observed in both process and outcome indicators.

Faculty Development on the Use of a Clinical Judgment Model in the Pre-licensure Nursing Curriculum

Clinical judgment is an essential component of safe nursing practice that pre-licensure nursing students should develop by graduation from accredited nursing programs. For novice nurses, the consequences of underdeveloped clinical judgment skills that do not meet the demands of clinical practice are serious. This theory-practice gap correlates with increased numbers of errors occurring during care delivery, resulting in poorer patient outcomes. From a student perspective, this problem correlates with lower first-time pass rates on the NCLEX licensing exam. For nurse educators, there are uncertainties about how to resolve this complex and costly problem, but faculty development is one evidence-based solution to explore. The purpose of this article is to describe a three-pronged quality improvement project consisting of: 1) a faculty development session to teach faculty to implement the National Council State Boards of Nursing's Clinical Judgment Model (CJM) in their courses; 2) the use of the Clinical Judgment Tool; and 3) the implementation of a faculty champion to sustain and maintain ongoing faculty momentum to foster clinical judgment. This article focuses on how faculty can develop their own CJM faculty development session and use a CJM across the course curriculum.

Facilitation in evidence implementation - experiences, challenges, and determinants of perceived effectiveness: a qualitative systematic review

INTRODUCTION

Facilitation is a key element of evidence implementation. Although quantitative systematic reviews have been undertaken to examine its components and effectiveness, no attempt has been made to synthesize qualitative evidence examining the experiences of facilitators on how facilitation is operationalized, the challenges associated with it, and the factors that can influence its perceived effectiveness.

METHODS

A systematic review of qualitative studies was conducted using the JBI methodology.

RESULTS

A total of 36 qualitative studies was included in the systematic review, with the majority being assessed as high quality following critical appraisal. The findings were extracted and further synthesized, highlighting that facilitation involves providing technical and non-technical support to health professionals, as well as high-intensity collaborations and relationship building. Determinants of perceived effectiveness of facilitation include facilitators' access to resources and learning support; their skills, traits/attitudes, and approach to facilitation; and the context of the organization where the implementation occurs. Work demands, emotional stress, and lack of clarity in roles and career development can pose challenges for facilitators.

CONCLUSION

To maximize the outcomes of facilitation in evidence implementation, the team of facilitators should be carefully selected to ensure they have the right skills, traits/attitudes, and approach to facilitation. They should also be provided with dedicated time to conduct the facilitation and have access to resources, training, and mentoring support. Future research should aim to examine the perspectives of the "implementers" who received support from facilitators to gain a better understanding of which facilitation strategies have an impact on clinical practice behavior.

REVIEW REGISTRATION NUMBER

PROSPERO CRD42023402496.

Nursing Care Management of Responsive Behaviors for Persons Living With Dementia in Acute Care Settings: An Integrative Review

The current integrative review was performed to understand how acute care nurses manage responsive behaviors among persons living with dementia (PLWD) in acute care settings. Eight studies were included, and three themes were developed: Person-Centered Approach, Non-Person-Centered Approach, and Facilitators and Barriers to Care Approaches. Nurses expressed difficulties in caring for hospitalized PLWD due to lack of knowledge of dementia care, pressure to work more efficiently, and prioritization of acute medical concerns. Nurses frequently used nonpharmacological approaches that required less time spent with patients. Results suggest that nurses in acute care settings require further education regarding dementia and person-centered care approaches for PLWD. Nursing management can support nurses' learning needs through education and policies to improve patient outcomes. [Journal of Gerontological Nursing, 49(2), 19-25.].

The effectiveness of champions in implementing innovations in health care: a systematic review

BACKGROUND

Champions have been documented in the literature as an important strategy for implementation, yet their effectiveness has not been well synthesized in the health care literature. The aim of this systematic review was to determine whether champions, tested in isolation from other implementation strategies, are effective at improving innovation use or outcomes in health care.

METHODS

The JBI systematic review method guided this study. A peer-reviewed search strategy was applied to eight electronic databases to identify relevant articles. We included all published articles and unpublished theses and dissertations that used a quantitative study design to evaluate the effectiveness of champions in implementing innovations within health care settings. Two researchers independently completed study selection, data extraction, and quality appraisal. We used content analysis and vote counting to synthesize our data.

RESULTS

After screening 7566 records titles and abstracts and 2090 full text articles, we included 35 studies in our review. Most of the studies (71.4%) operationalized the champion strategy by the presence or absence of a champion. In a subset of seven studies, five studies found associations between exposure to champions and increased use of best practices, programs, or technological innovations at an organizational level. In other subsets, the evidence pertaining to use of champions and innovation use by patients or providers, or at improving outcomes was either mixed or scarce.

CONCLUSIONS

We identified a small body of literature reporting an association between use of champions and increased instrumental use of innovations by organizations. However, more research is needed to determine causal relationship between champions and innovation use and outcomes. Even though there are no reported adverse effects in using champions, opportunity costs may be associated with their use. Until more evidence becomes available about the effectiveness of champions at increasing innovation use and outcomes, the decision to deploy champions should consider the needs and resources of the organization and include an evaluation plan. To further our understanding of champions' effectiveness, future studies should (1) use experimental study designs in conjunction with process evaluations, (2) describe champions and their activities and (3) rigorously evaluate the effectiveness of champions' activities.

REGISTRATION

Open Science Framework ( https://osf.io/ba3d2 ). Registered on November 15, 2020.

Scaling up utilization of nurse champion for the implementation of a quality improvement initiative: CoACT collaborative care unit Lead

This is the first paper describing the scaling up utilization of the unit level champion role in order to implement Collaborative Care framework as an evidence-based practice in the province of Alberta. The clear selection criteria of Unit Lead, funding (.2 FTE) that allows for the dedication of the role, support with various education, coaching from the project management team, and community of practices were suggested as important factors for successful utilization of Unit Leads to implement quality improvement initiatives in a large scale. Future initiatives may consider using a peer-leader champion as a change agent who is committed to the change initiative, credible and personally connected to the unit staff, possesses knowledge about the organizational culture, and develops a unit-tailored strategy via performance monitoring data to fully implement an evidence-based practice for quality care.

The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis

Background

Middle Managers (MMs) are thought to play a pivotal role as knowledge brokers (KBs) in healthcare organizations. However, the role of MMs who function as KBs (MM KBs) in health care is under-studied. Research is needed that contributes to our understanding of how MMs broker knowledge in health care and what factors influence their KB efforts.

Methods

We used a critical interpretive synthesis (CIS) approach to review both qualitative and quantitative studies to develop an organizing framework of how MMs enact the KB role in health care. We used compass questions to create a search strategy and electronic searches were conducted in MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC and the Cochrane Library. Searching, sampling, and data analysis was an iterative process, using constant comparison, to synthesize the results.

Results

We included 41 articles (38 empirical studies and 3 conceptual papers) that met the eligibility criteria. No existing review was found on this topic. A synthesis of the studies revealed 12 MM KB roles and 63 associated activities beyond existing roles hypothesized by extant theory, and we elaborate on two MM KB roles: 1) convincing others of the need for, and benefit of an innovation or evidence-based practice; and 2) functioning as a strategic influencer. We identified organizational and individual factors that may influence the efforts of MM KBs in healthcare organizations. Additionally, we found that the MM KB role was associated with enhanced provider knowledge, and skills, as well as improved organizational outcomes.

Conclusion

Our findings suggest that MMs do enact KB roles in healthcare settings to implement innovations and practice change. Our organizing framework offers a novel conceptualization of MM KBs that advances understanding of the emerging KB role that MMs play in healthcare organizations. In addition to roles, this study contributes to the extant literature by revealing factors that may influence the efforts and impacts of MM KBs in healthcare organizations. Future studies are required to refine and strengthen this framework.

Trial registration

A protocol for this review was not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07387-z.

Sustaining a nursing best practice guideline in an acute care setting over 10 years: A mixed methods case study

Background

To improve patient outcomes many healthcare organizations have undertaken a number of steps to enhance the quality of care, including the use of evidence-based practices (EBPs) such as clinical practice guidelines. However, there is little empirical understanding of the longer-term use of guideline-based practices and how to ensure their ongoing use. The aim of this study was to identify the determinants and knowledge translation interventions (KTIs) influencing ongoing use of selected recommendations of an institutional pain policy and protocol over time from an organizational perspective and 10 years post implementation on two units within an acute care setting.

Methods

We conducted a mixed methods case study guided by the Dynamic Sustainability Framework of an EBP 10 years post implementation. We examined protocol sustainability at the nursing department and unit levels of a multi-site tertiary center in Canada. Data sources included document review (n = 29), chart audits (n = 200), and semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level.

Results

We identified 32 sustainability determinants and 29 KTIs influencing ongoing use of an EBP in acute care. Three determinants and eight KTIs had a continuous influence in all three time periods: implementation phase (0-2 yrs), sustained phase (>2-10 yrs.), and at the 10-year mark. Implementation of KTIs evolved with the level of application (e.g., department vs. unit) to fit the EBP within the context highlighting the need to focus on determinants influencing ongoing use. Sustainability was associated with continual efforts of monitoring and providing timely feedback regarding adherence to recommendations. KTIs used to embed recommendations into routine practices/processes positively influenced high adherence rates. Use of a participatory approach for implementation and sustainment and linking KTIs designed to incrementally address low adherence rates facilitated sustainment.

Conclusion

This research provides insight into the relationship between implementation and sustainability determinants and related KTIs during implementation and sustained use phases. Unique determinants identified by department and unit nurses reflect their different perspectives toward the innovation based on their respective roles and responsibilities. KTIs fostered changed behaviors and facilitated EBP sustainment in acute care. Findings confirm the concept of sustainability is a dynamic "ongoing process."

Strategies for the implementation of a nasal decolonization intervention to prevent surgical site infections within the Veterans Health Administration

As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: "train and educate stakeholders," "use evaluative and iterative strategies," "adapt and tailor to context," and "develop stakeholder interrelationships." Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion.

Trial registration

ClinicalTrials.gov, identifier: NCT02216227.

Evaluation and Effectiveness of Dementia Staff Training Programs in General Hospital Settings: A Narrative Synthesis with Holton's Three-Level Model Applied

Background:

People with Dementia (PwD) are frequently admitted to hospital settings. The lack of proper dementia knowledge, poor communication skills, negative attitudes toward dementia, and lack of confidence affects the quality of care, thus development of dementia trainings has increased. Nevertheless, literature regarding the effectiveness of training implementation is limited.

Objective:

The aim of this narrative synthesis is to 1) identify the characteristics of training programs and 2) explore the effectiveness of these training programs in everyday clinical practice.

Methods:

A systematic search in PubMed, PsycINFO, CINAHL, and Cochrane was conducted, including qualitative and quantitative peer-reviewed studies. Holton’s evaluation model with its three outcome levels (learning, individual performance, and organizational results) was adopted. 14 studies were included.

Results:

The synthesis of the results was divided into two parts: 1) to describe the characteristics and content of trainings 2) to evaluate the effectiveness of training programs according to the three outcome levels of Holton’s model, taking into consideration its construct domains: ability, motivation, and environment. Learning outcomes were assessed in all selected studies: 13 studies observed changes in individual performance, four studies reported changes within the organizational level, and only five showed sustainable changes over time.

Conclusion:

Person-centered care (PCC) approaches, interactive and varied teaching methods, supporting conditions like champions, action plans, and setting care policies, are all characteristics of effective trainings. Successful programs should be sustainable over time, demonstrating positive outcomes across the organization. Based on current findings, there is a lack of adequate evaluation with regard to training programs on the organizational level.

Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen

As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.

Barriers and facilitators to implementing the CURE stop smoking project: a qualitative study

BACKGROUND

The Conversation, Understand, Replace, Experts and evidence-based treatment (CURE) project aims to provide a comprehensive offer of both pharmacotherapy and specialist support for tobacco dependence to all smokers admitted to hospital and after discharge. CURE was recently piloted within a single trust in Greater Manchester, with preliminary evidence suggesting this intervention may be successful in improving patient outcomes. Plans are currently underway to pilot a model based upon CURE in other sites across England. To inform implementation, we conducted a qualitative study, which aimed to identify factors influencing healthcare professionals' implementation behaviour within the pilot site.

METHODS

Individual, semi-structured telephone interviews were conducted with 10 purposively sampled health professionals involved in the delivery and implementation of the CURE project pilot. Topic guides were informed by the Theoretical Domains Framework (TDF). Transcripts were analysed in line with the framework method, with data coded to TDF domains to highlight important areas of influence and then mapped to the COM-B to support future intervention development.

RESULTS

Eight TDF domains were identified as important areas influencing CURE implementation; 'environmental context and resources' (physical opportunity), 'social influence' (social opportunity), 'goals', 'professional role and identity' and 'beliefs about consequences' (reflective motivation), 'reinforcement' (automatic motivation), 'skills' and 'knowledge' (psychological capability). Most domains had the potential to both hinder and/or facilitate implementation, with the exception of 'beliefs about consequences' and 'knowledge', which were highlighted as facilitators of CURE. Participants suggested that 'environmental context and resources' was the most important factor influencing implementation; with barriers most often related to challenges integrating into the wider healthcare context.

CONCLUSIONS

This qualitative study identified multi-level barriers and facilitators to CURE implementation. The use of theoretical frameworks allowed for the identification of domains known to influence behaviour change, and thus can be taken forward to develop targeted interventions to support future service implementation. Future work should focus on discussing these findings with a broad range of stakeholders, to ensure resultant intervention strategies are feasible and practicable within a healthcare context. These findings complement wider evaluative work to support nationwide roll out of NHS funded tobacco dependence treatment services in acute care trusts.

A National Survey Identifying the Factors Associated With Cardiovascular Care Nurses' Perceived Knowledge of International Practice Guidelines: The First Step in the Development of an Implementation Strategy

BACKGROUND

The implementation of international guidelines within everyday practice remains problematic, which can have a detrimental impact on quality of care delivered. This study aimed to ascertain the factors associated with clinical nurses' perceived knowledge of international guidelines.

METHODS

In this cross-sectional survey, nurses from 45 hospitals across Ireland were recruited. A previously validated anonymous questionnaire that assessed guideline knowledge, use, and barriers to implementation was used. Data were analyzed using SPSS 23 and logistic regression.

RESULTS

Of the 542 responses, 54% had used international guidelines relevant to their practice and 50% had consulted within the last year. Most nurses perceived that poor patient follow-up, lack of time and resources, poor clinical leadership, workload, long guidelines, and not understanding guideline detail were barriers to guideline use and implementation. Forty-five percent rated their perceived knowledge of guidelines as "low." Logistic regression identified that "high" knowledge levels were significantly associated with having read guidelines in the last year and their use with practice. In contrast, low knowledge of the guidelines was associated with perceptions that they were lengthy and not easy to use, lack of confidence to challenge colleagues when guidelines are not implemented, or not being able to influence current practice.

CONCLUSIONS

This study identified the specific knowledge needs in this cohort of mainly basic grade registered nurses, with low perceived guideline knowledge. A whole unit or team approach led by nurse champions is needed to develop and establish practice and educational strategies that would increase the availability, application, and knowledge of guidelines within everyday practice.

Care to Quit: a stepped wedge cluster randomised controlled trial to implement best practice smoking cessation care in cancer centres

BACKGROUND

Cigarette smoking in people with cancer is associated with negative treatment-related outcomes including increased treatment toxicity and complications, medication side effects, decreased performance status and morbidity. Evidence-based smoking cessation care is not routinely provided to patients with cancer. The purpose of this study is to determine the effectiveness of a smoking cessation implementation intervention on abstinence from smoking in people diagnosed with cancer.

METHODS

A stepped wedge cluster randomised design will be used. All sites begin in the control condition providing treatment as usual. In a randomly generated order, sites will move to the intervention condition. Based on the Theoretical Domains Framework, implementation of Care to Quit will include (i) building the capability and motivation of a critical mass of key clinical staff and identifying champions; and (ii) identifying and implementing cessation care models/pathways. Two thousand one hundred sixty patients with cancer (diagnosed in the prior six months), aged 18+, who report recent combustible tobacco use (past 90 days or in the 30 days prior to cancer diagnosis) and are accessing anti-cancer therapy, will be recruited at nine sites. Assessments will be conducted at baseline and 7-month follow-up. The primary outcome will be 6-month abstinence from smoking. Secondary outcomes include biochemical verification of abstinence from smoking, duration of quit attempts, tobacco consumption, nicotine dependence, provision and receipt of smoking cessation care, mental health and quality of life and cost effectiveness of the intervention.

DISCUSSION

This study will implement best practice smoking cessation care in cancer centres and has the potential for wide dissemination.

TRIAL REGISTRATION

The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN ( ACTRN12621000154808 ) prior to the accrual of the first participant and will be updated regularly as per registry guidelines.

Barriers and opportunities to using health information in policy implementation: The case of adolescent and youth friendly health services in the Western Cape

Background

The production, use and exchange of health information is an essential part of the health services, as it is used to inform daily decision-making and to develop new policies, guidelines and programmes. However, there is little insight into how health care workers (HCWs) get access to and use health information when implementing new health programmes.

Aim

This study explored the multifaceted role of health information within policy implementation processes and aimed to understand the complexities experienced by HCWs who need to develop adolescent health profiles (AHPs), a criterion of implementing a larger Adolescent and Youth Friendly Services Programme (AYFSP).

Setting

This case study was undertaken in Gugulethu, a peri-urban, low-income neighbourhood in Cape Town, South Africa.

Methods

Data were collected through ethnographic qualitative methods, including participant observation, interviews and workshops, and 15 participants were enrolled for this purpose.

Results

Findings showed that HCWs experienced different barriers when accessing information to develop the AHPs, including a lack of access to databases, a lack of support and inadequate guidelines. Nevertheless, HCWs were resourceful in using informal information and building strategic relationships to navigate and gain access to the necessary data to develop AHPs.

Conclusion

This case study provided insights into the practical difficulties and innovative strategies which arise when HCWs attempt to access and use health information within a real-life health programme. Findings highlighted the need for more training, support and guidance for HCWs to improve the meaningful use of health information during policy implementation processes and to strengthen health services in South African primary care clinics.

Palliative care nurse champions' views on their role and impact: a qualitative interview study among hospital and home care nurses

Background

One of the strategies to promote the quality of palliative care in non-specialised settings is the appointment of palliative care nurse champions. It is unclear what the most effective model to implement the concept of nurse champions is and little is known about palliative care nurse champions’ own views on their role and responsibilities. This paper aims to describe views of palliative care nurse champions in hospitals and home care on their role, responsibilities and added value.

Methods

In 2018, a qualitative interview study was conducted with 16 palliative care nurse champions in two hospitals and four home care organisations in the southwest of the Netherlands. The framework approach was used to analyse the data.

Results

Most palliative care nurse champions described their role by explaining concrete tasks or activities. Most nurse champions perceive their main task as disseminating information about palliative care to colleagues. A few nurses mentioned activities aimed at raising awareness of palliative care among colleagues. Most nurses were to a limited extent involved in collaboration with the palliative care expert team. Hospital nurse champions suggested that more support from the palliative care expert team would be helpful. Most nurse champions feel little responsibility for organisational tasks and inter-organisational collaboration. Especially hospital nurses found it difficult to describe their role.

Conclusion

The role of palliative care nurse champions in hospital and home care varies a lot and nurses have diverging views on palliative care in these settings. Comprehensively fulfilling the role of palliative care nurse champion is a challenge. Careful selection, training, support and task descriptions for nurse champions are needed to make the concept of nurse champions work in palliative care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00726-1.

Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home

BACKGROUND

Despite widespread adoption of patient-centered medical home (PCMH), little is known about why practices pursue PCMH and what is needed to undergo transformation.

OBJECTIVE

Examine reasons practices obtained and maintained PCMH recognition and what resources were needed.

DESIGN

Qualitative study of practice leader perspectives on PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by US region, practice size, PCMH recognition history, and practice use of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) PCMH survey.

PARTICIPANTS

105 practice leaders from 294 sampled practices (36% response rate).

APPROACH

Content analysis of interviews with practice leaders to identify themes.

RESULTS

Most practice leaders had local control of PCMH transformation decisions, even if practices adopted quality initiatives under the direction of an organization or network. Financial incentives, being in a statewide effort, and the intrinsic desire to improve care or experiences were the most common reasons practice leaders decided to obtain PCMH recognition and pursue associated care delivery changes. Leadership support and direction were highlighted as essential throughout PCMH transformation. Practice leaders reported needing specialized staff knowledge and significant resources to meet PCMH requirements, including staff knowledgeable about how to implement PCMH changes, track and monitor improvements, and navigate implementation of simultaneous changes, and staff with specific quality improvement (QI) expertise related to evaluating changes and scaling-up programs.

CONCLUSION

PCMH efforts necessitated support and assistance to frontline, on-site practice leaders leading care delivery changes. Such change efforts should include financial incentives (e.g., direct payment or additional reimbursement), leadership direction and support, and internal or external staff with experience with the PCMH application process, implementation changes, and QI expertise in monitoring process and outcome data. Policies that recognize and meet the needs of on-site practice leaders will better promote primary care practice transformation and move practices further toward their PCMH transformation goals.

Impact of the implementation of best practice guidelines on nurse's evidence-based practice and on nurses' work environment: Research protocol

AIM

To determine the impact of the Best Practice Spotlight Organization® initiative on nurses' perception of their work environment and their attitudes to evidence-based practice.

DESIGN

Quasi-experimental, multicentre study. The intervention is the participation in Best Prectice Spotilight Organizations to implement Best Practice Guidelines.

METHODS

The study will include seven centres in the interventional group and 10 in the non-equivalent control group, all of them belonging to the Spanish national health system. The Practice Environment Scale of the Nursing Work Index, and the Health Sciences Evidence-Based Practice Questionnaire will be administered to a sample of 1,572 nurses at the beginning of the programme and at 1 year. This 3-year study started in April 2018 and will continue until December 2021. Statistical analyses will be carried out using the SPSS 25.0. This project was approved by the Drug Research Ethics Committee of the Parc de Salut Mar and registered in Clinical Trials.

DISCUSSION

The study findings will show the current state of nurses' perception of their work environment and attitudes to evidence-based practice, and possible changes in these parameters due to the programme.

IMPACT

The findings could provide a strong argument for health policymakers to scale up the Best Practice Spotlight Organization® initiative in the Spanish national health system.

Using the Knowledge-to-Action Framework to understand experiences of breastfeeding guideline implementation: A qualitative study

AIM

To examine the perceptions and experiences of health care professionals and mothers in relation to the implementation of a breastfeeding clinical practice guideline (CPG).

BACKGROUND

Breastfeeding CPG applications remain limited, and qualitative studies have indicated the need to overcome the perception by professionals of difficulties in applying recommendations.

METHODS

A qualitative study was conducted in a Spanish public hospital that implemented the Registered Nurses´ Association of Ontario breastfeeding CPG from 2012 through 2015. Between May and August 2017, 27 semi-structured interviews were conducted with managers, with professionals in maternity and paediatric departments and with mothers. Deductive content analysis was performed following the stages in the Knowledge-To-Action (KTA) Framework.

RESULTS

We obtained five main categories: (a) problem as opportunity; (b) adequate context and adapted recommendations; (c) extent of implementation; (d) impact of results; and (e) knowledge use normalization.

CONCLUSIONS

The KTA Framework assists understanding of the participation of the main actors in breastfeeding CPG implementation.

IMPLICATIONS FOR NURSING MANAGEMENT

The nature of the interventions and the participation of managers, different professionals and mothers in a multi-unit setting generate a complex implementation process that reveals key factors to be taken into account in future CPG implementations.

A training program for primary health care nurses on timely diagnosis and management of dementia in general practice: An evaluation study

BACKGROUND

Primary health care nurses can play an important role in assisting the diagnosis and management of dementia. This study describes the evaluation outcome of a training program developed on the 'Four Steps to Building Dementia Practice in Primary Care'.

OBJECTIVE

To evaluate a training program for primary health care nurses by assessing change in current practice and future intention; and their knowledge, confidence, and perceived importance about dementia diagnosis and management.

DESIGN

A longitudinal survey. Participants were surveyed at three time points: pre-training, immediately post-training and six months (+/- 3 months) following their training.

SETTING

All states and territories in Australia.

PARTICIPANTS

Primary health care nurses (n = 1,290).

METHODS

A face-to-face and online training program on timely diagnosis and management of dementia was offered to primary health care nurses. A questionnaire was administered face-to-face and online to assess whether certain processes and services were 'currently in practice', 'working towards', or 'not in current practice' in their primary care facility. Three 10-point Likert scales were created to assess self-perceived levels of importance, knowledge and confidence about the diagnosis and management of dementia. A paired t-test was used to examine the differences between (a) post and pre-scores, and (b) follow-up and post scores. Linear regressions were used to identify the significant factors associated with pre-training scores for importance, confidence and knowledge.

RESULTS

Of 1290 primary health care nurses who participated in the training, 471 attended face-to-face and 819 participated online. Participants demonstrated improvements in all items in all four steps of the survey, with considerably higher improvement in the face-to-face mode. The average post-training score was significantly higher than the pre-training score for perceived importance, knowledge and confidence. The average follow-up score was significantly higher than the post-training score for perceived knowledge and confidence but not for perceived importance. Primary health care nurses who had 20 or more years of experience reported significantly more knowledge in attending patients with dementia than those with less than five years of experience (0.56, 95% CI: 0.11-1.01).

CONCLUSIONS

With a growing ageing population, the demand for dementia care is rising. Primary health care nurses can lead practice change and promote the timely diagnosis and management of dementia in general practice. Training programs of this kind that build knowledge, confidence, awareness and skills should be made available to the primary care nursing workforce. Further research is recommended to examine the translation of this training outcome into practice.

Nursing home staff experiences of implementing mentorship programmes: A systematic review and qualitative meta-synthesis

AIM

To determine nursing home staff experiences in mentorship programmes, and staff perceptions of the enablers and barriers to implement mentorship programmes.

BACKGROUND

Mentorship programmes are perceived as playing an important role in improving the quality of care in nursing homes. However, little is known about research evidence across the global about staff's experiences in the programmes.

METHODS

A search for studies published from the earliest available date to April 2019 was undertaken. Two reviewers performed data extraction and an appraisal of eight studies using tools from the Joanna Briggs Institute. A pragmatic meta-aggregative approach was applied to synthesise the findings. The qualitative research that was included was analysed to identify 63 findings that were organised into 12 categories and combined into three syntheses.

RESULTS

The implementation of effective mentorship programmes is influenced by three factors: mentor capability, opportunity in the mentorship programmes, and motivation in the mentorship programmes.

CONCLUSIONS

There are a number of studies of nursing home staff experiences of mentorship programmes. However, systematic reviews that synthesise findings in this field are lacking. It is crucial to tailor the programme design to suit each unique nursing home care setting. We identified barriers and enablers, and learned that no barriers are insurmountable.

IMPLICATIONS FOR NURSING MANAGEMENT

Findings will inform nurse managers of an ideal environment for the implementation of a successful mentorship programme. Nursing homes need to establish and sustain mentorship programmes to help improve workforce capacity in delivering high-quality care for residents.

"The role as a champion is to not only monitor but to speak out and to educate": the contradictory roles of hand hygiene champions

BACKGROUND

Implementation science experts define champions as "supporting, marketing, and driving through an implementation, overcoming indifference or resistance that the intervention may provoke in an organization." Many hospitals use designated clinical champions-often called "hand hygiene (HH) champions"-typically to improve hand hygiene compliance. We conducted an ethnographic examination of how infection control teams in the Veterans Health Administration (VHA) use the term "HH champion" and how they define the role.

METHODS

An ethnographic study was conducted with infection control teams and frontline staff directly involved with hand hygiene across 10 geographically dispersed VHA facilities in the USA. Individual and group semi-structured interviews were conducted with hospital epidemiologists, infection preventionists, multi-drug-resistant organism (MDRO) program coordinators, and quality improvement specialists and frontline staff from June 2014 to September 2017. The team coded the transcripts using thematic content analysis content based on a codebook composed of inductive and deductive themes.

RESULTS

A total of 173 healthcare workers participated in interviews from the 10 VHA facilities. All hand hygiene programs at each facility used the term HH champion to define a core element of their hand hygiene programs. While most described the role of HH champions as providing peer-to-peer coaching, delivering formal and informal education, and promoting hand hygiene, a majority also included hand hygiene surveillance. This conflation of implementation strategies led to contradictory responsibilities for HH champions. Participants described additional barriers to the role of HH champions, including competing priorities, staffing hierarchies, and turnover in the role.

CONCLUSIONS

Healthcare systems should consider narrowly defining the role of the HH champion as a dedicated individual whose mission is to overcome resistance and improve hand hygiene compliance-and differentiate it from the role of a "compliance auditor." Returning to the traditional application of the implementation strategy may lead to overall improvements in hand hygiene and reduction of the transmission of healthcare-acquired infections.

Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings

The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].

Establishing and Sustaining a Culture of Evidence-Based Practice: An Evaluation of Barriers and Facilitators to Implementing the Best Practice Spotlight Organization Program in the Australian Healthcare Context

Background: Nurses and midwives are central to the implementation and delivery of quality care through evidence-based practice (EBP). However, implementation of EBP in nursing and midwifery is under-researched with few examples of systematic and sustained change. The Registered Nurses Association of Ontario’s Best-Practice Spotlight Organization (BPSO) Program was adopted in South Australia as a framework to systematically implement EBP in two diverse and complex healthcare settings. Methods: The study was a post-implementation, mixed-method evaluation conducted at two healthcare settings in Adelaide, South Australia utilizing qualitative and quantitative data. Proctor’s implementation evaluation framework guided the evaluation design. Information sources included; interviews, focus groups, questionnaires, and document review. Results: Clinical and executive staff (n = 109 participants) from a broad range of stakeholder groups participated in the interviews, focus groups, and returned questionnaires. A number of facilitators directly affecting program implementation were identified; these pertained to embedding continuity into the program’s implementation and delivery, a robust governance structure, and executive sponsorship. Barriers to implementation were also identified. These barriers pertained to organizational or workforce challenges; staff turnover and movement (e.g., secondment), insufficient staff to allow people to attend training, and a lack of organizational commitment to the program, especially at an executive level. As a result of successful implementation, it was observed that over three years, the BPSO program positively influenced the uptake and implementation of EBP by clinicians and the organizations into which they were introduced. Conclusions: The BPSO model can be translocated to new healthcare systems and has the potential to act as a mechanism for establishing and sustaining EBP change. This study was the first to apply an implementation evaluation framework to the BPSO program, which allowed for structured analysis of facilitating or impeding factors that affected implementation success. The findings have important implications for other health systems looking to translocate the same or similar EBP programs, as well as contributing to the growing body of implementation evaluation literature.

Improving the accuracy of fluid intake charting through patient involvement in an adult surgical ward: a best practice implementation project

OBJECTIVES

The main objective of this evidence-based utilization project was to improve the accuracy of fluid intake charting through patient involvement.

INTRODUCTION

The accurate documentation and maintenance of fluid balance charts constitute an integral part of nursing care. However, inaccuracies in fluid balance charting by nurses often occur. Inaccurate charting can result in delayed interventions, affecting the safety of patients. It has been found that fluid intake charting in an acute surgical inpatient ward is highly inaccurate. Many expressions of dissatisfaction are evident among medical healthcare professionals and patients regarding the accurate updating of the charts. Therefore, evidence-based measures need to be implemented in order to improve the safety of patient care through accurate recording of patients' fluid intake.

METHODS

The project took place in a 21-bed acute surgical ward which had 30 patients. The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) tools were used to implement the evidence-based project. A pre- and post- audit methodology congruent with the framework was applied. The project was implemented in three phases from April to September 2016. The audit criteria obtained from JBI-PACES were used. The project's primary focus was to harness patient involvement in improving the accuracy of fluid intake charting.

RESULTS

Criteria 1 and 2 revealed low levels of compliance during the pre-implementation audit, 3% and 10%, respectively. There were significant improvements one month post-implementation for both Criteria 1 and 2, 100% and 87%, also respectively. Fisher's exact test was carried out and the statistical significance of the results was achieved (p < 0.001), compared to the pre-implementation audit. At six months post-implementation, the audit found that both criteria were adequately sustained as a practice in the ward (Criterion 1: 100%, Criterion 2: 83%).

CONCLUSIONS

This project has demonstrated the effectiveness of improving the accuracy of fluid intake charting through patient involvement. The use of JBI-PACES and GRiP has allowed the effective utilization of evidence in practice. It has also provided evidence that effective engagement of the ground nurses and stakeholders coupled with the commitment of change champions and ground nurses can contribute to improving practice in a highly demanding acute care setting and lead to healthcare success.

Improving Respiratory Rate Accuracy in the Hospital: A Quality Improvement Initiative

Respiratory rate (RR) is a predictor of adverse outcomes. However, RRs are inaccurately measured in the hospital. We conducted a quality improvement (QI) initiative using plan-do-study-act methodology on one inpatient unit of a safety-net hospital to improve RR accuracy. We added time-keeping devices to vital sign carts and retrained patient-care assistants on a newly modified workflow that included concomitant RR measurement during automated blood pressure measurement. The median RR was 18 (interquartile range [IQR] 18-20) preintervention versus 14 (IQR 15-20) postintervention. RR accuracy, defined as ±2 breaths of gold-standard measurements, increased from 36% preintervention to 58% postintervention (P < .01). The median time for vital signs decreased from 2:36 minutes (IQR, 2:04-3:20) to 1:55 minutes (IQR, 1:40-2:22; P < .01). The intervention was associated with a 7.8% reduced incidence of tachypnea-specific systemic inflammatory response syndrome (SIRS = 2 points with RR > 20; 95% CI, -13.5% to -2.2%). Our interdisciplinary, low-cost, low-tech QI initiative improved the accuracy and efficiency of RR measurement.

Patient perspectives on a harm reduction-oriented addiction medicine consultation team implemented in a large acute care hospital

BACKGROUND

Addiction medicine consultation teams [AMCTs] are a promising strategy for improving hospital care for patients with substance use disorders. Yet very little research has examined AMCT implementation in acute care settings. To address this gap, we conducted a process evaluation of a novel harm reduction-oriented AMCT. Our specific aims included examining patients' perspectives on factors that facilitated or hindered AMCT delivery, and its impact on their hospital care and outcomes.

METHODS

The AMCT provided integrated addiction medicine, harm reduction services, and wraparound health and social supports for patients of a large, urban acute care hospital in Western Canada. We adopted a focused ethnographic design and recruited 21 patients into semi-structured interviews eliciting their views on the care they received from the team.

RESULTS

Participants highlighted the AMCT's harm reduction approach; reputation amongst peers; and specialized training as especially important intervention facilitators. Key barriers that constrained the impact of the team included unmet expectations; difficulty accessing follow-up care; and residual conflicts between the AMCT's harm reduction approach and the abstinence-only orientation of some hospital staff. For a few participants these conflicts led to negative experiences. Despite this, participants reported that the AMCT had positive impacts overall, including declines in substance use, enhanced mental and emotional wellbeing, and improved socio-economic circumstances.

CONCLUSIONS

A novel harm reduction-oriented AMCT led to better hospital experiences and perceived outcomes for patients. However, further efforts are needed to ensure adequate post-discharge follow-up, and a consistent approach to substance use disorder care amongst all hospital staff.

Identifying patient-centered outcomes for children with cancer and their caregivers when they seek care in the emergency department

BACKGROUND

Children with cancer have high utilization of the emergency department (ED), but little is known about which outcomes are most important to them and their caregivers when they seek care in the ED.

PROCEDURE

A qualitative evaluation of ED experience for children with cancer and their caregivers was performed using self-reported interactive toolkits. Eligible participants included children with cancer (ages 11-19) and caregivers of children with cancer whose child received cancer therapy within the last year and had an ED visit within the last 2 years. Eligible participants received toolkits by mail and received incentives if they completed the toolkit. Toolkits were transcribed, thematically coded, and iteratively analyzed using Nvivo 11.0 software.

RESULTS

There were 26 toolkits received-seven by children aged 11-17 years and 19 by caregivers (11 with children aged 2-7 years, eight with children aged 11-17 years). About half were from within 1 h of their treating institution. The most important outcomes to this population included system-level issues (eg, cleanliness of space, timeliness of evaluation) and oncology-provider- and ED-provider-level issues (eg, ability to access port-a-caths, quality of communication). Participants also identified outcomes that were within the control of the patient/caregiver, such as improving their sense of preparedness.

CONCLUSION

The important outcomes to children with cancer and their caregivers when they seek care in the ED are distinct from current quality metrics. Future research should focus on the development and validation of a patient-centered outcomes tool.

Making New Health Services Work: Nurse Leaders as Facilitators of Service Development in Rural Emergency Services

Nurse leaders in middle management positions in Norway and other Western countries perform additional new tasks due to high demands for quality and efficacy in healthcare services. These nurses are increasingly becoming responsible for service development and innovation in addition to their traditional leadership and management roles. This article analyses two Norwegian nurse leaders efforts in developing an emergency service in rural municipal healthcare. The analysis applies an ethnographic approach to the data collection by combining interviews with the nurse leaders with observations and interviews with six nurses in the emergency service. The primary theoretical concepts used to support the analysis include “organizing work” and “articulation work”. The results show that in the development of an existing emergency room service, the nurse leaders drew upon their experience as clinical nurses and leaders in various middle management positions in rural community healthcare. Due to their local knowledge and experience, the nurses were able to mobilize and facilitate cooperation among relevant actors in the community and negotiate for resources required for emergency medical equipment, professional development, and staffing to perform emergency care within the rural healthcare context. Due to their distinctive professional and organizational competency and experience, the nurse leaders were well equipped to play a key role in developing services. While mobilizing actors and negotiating for resources, the nurses creatively balanced these two aspects of nursing work to develop the service in accordance to their expectation of providing the highest quality of nursing care to their patients. The nurse leaders balanced their professional ambitions for the service with legal directives, economic incentives, and budgets. Throughout the development process, the nurses carefully combined value-based and goal-based management concerns. In contrast, other studies investigating nursing management and leadership have described that these orientations are in opposition to each other. This study shows that nurses leading the processes of change in rural communities manage the change process by combining the professional and organizational domains of the services.

Characteristics and behaviours of formal versus informal nurse champions and their relationship to innovation success

AIMS

To identify the sociodemographic attributes, project characteristics and champion strategies that differentiate formal from informal nursing champions, and to test their success in terms of project spread and novelty.

BACKGROUND

Champions spread innovation in healthcare organizations. Empirical research has not explored the differences between formal and informal champions in terms of their antecedents and success.

DESIGN

A quantitative cross-sectional design.

METHOD

Data were collected on 93 nursing champions in three hospitals from 2015 - 2016. Champions were identified according to a validated approach; data on their sociodemographic attributes, project characteristics and strategies were assembled through interviews and validated questionnaires. Their success in terms of novelty and spread was assessed via expert ratings and validated questionnaire.

FINDINGS

Informal champions had longer tenure and were involved mainly in bottom-up projects aimed mostly at improving human resources and services; formal champions were mostly involved in top-down projects aimed at quality control. Informal champions expressed more enthusiasm and confidence about the innovation; formal champions tended to use more online resources and peer-monitoring strategies. Projects of informal champions were more novel than those of formal champions. Project spread did not differ between the two groups.

CONCLUSION

Formal and informal champions differ in their characteristics and implementation strategies. To encourage project's innovation, the organizational climate should encourage the emergence of informal champions; formal and informal champions should be chosen wisely, assuring that they possess enough organizational resources; and coaching programmes for junior champions should be planned to equip them with championing behaviours.

Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States

BACKGROUND

Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states.

METHODS

This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG.

RESULTS

Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period.

CONCLUSION

Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.

Process Evaluation of a Participatory, Multimodal Intervention to Improve Evidence-Based Care in Long-Term Care Settings

BACKGROUND

Evidence-based improvements in long-term care (LTC) are challenging due to human resource constraints.

AIMS

To evaluate implementation of a multimodal, participatory intervention aimed at improving evidence-based care.

METHODS

Using a qualitative descriptive design, we conducted and inductively analyzed individual interviews with staff at midpoint and end-point to identify action plan implementation processes and challenges. The 9-month intervention engaged professional and unregulated staff in an on-site workshop and provided support for their development and implementation of site-specific action plans.

RESULTS

Ten of 12 enrolled sites participated for the full study period. Interviews were conducted with 44 and 69 participants at midpoint and end-point, respectively. Seven of 10 sites focused their action plan on team functioning and communication. Main achievements described at end-point were improved team communication, better staff engagement, and improved teamwork. Internal and external supports for action plan implementation were described as critical for success.

DISCUSSION

Three factors influenced change: vertically and horizontally linked teams, external facilitator support for action plan implementation, and coaching by Best Practice Coordinators that emphasized organizational change and normalization of evidence-based practice.

IMPLICATIONS

Team functioning and communication are forerunners of clinical practice changes in LTC. An off-site model of facilitation is promising and may provide a more efficient means to reach a wider array of LTC settings.

LINKING EVIDENCE TO ACTION

Practice changes need engagement of all staff.

Critical Contextual Elements in Facilitating and Achieving Success with a Person-Centred Care Intervention to Support Antipsychotic Deprescribing for Older People in Long-Term Care

Antipsychotic and other tranquilising medicines are prescribed to help care staff manages behaviour in one-quarter of older people living in Australian long-term care homes. While these medicines pose significant health risks, particularly for people with dementia, reliance on their use occurs when staff are not educated to respond to resident behaviour using nonpharmacological approaches. The Halting Antipsychotic use in Long-Term care (HALT) single-arm study was undertaken to address this issue with 139 people 60 years and over with behaviours of concern for staff living in 24 care homes. A train-the-trainer approach delivered person-centred care education and support for 22 HALT (nurse) champions and 135 direct care staff, dementia management education for visiting general practitioners (GP) and pharmacists, use of an individualised deprescribing protocol for residents, and awareness-raising for the resident's family. The HALT champions completed open-ended questionnaires and semistructured interviews to identify the contextual elements they considered most critical to facilitating, educating care staff, and achieving success with the study intervention. They reported that person-centred approaches helped care staff to respond proactively to resident behaviours in the absence of antipsychotic medicines; the champions considered that this required strong managerial support, champion empowerment to lead change, reeducation of care staff, and the cooperation of families and GPs.

A Technology Intervention for Nurses Engaged in Preventing Catheter-Associated Urinary Tract Infections

Catheter-associated urinary tract infections account for 40% of healthcare-acquired infections. This study explored the addition of cloud-based software technology to an established nursing quality improvement program to reduce catheter-associated urinary tract infections. Unit-based nurse champions evaluated peers' evidence-based catheter-associated urinary tract infection prevention practices using manual, paper-based feedback. That process achieved reduced rates of catheter-associated urinary tract infection over 18 months. However, it was resource intensive. Cloud-based software technology was introduced to replace the paper. Nurse champions' satisfaction, catheter-associated urinary tract infection and indwelling urinary catheter utilization, and prevention practices were compared before and after the technology intervention. Compliance with the provision of a chlorhexidine bath demonstrated improvement (P = .003), while other practice measures did not significantly change. The indwelling urinary catheter utilization ratio was lower (P = .01), yet the intervention yielded no change in catheter-associated urinary tract infection rates. The short time interval of the intervention was potentially a contributing factor in no significant rate change. Nurse champions (N = 14) were more satisfied with the cloud-based technology (P = .004), the clarity of improvement targets (P = .004), and the speed of sharing data (P = .001). Their time to share data decreased from 4 days or more to 1 hour or less. Nurse champions readily adopted the cloud-based technology. These findings suggest additional research on technology innovations for nursing quality improvement is needed.

Acute care nurses' views on family participation and collaboration in fundamental care

AIMS AND OBJECTIVES

To understand the beliefs, attitudes and perceptions of nurses regarding family participation and collaboration in the care of their hospitalized adult relative.

BACKGROUND

Family participation in care is known to enhance the quality of patient care. Nurses are uniquely placed to support such participation, including the delivery of fundamental care. However, nurses' attitudes and beliefs may help or hinder participation.

DESIGN

A mixed methods approach with an exploratory sequential design was used.

SETTING

A regional referral hospital in Australia.

PARTICIPANTS

Nurses were eligible to participate in the study if they were permanent staff of the hospital, and who in their day-to-day work had direct contact with adult patients and their families on acute care wards.

METHODS

Observer-as-participant observation data and semi-structured interviews were undertaken. 30 hr of observational data were gathered, and 14 nurses were interviewed. Data collection occurred between September and December 2016. Following separate analysis, data were triangulated.

RESULTS

Analysis uncovered two contrasting categories: (i) enacting family participation (four themes); and (ii) hindering family participation (five themes).

CONCLUSION

The findings of our study demonstrated that the practices of nurses do not always align with healthcare policies, and strategies to support nurses to enact patient- and family-centred practices are needed.

RELEVANCE TO CLINICAL PRACTICE

Nurses can use these findings to make informed evidence-based changes to the way they practice and communicate with families to ensure fundamental care is delivered.

An Interdisciplinary Approach to Implementing a Best Practice Guideline in Public Health

This article describes how one Ontario Public Health Unit implemented a best practice guideline throughout the organization and across disciplines to achieve best practice outcomes in the delivery of client-centered care. Integration of evidence-informed practice presents challenges for both implementation and sustainability. Applying a best practice guideline in the public health setting can add to the challenge. To address this, a variety of interventions were applied: building an interdisciplinary team, adapting a Registered Nurses' Association of Ontario Best Practice Guideline to reflect public health practice for nursing and other disciplines, developing a working definition of "client," engaging staff in knowledge translation, developing policy to support practice change, and incorporating client-centered care principles into daily practice. Outcomes indicate that nursing best practice guidelines, specific to client-centered care, can be successfully adapted and applied in public health practice. Considerations include the varied definitions of a "client," the various roles of public health professionals, and engagement of both internal and external clients. Moreover, interdisciplinary staff can apply the principles of client-centered care when working with clients and when engaging in education-, practice-, and policy-level initiatives to support evidence-informed practice.

Characteristics of Quality Improvement Champions in Nursing Homes: A Systematic Review With Implications for Evidence-Based Practice

BACKGROUND

Improving care quality while reducing cost has always been a focus of nursing homes. Certified nursing assistants comprise the largest proportion of the workforce in nursing homes and have the potential to contribute to the quality of care provided. Quality improvement (QI) initiatives using certified nursing assistants as champions have the potential to improve job satisfaction, which has been associated with care quality.

AIMS

To identify the role, use and preparation of champions in a nursing home setting as a way of informing future QI strategies in nursing homes.

METHODS

A systematic literature review. Medical Subject Headings and text words for "quality improvement" were combined with those for "champion*" to search Medline, CINAHL, Joanna Briggs Institute, MedLine In-Process, and other Nonindexed Citations. After duplicates were removed, a total of 337 potential articles were identified for further review. After full text review, seven articles from five original studies met inclusion criteria and were included in the synthesis.

RESULTS

Various types of QI initiatives and implementation strategies were used together with champions. Champions were identified by study authors as one of the single most effective strategies employed in all studies. The majority of studies described the champion role as that of a leader, who fosters and reinforces changes for improvement. Although all the included studies suggested that implementing nurse or aid champions in their QI initiatives were important facilitators of success, how the champions were selected and trained in their role is either missing or not described in any detail in the studies included in the review.

LINKING EVIDENCE TO ACTION

Utilizing certified nursing assistants as QI champions can increase participation in QI projects and has the potential to improve job satisfaction and contribute to improve quality of care and improved patient outcomes in nursing homes.

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

BACKGROUND

Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.

METHODS

We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.

RESULTS

Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.

CONCLUSIONS

We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

An Exploratory Descriptive Study of Registered Nurse Innovation: Implications for Levels of Adoption

PURPOSE

The aims of this study were to describe registered nurses' levels of personal innovativeness and registered nurses' perceived organizational innovativeness and determine the relationship between these 2 variables.

BACKGROUND

There is limited research to describe the levels of innovation of nurses within a hospital. The levels of innovation can determine the likelihood of adoption of evidence-based practices at the bedside. As change agents, clinical nurse specialists can determine successful implementation strategies tailored to nurse levels of innovation.

DESCRIPTION

This was a descriptive study at a midwest, urban, teaching, 408-bed Magnet hospital.

OUTCOMES

Surveys were completed by 217 nurses. The participants reported high personal innovativeness ((Equation is included in full-text article.)= 32.1; SD, 6.4), and the institution was perceived as innovative, with 90.3% of scores categorized as positive innovativeness. The statistically significant correlation was in the medical-surgical unit (r = -0.52, P < .01). There is no correlation between personal innovativeness and organizational innovativeness except for medical-surgical nurses (P = .03). They are likely to perceive the organization more innovative than themselves.

CONCLUSIONS

Determining adopter characteristics can be valuable to the clinical nurse specialist by adapting strategic interventions to advance nursing practice. Exploring levels of adoption can be an innovative strategy to transform nursing at the bedside and throughout the organization.

Sustaining guideline implementation: A multisite perspective on activities, challenges and supports

AIMS AND OBJECTIVES

To examine activities conducted, challenges encountered and supports used when sustaining nursing practice guideline implementation in multiple healthcare organisations over 3 years.

BACKGROUND

Numerous models and frameworks exist to guide the implementation of guidelines, yet very few focus on sustaining improved practice changes. It is not known if one intervention or multiple interventions are required, nor the long-term activities, challenges and supports for sustaining improved practices.

DESIGN

Qualitative descriptive study.

METHODS

We conducted focus group interviews with steering committee members and individual interviews with leaders and direct care providers at the end of a 3-year guideline implementation study. The National Health Service Sustainability Model was used to guide data collection and analysis.

RESULTS

The eight sites included three teaching hospitals, a community hospital, a long-term care facility, two community health agencies and a community health centre. Individual interviews were conducted with 36 leaders and 26 direct care providers. Focus group interviews were conducted with steering committee members (n = 70) at each site. Guideline implementation activities (n = 45) included developing new outcome monitoring systems, conducting chart audits, communicating progress to internal stakeholders, appointing interprofessional staff to steering committees, developing educational sessions and resources for staff and patients, revising policies and procedures, and developing partnerships with external organisations. Supports included lessons learned from previous and concurrent change initiatives, and commitment, involvement and positive attitudes of staff and leaders.

CONCLUSION

Activities identified by the participants addressed all 10 factors in the Sustainability Model in the three areas of process, staff and organisation. The challenges and supports encountered provide insights into the process of guideline implementation and sustainability.

RELEVANCE TO CLINICAL PRACTICE

A multilevel action plan for staff, leaders and the organisation is recommended when introducing and sustaining practice changes.