Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings

Stimulating implementation of clinical practice guidelines in hospital care from a central guideline organization perspective: A systematic review

BACKGROUND

The uptake of guidelines in care is inconsistent. This review focuses on guideline implementation strategies used by guideline organizations (governmental agencies, scientific/professional societies and other umbrella organizations), experienced implementation barriers and facilitators and impact of their implementation efforts.

METHODS

We searched PUBMED, EMBASE and CINAHL and conducted snowballing. Eligibility criteria included guidelines focused on hospital care and OECD countries. Study quality was assessed using the Mixed Methods Appraisal Tool. We used framework analysis, narrative synthesis and summary statistics.

RESULTS

Twenty-six articles were included. Sixty-two implementation strategies were reported, used in different combinations and ranged between 1 and 16 strategies per initiative. Most frequently reported strategies were educational session(s) and implementation supporting materials. The most commonly reported barrier and facilitator were respectively insufficient healthcare professionals' time and resources; and guideline's credibility, evidence base and relevance. Eighty-five percent of initiatives that measured impact achieved improvements in adoption, knowledge, behavior and/or clinical outcomes. No clear optimal approach for improving guideline uptake and impact was found. However, we found indications that employing multiple active implementation strategies and involving external organizations and hospital staff were associated with improvements.

CONCLUSION

Guideline organizations employ diverse implementation strategies and encounter multiple barriers and facilitators. Our study uncovered potential effective implementation practices. However, further research is needed on effective tailoring of implementation approaches to increase uptake and impact of guidelines.

Management of Pediatric Pneumonia: A Decade After the Pediatric Infectious Diseases Society and Infectious Diseases Society of America Guideline

BACKGROUND

Incomplete uptake of guidelines can lead to nonstandardized care, increased expenditures, and adverse clinical outcomes. The objective of this study was to evaluate the impact of the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric community-acquired pneumonia (CAP) guideline that emphasized aminopenicillin use and de-emphasized the use of chest radiographs (CXRs) in certain populations.

METHODS

This quasi-experimental study queried a national administrative database of children's hospitals to identify children aged 3 months-18 years with CAP who visited 1 of 28 participating hospitals from 2009 to 2021. PIDS/IDSA pediatric CAP guideline recommendations regarding antibiotic therapy, diagnostic testing, and imaging were evaluated. Segmented regression interrupted time series was used to measure guideline-concordant practices with interruptions for guideline publication and the Coronavirus Disease 2019 (COVID-19) pandemic.

RESULTS

Of 315 384 children with CAP, 71 804 (22.8%) were hospitalized. Among hospitalized children, there was a decrease in blood culture performance (0.5% per quarter) and increase in aminopenicillin prescribing (1.1% per quarter). Among children discharged from the emergency department (ED), there was an increase in aminopenicillin prescription (0.45% per quarter), whereas the rate of obtaining CXRs declined (0.12% per quarter). However, use of CXRs rebounded during the COVID-19 pandemic (increase of 1.56% per quarter). Hospital length of stay, ED revisit rates, and hospital readmission rates remained stable.

CONCLUSIONS

Guideline publication was associated with an increase of aminopenicillin prescribing. However, rates of diagnostic testing did not materially change, suggesting the need to consider implementation strategies to meaningfully change clinical practice for children with CAP.

Effects of non-pharmacologic prevention on delirium in critically ill patients: A network meta-analysis

BACKGROUND

Delirium is a common complication among patients in the intensive care unit (ICU). It is important to prevent the occurrence of delirium in critically ill patients.

AIM

This review aimed to evaluate the efficacy of non-pharmacological interventions and determine what combination of these is effective in preventing delirium among Intensive Care Unit patients.

STUDY DESIGN

A systematic review and meta-analysis. This review follows the guidelines of the Preferred Reporting Items for Systematic reviews and Meta Analysis statements for Network Meta-Analysis (PRISMA-NMA). Data sources included the Cumulative Index to Nursing & Allied Health Literature., MEDLINE, and Cochrane library databases. The integrated data were investigated with odds ratio (OR) and 95% confidence interval (95% CI), using the random-effects Mantel-Haenszel model. Data were considered significant when p < 0.05. Furthermore, to reveal what combination of care is effective, we performed a network meta-analysis estimated OR, 95% CI.

RESULTS

We identified three randomized controlled trials and eight controlled before-after trials (11 in total, with 2549 participants). The pooled data from 11 trials of multicomponent intervention had a significant effect on delirium prevention (OR 0.58, 95% CI 0.44-0.76, p < 0.001). As a result of network meta-analysis, two bundles were effective compared to the control group in reducing the incidence of delirium: a) the combination of sleep promotion (SP), cognitive stimulation (CS), early mobilization (EM), pain control (PC), and assessment (AS) (OR 0.47, 95% CI 0.35-0.64, p < 0.002), and b) the combination of SP and CS (OR 0.46, 95% CI 0.28-0.75, p < 0.001).

CONCLUSION

This study revealed that non-pharmacological interventions, particularly multicomponent interventions, helped to prevent delirium in critically ill patients. In the network meta-analysis, the most effective care combination for reducing incidence of delirium was found to be multicomponent intervention, which comprises SP-CS-EM-PC-AS, and SP-CS.

RELEVANCE TO CLINICAL PRACTICE

These findings reveal an efficient combination of multicomponent interventions for preventing delirium, which may be a very important prerequisite in planning care programs in the future.

The SITS framework: sustaining innovations in tertiary settings

Background

To date, little attention has focused on what the determinants are and how evidence-based practices (EBPs) are sustained in tertiary settings (i.e., acute care hospitals). Current literature reveals several frameworks designed for implementation of EBPs (0-2 years), yet fewer exist for the sustainment of EBPs (>2 years) in clinical practice. Frameworks containing both phases generally list few determinants for the sustained use phase, but rather state ongoing monitoring or evaluation is necessary. Notably, a recent review identified six constructs and related strategies that facilitate sustainment, however, the pairing of determinants and how best to sustain EBPs in tertiary settings over time remains unclear. The aim of this paper is to present an evidence-informed framework, which incorporates constructs, determinants, and knowledge translation interventions (KTIs) to guide implementation practitioners and researchers in the ongoing use of EBPs over time.

Methods

We combined the results of a systematic review and theory analysis of known sustainability frameworks/models/theories (F/M/Ts) with those from a case study using mixed methods that examined the ongoing use of an organization-wide pain EBP in a tertiary care center (hospital) in Canada. Data sources included peer-reviewed sustainability frameworks (n = 8) related to acute care, semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level, chart audits (n = 200), and document review (n = 29). We then compared unique framework components to the evolving literature and present main observations.

Results

We present the Sustaining Innovations in Tertiary Settings (SITS) framework which consists of 7 unique constructs, 49 determinants, and 29 related KTIs that influence the sustainability of EBPs in tertiary settings. Three determinants and 8 KTIs had a continuous influence during implementation and sustained use phases. Attention to the level of application and changing conditions over time affecting determinants is required for sustainment. Use of a participatory approach to engage users in designing remedial plans and linking KTIs to target behaviors that incrementally address low adherence rates promotes sustainability.

Conclusions

The SITS framework provides a novel resource to support future practice and research aimed at sustaining EBPs in tertiary settings and improving patient outcomes. Findings confirm the concept of sustainability is a "dynamic ongoing phase".

Adaptation, implementation, and mixed methods evaluation of an interprofessional modular clinical practice guideline for delirium management on an inpatient palliative care unit

BACKGROUND

Using delirium clinical guidelines may align interprofessional clinical practice and improve the care of delirious patients and their families. The aim of this project was to adapt, implement and evaluate an interprofessional modular delirium clinical practice guideline for an inpatient palliative care unit.

METHODS

The setting was a 31-bed adult inpatient palliative care unit within a university-affiliated teaching hospital. Participants for the evaluation were interprofessional team members. Using integration of guideline adaptation and an education initiative, an interprofessional guideline adaptation group developed a face-to-face 'starter kit' module and four online self-learning modules. The mixed methods evaluation comprised pre-and post-implementation review of electronic patient records, an online survey, and analysis of focus groups/ interviews using an iterative, inductive thematic analysis approach.

RESULTS

Guideline implementation took 12 months. All palliative care unit staff attended a 'starter kit' session. Overall completion rate of the four e-Learning modules was 80.4%. After guideline implementation, nursing documentation of non-pharmacological interventions occurring before medication administration was observed. There was 60% less scheduled antipsychotic use and an increase in 'as needed' midazolam use. The online survey response rate was 32% (25/77). Most participants viewed the guideline's implementation favourably. Six key themes emerged from the qualitative analysis of interviews and focus groups with ten participants: prior delirium knowledge or experiences, challenges of facilitating change, impacts on practice, collaborative effort of change, importance of standardized guidelines, and utility of guideline elements.

CONCLUSIONS

Guideline implementation warrants concerted effort, time, and management support. Interprofessional team support facilitates the modular approach of guideline adaptation and implementation, leading to a change in clinical practice.

Use of environmental scans in health services delivery research: a scoping review

OBJECTIVE

To examine the extent and nature of evidence on the use of the environmental scan (ES) in the health services delivery literature.

DESIGN

Scoping review.

METHODS

This scoping review followed the five-stage scoping review methodology outlined by Khalil et al. A Peer Review of Electronic Search Strategies was completed. Seven electronic databases and the grey literature were searched. Pairs of researchers independently performed two levels of screening and data extraction. Data were analysed using qualitative content and thematic analysis.

RESULTS

Ninety-six studies were included in the scoping review. Researchers conducted ESs for many purposes, the most common being to examine the current state of programmes, services or policies. Recommendations were informed by ESs in 20% of studies. Most common data collection methods were literature review (71%), key informant or semistructured interviews (46%) and surveys (35%). Over half (53%) of the studies used a combination of passive (looking at information eg, literature, policies, guidelines) and active (looking for information eg, surveys, interviews) approaches to data collection. Person sources of data (eg, healthcare stakeholders, community representatives) and non-person sources of data (eg, documents, electronic databases, the web) were drawn on to a similar extent. The thematic analysis of the definitions/descriptions yielded several themes including instrument of discovery, knowledge synthesis, forward-looking and decision making. Research gaps identified included absence of a standard definition, inconsistencies in terminology and lack of guiding frameworks in the health services delivery context.

CONCLUSION

ESs were conducted to gather evidence and to help inform decision making on a range of policy and health services delivery issues across the continuum of care. Consistency in terminology, a consensus definition and more guidance on ES design may help provide structure for researchers and other stakeholders, and ultimately advance ES as a methodological approach. A working definition of ES in a health services delivery context is presented.

ERS/EAACI statement on adherence to international adult asthma guidelines

Guidelines aim to standardise and optimise asthma diagnosis and management. Nevertheless, adherence to guidelines is suboptimal and may vary across different healthcare professional (HCP) groups.Further to these concerns, this European Respiratory Society (ERS)/European Academy of Allergy and Clinical Immunology (EAACI) statement aims to: 1) evaluate the understanding of and adherence to international asthma guidelines by HCPs of different specialties via an international online survey; and 2) assess strategies focused at improving implementation of guideline-recommended interventions, and compare process and clinical outcomes in patients managed by HCPs of different specialties via systematic reviews.The online survey identified discrepancies between HCPs of different specialties which may be due to poor dissemination or lack of knowledge of the guidelines but also a reflection of the adaptations made in different clinical settings, based on available resources. The systematic reviews demonstrated that multifaceted quality improvement initiatives addressing multiple challenges to guidelines adherence are most effective in improving guidelines adherence. Differences in outcomes between patients managed by generalists or specialists should be further evaluated.Guidelines need to consider the heterogeneity of real-life settings for asthma management and tailor their recommendations accordingly. Continuous, multifaceted quality improvement processes are required to optimise and maintain guidelines adherence. Validated referral pathways for uncontrolled asthma or uncertain diagnosis are needed.

Intervention for Alleviating Clinical Inertia in the Management of Urinary Incontinence

PURPOSE

The purpose of this study was to determine whether clinical inertia exists in the care of patients with urinary incontinence and to test the effects of an educational intervention designed to alleviate inertia related to care of urinary incontinence.

DESIGN

Single-group, pretest/posttest design.

SUBJECTS AND SETTING

The sample comprised 132 participants practicing in 6 medical-surgical inpatient care units at an urban hospital in Almería, Spain; 66 (50%) were RNs, and all other participants were unlicensed assistive personnel. Most participants (87.9%) were female; their average age was 43.99 years (SD = 7.85 years).

METHODS

An educational intervention (online course) was provided. The main objective of the course was application of evidence-based knowledge for prevention and management of urinary incontinence in hospitalized patients. The course program comprised 3 didactic units: (1) introduction and evaluation of the patient with urinary incontinence, (2) care plans, and (3) instructions and rational use of absorbent products. Data collection included demographic and professional characteristics of respondents, desired results when caring for patients with incontinence, a medical record checklist, an occupational environment and satisfaction scale, and an assessment record of knowledge/skills and training activity satisfaction.

RESULTS

After comparing the pre- and posttest scores of knowledge on urinary incontinence, significant differences were found before and after the intervention (z = -14.113, P = .000). Specifically, analysis revealed differences in caring actions related to urinary incontinence (z = -14.248, P = .000) and differences in direct observation of urinary incontinence practice following the intervention (z = -14.326, P = .000).

CONCLUSIONS

Our findings indicate existence of inertia in nursing care for hospitalized patients with urinary incontinence. The educational intervention improved knowledge, observable nursing care activities related to incontinence management, and improved documentation of care.

Development and implementation of a transmural palliative care consultation service: a multiple case study in the Netherlands

Background

In the Netherlands, healthcare professionals attending patients in the last phase of life, can consult an expert palliative care team (PCT) in case of complex problems. There are two types of PCTs: regional PCTs, which are mainly consulted by general practitioners, and hospital PCTs, which are mainly consulted by healthcare professionals in the hospital. Integration of these PCTs is expected to facilitate continuity of care for patients receiving care in different settings. We studied facilitators and barriers in the process of developing and implementing an integrated transmural palliative care consultation service.

Methods

A multiple case study was performed in four palliative care networks in the southwest Netherlands. We aimed to develop an integrated transmural palliative care consultation service. Researchers were closely observing the process and participated in project team meetings. A within-case analysis was conducted for each network, using the Consolidated Framework for Implementation Research (CFIR). Subsequently, all findings were pooled.

Results

In each network, project team members thought that the core goal of a transmural consultation service is improvement of continuity of palliative care for patients throughout their illness trajectory. It was nevertheless a challenge for hospital and non-hospital healthcare professionals to arrive at a shared view on goals, activities and working procedures of the transmural consultation service. All project teams experienced the lack of evidence-based guidance on how to organise the service as a barrier. The role of the management of the involved care organisations was sometimes perceived as unsupportive, and different financial reimbursement systems for hospital and out-of-hospital care made implementation of a transmural consultation service complex. Three networks managed to develop and implement a transmural service at some level, one network did not manage to do so.

Conclusions

Healthcare professionals are motivated to collaborate in a transmural palliative care consultation service, because they believe it can contribute to high-quality palliative care. However, they need more shared views on goals and activities of a transmural consultation service, more guidance on organisational issues and appropriate financing. Further research is needed to provide evidence on benefits and costs of different models of integrated transmural palliative care consultation services.

SUMAMOS EXCELENCIA® Project: Results of the Implementation of Best Practice in a Spanish National Health System (NHS)

The use of certain strategies for the implementation of a specific recommendation yields better results in clinical practice. The aim of this study was to assess the effectiveness of an evidence-based model using clinical audits (GRIP model), for the implementation of recommendations in pain and urinary incontinence management as well as fall prevention, in the Spanish National Health System during the period 2015-2018. A quasi-experimental study has been conducted. The subjects were patients treated in hospitals, primary care units and nursing home centers. There were measures related to pain, fall prevention and urinary incontinence. Measurements were taken at baseline and at months 3, 6, 9, and 12. The sample consisted of 22,114 patients. The frequency of pain assessment increased from 59.9% in the first cycle to a mean of 71.6% in the last cycle, assessments of risk of falling increased from 56.8% to 87.8% in the last cycle; and finally, the frequency of assessments of urinary incontinence increased from a 43.4% in the first cycles to a mean of 62.2% in the last cycles. The implementation of specific evidence-based recommendations on pain, fall prevention, and urinary incontinence using a model based on clinical audits improved the frequency of assessments and their documentation.

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.

Analysis of risk factors of diabetes peripheral neuropathy in type 2 diabetes mellitus and nursing intervention

The aim of the present study was to explore the risk factors of diabetes peripheral neuropathy (DPN) in type 2 diabetes mellitus, and to propose corresponding nursing intervention measures to provide the basis for early diagnosis, treatment and prevention of DPN. A retrospective analysis was performed on 130 patients with type 2 diabetes mellitus (T2DM) in the communities surrounding our hospital from January 2017 to June 2018. They were divided into a DPN group (62 cases) and non-DPN group (control group, 68 cases). First, a univariate analysis was performed. DPN or non-DPN were used as dependent variables, and statistically significant parameters in univariate analysis were used as independent variables. Multivariate logistic regression analysis was included to analyze the peripheral nerves in type 2 diabetes mellitus. At the same time, the patients with DPN were given individualized comprehensive nursing intervention. Univariate analysis showed that body mass index (BMI), diabetes duration, smoking history, drinking history, family history of diabetes, fasting blood glucose (FBG), postprandial blood glucose (PBG), glycosylated hemoglobin (HbA1c), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), systolic blood pressure, 24-h urine microalbumin excretion (24hmALB), glomerular filtration rate (GFR), serum creatinine in DPN group were significantly different from those in the control group (P<0.05). Logistic regression analysis showed that the duration of diabetes, PBG, glycosylated hemoglobin (HbA1c), HDL-C, 24hmALB, and GFR were independent risk factors for DPN. The quality of life [Physiological function (PF), Role-physical (RP), Role-emotional (RE), General health (GH), Social function (SF), Mental health (MH), Bodily pain (BP), Vitality (VT)] in the DPN group was significantly improved after six months of individualized nursing intervention compared with that before intervention (P<0.05). In conclusion, the high risk factors of DPN should be identified as early as possible, to prevent and delay the occurrence and development of diabetes peripheral neuropathy, so as to improve the quality of life of these patients.

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.

The SUMAMOS EXCELENCIA Project

AIM

The gap between research and clinical practice leads to inconsistent decision-making and clinical audits are an effective way of improving the implementation of best practice. Our aim is to assess the effectiveness of a model that implements evidence-based recommendations for patient outcomes and healthcare quality.

DESIGN

National quasi-experimental, multicentre, before and after study.

METHODS

This study focuses on patients attending primary care and hospital care units and associated socio-healthcare services. It uses the Joanna Brigg's Institute Getting Research into Practice model, which improves processes by referring to prior baseline clinical audits. The variables are process and outcome criteria for pain, urinary incontinence, and fall prevention, with data collection at baseline and key points over 12 months drawn from clinical histories and records. Project funding was received from the Spanish Strategic Health Action in November 2014.

DISCUSSION

The project results will provide knowledge on the effectiveness of the Getting Research into Practice model, to apply evidence-based recommendations for the detection and management of pain, urinary incontinence, and fall prevention. It will also establish whether using research results, based on clinical audits and situation analysis, is effective for implementing evidence-based recommendations and improving patients' health.

IMPACT

This nationwide Spanish project aims to detect and prevent high-prevalence healthcare problems, namely pain in patients at any age and falls and urinary incontinence in people aged 65 and over. Tailoring clinical practice to evidence-based recommendations will reduce unjustified clinical variations in providing healthcare services. Clinical Trial ID: NCT03725774.

Factors associated with breastfeeding support from health care professionals by implementing a Clinical Practice Guideline

BACKGROUND

The prevalence and duration of breastfeeding are at low levels and may be improved by the support of health care professionals. Our objective was to determine the effect of implementing a breastfeeding clinical practice guideline on factors associated with breastfeeding support by health care professionals, adopting a Theory of Planned Behavior approach.

METHODS

We conducted an observational, cross-sectional study during 2016 in a health area with implemented clinical practice guideline on breastfeeding, comparing the results with data from a previous cross-sectional study (2011) in the same area, in a standard-care area, and in a Baby-Friendly Hospital Initiative (BFHI)-accredited area. A validated questionnaire (four scales: attitudes, beliefs, subjective norms, and behavioral intention) was completed by professionals in each area. Descriptive analysis was followed by comparisons among the different settings using the chi-square test.

RESULTS

In the area with the implemented clinical practice guideline, the professionals scored significantly higher in subjective norms and beliefs than had been recorded in 2011 (preimplementation), and their scores for all four scales were significantly higher than in the standard-care area. Professionals obtained significantly higher scores for subjective norms in the BFHI-accredited area than in the other settings.

CONCLUSIONS

Clinical practice guideline implementation improved the responses of professionals on breastfeeding support in subjective norms and beliefs scales. There is a need for activities to assist breastfeeding in a practical manner and for more effective measures to ensure compliance with the International Code of Marketing of Breast-milk Substitutes.

The Impact of Quality Assurance Initiatives and Workplace Policies and Procedures on HIV/AIDS-Related Stigma Experienced by Patients and Nurses in Regions with High Prevalence of HIV/AIDS

Stigma is commonly experienced by people living with HIV/AIDS and by those providing care to HIV/AIDS patients. Few intervention studies have explored the impact of workplace policies and/or quality improvement on stigma. We examine the contribution of health care workplace policies, procedures and quality assurance initiatives, and self- and peer-assessed individual nurse practices, to nurse-reported HIV/AIDS-stigma practices toward patients living with HIV/AIDS and nurses in health care settings. Our sample of survey respondents (n = 1157) included managers (n = 392) and registered/enrolled nurses (n = 765) from 29 facilities in 4 countries (South Africa, Uganda, Jamaica, Kenya). This is one of the first studies in LMIC countries to use hierarchical linear modeling to examine the contributions of organizational and individual factors to HIV/AIDS stigma. Based on our results, we argue that organizational interventions explicitly targeting HIV/AIDS stigma are required to reduce the incidence, prevalence and morbidity of HIV/AIDS.

Managerial leadership for research use in nursing and allied health care professions: a systematic review

Background

Leadership by point-of-care and senior managers is increasingly recognized as critical to the acceptance and use of research evidence in practice. The purpose of this systematic review was to identify the leadership behaviours of managers that are associated with research use by clinical staff in nursing and allied health professionals.

Methods

A mixed methods systematic review was performed. Eight electronic bibliographic databases were searched. Studies examining the association between leadership behaviours and nurses and allied health professionals’ use of research were eligible for inclusion. Studies were excluded if leadership could not be clearly attributed to someone in a management position. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. Narrative synthesis was conducted.

Results

The search yielded 7019 unique titles and abstracts after duplicates were removed. Three hundred five full-text articles were reviewed, and 31 studies reported in 34 articles were included. Methods used were qualitative (n = 19), cross-sectional survey (n = 9), and mixed methods (n = 3). All studies included nurses, and six also included allied health professionals. Twelve leadership behaviours were extracted from the data for point-of-care managers and ten for senior managers. Findings indicated that managers performed a diverse range of leadership behaviours that encompassed change-oriented, relation-oriented and task-oriented behaviours. The most commonly described behavior was support for the change, which involved demonstrating conceptual and operational commitment to research-based practices.

Conclusions

This systematic review adds to the growing body of evidence that indicates that manager-staff dyads are influential in translating research evidence into action. Findings also reveal that leadership for research use involves change and task-oriented behaviours that influence the environmental milieu and the organisational infrastructure that supports clinical care. While findings explain how managers enact leadership for research use, we now require robust methodological studies to determine which behaviours are effective in enabling research use with nurses and allied health professionals for high-quality evidence-based care.

Trial registration

PROSPERO CRD42014007660

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0817-7) contains supplementary material, which is available to authorized users.

CogChamps: impact of a project to educate nurses about delirium and improve the quality of care for hospitalized patients with cognitive impairment

BACKGROUND

Achieving sustainable practice changes to ensure best-practice nursing care in acute hospital environments can be challenging and is not well understood. A multi-faceted practice change intervention was implemented in a large Australian hospital to enhance the capacity of the nursing workforce to provide quality care for older patients with cognitive impairment (CI).

METHODS

Thirty-four experienced Registered Nurses (RNs) became Cognition Champions (CogChamps), and led practice-change initiatives to improve nursing care for older patients (≥65 years) on six wards in one hospital. The CogChamps received comprehensive education about dementia and the identification, prevention, and management of delirium. Over five months, they were supported to develop and implement ward-specific Action Plans designed to change care practices. Nurse-patient interactions were observed and patient charts were audited prior to the implementation of the plans and regularly throughout, using a purpose built Audit/ Observational tool. Data were also collected at a comparable hospital where there were no CogChamps. Data were analyzed for evidence of practice change.

RESULTS

Observational and audit data were collected for 181 patients (average age = 82.5 years) across the two hospitals. All patients had CI and both cohorts had similar behavioral characteristics requiring a high level of care assistance [e.g. 38% displayed evidence of confusion/disorientation and a majority experienced meal-time difficulty (62-70%)]. While nursing practices were generally the same at both hospitals, some differences were evident (e.g. analgesia use was higher at the control hospital). Following implementation of Action Plans, significant increases in nurses' assessments of patients' cognitive functioning (35 to 69%), and administration of analgesia (27 to 48%) were observed at the intervention hospital, although only the improvement in cognitive assessments was maintained at three months follow-up. No other changes in nursing processes were evident.

CONCLUSION

The CogChamps project demonstrates how RN champions were empowered to educate their colleagues about dementia and delirium resulting in a sustained increase in cognitive assessments by ward nurses. Practice improvements were mostly associated with clearly defined Action Plan tasks and goals and where responsibility for task completion was clearly assigned. These elements appear to be important when implementing practice changes.

TRIAL REGISTRATION

Australian Clinical Trials Registration Number: ACTRN 12617000563369 . Retrospectively registered.

A Sustainability Oriented and Mentored Approach to Implementing a Fall Prevention Guideline in Acute Care Over 2 Years

The purpose of this study was to assess the impact of a mentored guideline implementation (Registered Nurses' Association of Ontario Prevention of Falls and Falls Injuries in the Older Adult Best Practice Guideline) focused on enhancing sustainability in reducing fall rates and number of serious falls and the experience of staff in three acute care hospitals. The National Health Service (NHS) Sustainability Model was used to guide the study. Interviews and focus groups were held with 82 point-of-care professional staff, support staff, volunteers, project leaders, clinical leaders, and senior leaders. Study results supported the importance of the factors in the NHS model for sustainability of the guideline in these practice settings. There were no statistically significant decreases in the overall fall rate and number of serious falls. The results supported strategies of participating hospitals to become senior friendly organizations and provided opportunities to enhance staff collaboration with patients and families.

When east meets west: a qualitative study of barriers and facilitators to evidence-based practice in Hunan China

Background

Research into evidence-based practice has been extensively explored in nursing and there is strong recognition that the organizational context influences implementation. A range of barriers has been identified; however, the research has predominantly taken place in Western cultures, and there is little information about factors that influence evidence-based practice in China. The purpose of this study was to explore barriers and facilitators to evidence-based practice in Hunan province, a less developed region in China.

Methods

A descriptive qualitative methodology was employed. Semi-structured interviews were conducted with staff nurses, head nurses and directors (n = 13). Interviews were translated into English and verified for accuracy by two bilingual researchers. Both Chinese and English data were simultaneously analyzed for themes related to factors related to the evidence to be implemented (Innovation), nurses’ attitudes and beliefs (Potential Adopters), and the organizational setting (Practice Environment).

Results

Barriers included lack of available evidence in Chinese, nurses’ lack of understanding of what evidence-based practice means, and fear that patients will be angry about receiving care that is perceived as non-traditional. Nurses believed evidence-based practice was to be used when clinical problems arose, and not as a routine way to practice. Facilitators included leadership support and the pervasiveness of web based social network services such as Baidu (百度) for easy access to information.

Conclusion

While several parallels to previous research were found, our study adds to the knowledge base about factors related to evidence-based practice in different contextual settings. Findings are important for international comparisons to develop strategies for nurses to provide evidence-based care.

Electronic supplementary material

The online version of this article (10.1186/s12912-018-0295-x) contains supplementary material, which is available to authorized users.

Implementation of nursing process in clinical settings: the case of three governmental hospitals in Ethiopia, 2017

Objective

The purpose of this survey was to evaluate the implementation of the nursing process at three randomly selected governmental hospitals found in Amhara Region North West Ethiopia.

Result

From the total 338 reviewed documents, 264 (78.1%) have a nursing process format attached with the patient’s profile/file, 107 (31.7%) had no nursing diagnosis, 185 (54.7%) of nurses stated their plan of care based on priority, 173 (51.2%) of nurses did not document their interventions based on plan and 179 (53.0%) of nurses did not evaluate their interventions. The overall implementation of nursing process among Felege Hiwot Referal hospital, Debretabor general hospital and Finoteselam general hospitals were 49.12, 68.18, and 69.42% respectively. Nursing professionals shall improve documentation required in implementing the nursing process. Nursing managers (matron, ward heads) shall supervise the overall implementation of nursing process. Hospital nursing services managers (matrons) shall arrange and facilitate case presentations by the nursing staffs which focus on documentation and updates on nursing process. Hospitals need to establish and support nursing process coordinating staff in their institution.

Mentoring as a Knowledge Translation Intervention for Implementing Nursing Practice Guidelines: A Qualitative Study

An interpretive descriptive qualitative study was conducted to explore the characteristics and outcomes of mentoring used for implementing nursing practice guidelines. We interviewed six mentees, eight mentors, and four program leaders who were involved in the Registered Nurses' Association of Ontario fellowship program in Ontario, Canada. Inductive content analysis was used and study rigor was verified using triangulation of findings and member checking. Mentors were described as accessible, dedicated, and having expertise; mentees were described as enthusiastic, self-directed, and having mixed levels of expertise. The mentoring process included building relationships, developing learning plans, and using teaching and learning activities guided by learning plans to support development of mentees. Mentoring was described as positively impacting mentoring relationships, mentees, mentors, and organizations. A central feature of this fellowship program was the learning plan used to identify mentees' needs, guide mentoring activities, and monitor measureable outcomes.

Reduced prevalence and severity of wounds following implementation of the Champions for Skin Integrity model to facilitate uptake of evidence-based practice in aged care

AIMS AND OBJECTIVES

To evaluate the implementation of the Champions for Skin Integrity model on facilitating uptake of evidence-based wound management and improving skin integrity in residents of aged care facilities.

BACKGROUND

The incidence of skin tears, pressure injuries and leg ulcers increases with age, and such wounds can be a serious issue in aged care facilities. Older adults are not only at higher risk for wounds related to chronic disease but also injuries related to falls and manual handling requirements.

DESIGN

A longitudinal, pre-post design.

METHODS

The Champions for Skin Integrity model was developed using evidence-based strategies for transfer of evidence into practice. Data were collected before and six months after implementation of the model. Data on wound management and skin integrity were obtained from two random samples of residents (n = 200 pre; n = 201 post) from seven aged care facilities. A staff survey was also undertaken (n = 126 pre; n = 143 post) of experience, knowledge and evidence-based wound management. Descriptive statistics were calculated for all variables. Where relevant, chi-square for independence or t-tests were used to identify differences between the pre-/postdata.

RESULTS

There was a significant decrease in the number of residents with a wound of any type (54% pre vs 43% post, χ² 4·2, p = 0·041), as well as a significant reduction in specific wound types, for example pressure injuries (24% pre vs 10% post, χ² 14·1, p < 0·001), following implementation of the model. An increase in implementation of evidence-based wound management and prevention strategies was observed in the postimplementation sample in comparison with the preimplementation sample. This included use of limb protectors and/or protective clothing 6% pre vs 20% post (χ² 17·0, p < 0·001) and use of an emollient or soap alternative for bathing residents (50% pre vs 74% post, χ² 13·9, p = 0·001).

CONCLUSIONS

Implementation of the model in this sample fostered an increase in implementation of evidence-based wound management and prevention strategies, which was associated with a decrease in the prevalence and severity of wounds.

RELEVANCE TO CLINICAL PRACTICE

This study suggests the Champions for Skin Integrity model has the potential to improve uptake of evidence-based wound management and improve skin integrity for older adults.

Translating research findings to clinical nursing practice

AIMS AND OBJECTIVES

To describe the importance of, and methods for, successfully conducting and translating research into clinical practice.

BACKGROUND

There is universal acknowledgement that the clinical care provided to individuals should be informed on the best available evidence. Knowledge and evidence derived from robust scholarly methods should drive our clinical practice, decisions and change to improve the way we deliver care. Translating research evidence to clinical practice is essential to safe, transparent, effective and efficient healthcare provision and meeting the expectations of patients, families and society. Despite its importance, translating research into clinical practice is challenging. There are more nurses in the frontline of health care than any other healthcare profession. As such, nurse-led research is increasingly recognised as a critical pathway to practical and effective ways of improving patient outcomes. However, there are well-established barriers to the conduct and translation of research evidence into practice.

DESIGN

This clinical practice discussion paper interprets the knowledge translation literature for clinicians interested in translating research into practice.

METHODS

This paper is informed by the scientific literature around knowledge translation, implementation science and clinician behaviour change, and presented from the nurse clinician perspective. We provide practical, evidence-informed suggestions to overcome the barriers and facilitate enablers of knowledge translation. Examples of nurse-led research incorporating the principles of knowledge translation in their study design that have resulted in improvements in patient outcomes are presented in conjunction with supporting evidence.

CONCLUSIONS

Translation should be considered in research design, including the end users and an evaluation of the research implementation. The success of research implementation in health care is dependent on clinician/consumer behaviour change and it is critical that implementation strategy includes this.

RELEVANCE TO PRACTICE

Translating best research evidence can make for a more transparent and sustainable healthcare service, to which nurses are central.

Factors Predicting the Provision of Smoking Cessation Services Among Occupational Health Nurses in Thailand

The purpose of this study was to identify factors predicting occupational health nurses' provision of smoking cessation services. Data were collected via a self-administered questionnaire distributed to 254 occupational health nurses in Thailand. Analysis by structural equation modeling revealed that self-efficacy directly and positively influenced smoking cessation services, and mediated the relationship between workplace factors, nurse factors, and smoking cessation services. The final model had good fit to the data, accounting for 20.4% and 38.0% of the variance in self-efficacy and smoking cessation services, respectively. The findings show that self-efficacy is a mediator that influences provision of smoking cessation services by occupational health nurses. Interventions to enhance nurses' self-efficacy in providing smoking cessation services are expected to promote provision of smoking cessation services to workers.

Transcultural Endocrinology: Adapting Type-2 Diabetes Guidelines on a Global Scale

Type-2 diabetes (T2D) needs to be prevented and treated effectively to reduce its burden and consequences. White papers, such as evidence-based clinical practice guidelines (CPG) and their more portable versions, clinical practice algorithms and clinical checklists, may improve clinical decision-making and diabetes outcomes. However, CPG are underused and poorly validated. Protocols that translate and implement these CPG are needed. This review presents the global dimension of T2D, details the importance of white papers in the transculturalization process, compares relevant international CPG, analyzes cultural variables, and summarizes translation strategies that can improve care. Specific protocols and algorithmic tools are provided.

Implementation of national guidelines for the prevention and treatment of overweight and obesity in children and adolescents: a phenomenographic analysis of public health nurses' perceptions

Objective

To explore and describe how public health nurses (PHNs) perceive the implementation of national guidelines for the prevention and treatment of overweight and obesity among children and adolescents in well-baby clinics and school health services.

Design, sample, and measurements

An explorative descriptive design was carried out through individual interviews with 18 PHNs and analysed according to the phenomenographic tradition.

Results

Four implementation strategies were described and assigned a metaphor: the structured PHN, pragmatic PHN, critical PHN, and the resigned PHN. Competence, patient receptiveness, internal consensus, interdisciplinary collaboration, resources, and organizational embedding were the determinants identified that most frequently affect implementation, and these determinants were distributed at different levels of the organization. The extent of facilitation seemed to determine which implementation strategy would be used.

Conclusions

How PHNs implemented the guidelines for overweight and obesity were affected by determinants at different organizational levels. Contextual facilitation of implementation seemed better in larger organizations, but factors such as leadership, drive, and experience compensated in smaller municipalities. The implementation of guidelines was hindered when the barriers exceeded the benefits.

The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa

BACKGROUND

The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care.

METHODS

A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test.

RESULTS

Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self-pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73-0.82), p = 0.002; workplace policies-pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance-pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising-pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002-and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation-pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps.

CONCLUSIONS

Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them.

Trends in guideline implementation: a scoping systematic review

BACKGROUND

There is currently no reliable way to choose strategies that are appropriate for implementing guidelines facing different barriers. This study examined trends in guideline implementation by topic over a 10-year period to explore whether and how strategies may be suitable for addressing differing barriers.

METHODS

A scoping systematic review was performed. MEDLINE and EMBASE were searched from 2004 to 2013 for studies that evaluated the implementation of guidelines on arthritis, diabetes, colorectal cancer and heart failure. Data on study characteristics, reason for implementation (new guideline or quality improvement), implementation strategy used, rationale for selecting that strategy and reported impact were extracted and summarized. Interventions were mapped against a published taxonomy of guideline implementation strategies.

RESULTS

The search resulted in 1,709 articles; 156 were retrieved and 127 were excluded largely because they did not evaluate guideline implementation, leaving 32 eligible for review (4 arthritis, 3 colorectal cancer, 21 diabetes, 4 heart failure). Six of 7 randomized trials and 8 of 25 observational studies had a low risk of bias. Most studies promoted guideline use for quality improvement (78.0%). Few studies rationalized strategy choice (18.8%). Most employed multiple approaches and strategies, most often educational meetings and print material for professionals or patients. Few studies employed organizational, financial or regulatory approaches. Strategies employed that were unique to the published taxonomy included professional (print material, tailoring guidelines, self-audit training or material) and patient strategies (education, counselling, group interaction, print material, reminders). Most studies achieved positive impact (87.5%). This did not appear to be associated with guideline topic, use of theory or barrier assessment, or number or type of implementation approaches and strategies.

CONCLUSIONS

While few studies were eligible, limiting insight on how to choose implementation strategies that address guideline-specific barriers, this review identified other important findings. Education for professionals or patients and print material were the most commonly employed strategies for translating guidelines to practice. Mapping of strategies onto the published taxonomy identified gaps in guideline implementation that represent opportunities for future research and expanded the taxonomy.

Spreading and sustaining best practices for home care of older adults: a grounded theory study

BACKGROUND

Improving health care quality requires effective and timely spread of innovations that support evidence-based practices. However, there is limited rigorous research on the process of spread, factors influencing spread, and models of spread. It is particularly important to study spread within the home care sector given the aging of the population, expansion of home care services internationally, the high proportion of older adult users of home care services, and the vulnerability of this group who are frail and live with multiple chronic conditions. The purpose of this study was to understand how best practices related to older adults are spread within home care organizations.

METHODS

Four home care organizations in Ontario, Canada that had implemented best practices related to older adults (falls prevention, pain management, management of venous leg ulcers) participated. Using a qualitative grounded theory design, interviews were conducted with frontline providers, managers, and directors at baseline (n = 44) and 1 year later (n = 40). Open, axial, and selective coding and constant comparison analysis were used.

RESULTS

A model of the process of spread of best practices within home care organizations was developed. The phases of spread included (1) committing to change, (2) implementing on a small scale, (3) adapting locally, (4) spreading internally to multiple users and sites, and (5) disseminating externally. Factors that facilitated progression through these phases were (1) leading with passion and commitment, (2) sustaining strategies, and (3) seeing the benefits. Project leads, champions, managers, and steering committees played vital roles in leading the spread process. Strategies such as educating/coaching and evaluating and feedback were key to sustaining the change. Spread occurred within the home care context of high staff and manager turnover and time and resource constraints.

CONCLUSIONS

Spread of best practices is optimized through the application of the phases of spread, allocation of resources to support spread, and implementing strategies for ongoing sustainability that address potential barriers. Further research will help to understand how best practices are spread externally to other organizations.

Measuring the effectiveness of mentoring as a knowledge translation intervention for implementing empirical evidence: a systematic review

BACKGROUND

Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice.

AIM

To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals' use of evidence in clinical practice.

METHODS

A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of healthcare professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee; (b) individualized support based on mentee's needs; and (c) involved in an interpersonal relationship as indicated by mutual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively.

RESULTS

Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners' knowledge (four of five studies), beliefs (four of six studies), and impact on organizational outcomes (three of four studies). There were mixed findings for changes in professionals' behaviors and impact on practitioners' and patients' outcomes: some outcomes improved, while others showed no difference.

LINKING EVIDENCE TO ACTION

Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.

A systematic review of the implementation and impact of asthma protocols

BACKGROUND

Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation.

METHODS

PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE.

STUDY SELECTION

Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor.

RESULTS

From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay.

CONCLUSIONS

Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.

Clinical practice guidelines for delirium management: potential application in palliative care

CONTEXT

Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear.

OBJECTIVES

This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development.

METHODS

We searched PubMed (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting.

RESULTS

There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from "expert opinion" for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care.

CONCLUSION

Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development.

Managerial leadership for research use in nursing and allied health care professions: a narrative synthesis protocol

BACKGROUND

Nurses and allied health care professionals (physiotherapists, occupational therapists, speech and language pathologists, dietitians) form more than half of the clinical health care workforce and play a central role in health service delivery. There is a potential to improve the quality of health care if these professionals routinely use research evidence to guide their clinical practice. However, the use of research evidence remains unpredictable and inconsistent. Leadership is consistently described in implementation research as critical to enhancing research use by health care professionals. However, this important literature has not yet been synthesized and there is a lack of clarity on what constitutes effective leadership for research use, or what kinds of intervention effectively develop leadership for the purpose of enabling and enhancing research use in clinical practice. We propose to synthesize the evidence on leadership behaviours amongst front line and senior managers that are associated with research evidence by nurses and allied health care professionals, and then determine the effectiveness of interventions that promote these behaviours.

METHODS/DESIGN

Using an integrated knowledge translation approach that supports a partnership between researchers and knowledge users throughout the research process, we will follow principles of knowledge synthesis using a systematic method to synthesize different types of evidence involving: searching the literature, study selection, data extraction and quality assessment, and analysis. A narrative synthesis will be conducted to explore relationships within and across studies and meta-analysis will be performed if sufficient homogeneity exists across studies employing experimental randomized control trial designs.

DISCUSSION

With the engagement of knowledge users in leadership and practice, we will synthesize the research from a broad range of disciplines to understand the key elements of leadership that supports and enables research use by health care practitioners, and how to develop leadership for the purpose of enhancing research use in clinical practice.

TRIAL REGISTRATION

PROSPERO CRD42014007660.

Implementation of the Canadian Paediatric Society's hyperbilirubinemia guidelines: A survey of Ontario hospitals

INTRODUCTION

In 2007, the Canadian Paediatric Society (CPS) published guidelines aimed at preventing severe hyperbilirubinemia.

OBJECTIVES

To determine whether hospitals had implemented these guidelines; to investigate how guideline-recommended care is organized; and to understand the factors influencing guideline implementation.

METHODS

The present study was an online survey conducted from December 2011 to May 2012 of all Ontario hospitals offering maternal-newborn services.

RESULTS

A total of 97 of 100 eligible hospitals responded. Seventy-seven of the 97 (79%) respondents reported having implemented universal neonatal bilirubin screening. Among these hospitals, hospital-based postdischarge follow-up was reported more frequently than follow-up at community-based locations: hospital laboratory (n=40 [52%]), mother-baby care unit (n=32 [42%]), outpatient clinic (n=25 [33%]), primary care provider in community (n=19 [25%]) and community laboratory (n=8 [10%]). The CPS guidelines were the most frequently reported factor influencing implementation (n=74 [96%]).

DISCUSSION

The survey provides valuable insight into the impact of a complex guideline in Canada's largest province. There was heterogeneity in how hospitals organized services, but there was a notable trend toward hospital-based postdischarge care. The shift to hospital-based care runs counter to current health policy directions and highlights the lack of integration among health care sectors.

CONCLUSION

The majority of Ontario hospitals implemented universal bilirubin screening following the release of the CPS guidelines. Further analysis is needed to determine the impact that the guidelines and the differences in implementation have had on clinical outcomes and the utilization of health services.

Adaptation of a best practice guideline to strengthen client-centered care in public health

Best practice guidelines (BPGs) were developed by the Registered Nurses Association of Ontario (RNAO) to support evidence-based nursing practice. One Ontario public health unit chose to implement the BPG on client-centered care (CCC). A critical review of this BPG revealed issues that would hinder successful implementation within a public health setting. These included a focus on the client as an individual, the predominance of acute care exemplars and training resources that were not representative of public health nursing practice, and the need to reconcile the enforcement roles of public health with the BPG principles. The purpose of this article is to describe the process of adapting the CCC BPG to more accurately reflect the broad scope of public health nursing practice. A model for CCC in public health nursing context is presented and processes for implementing, evaluating, and sustaining CCC are described.

Developing evidence-based practice champions in the Maldives

Evidence-based practice (EBP) is an approach that has gained recognition for facilitating the transfer of evidence into clinical practice. EBP champions is a strategy that can be adopted to encourage the uptake of EBP. This paper describes an action research project that was undertaken in Maldives. EBP champion model has been introduced in the Maldives early 2012 and aims to produce clinical leaders from variety of backgrounds who could implement EBP. This paper provides an extended discussion of the process that was undertaken to prepare EBP champions and their roles in implementing EBP.

Implementing a pediatric obesity care guideline in a freestanding children's hospital to improve child safety and hospital preparedness

Medical and surgical care of children with severe obesity is complicated and requires recognition of the problem, appropriate equipment, and safe management. There is little literature describing patient, provider, and institutional needs for the severely obese pediatric patient. Nonetheless, the limited data suggest 3 broad categories of needs unique to this population: (a) airway management, (b) drug dosing and pharmacology, and (c) equipment and infrastructure. We describe an opportunity at the Children's Hospital Colorado to better prepare and optimize care for this patient population by creation of a Pediatric Obesity Care Guideline that focused on key areas of quality and safety.

Improving child health promotion practices in multiple sectors - outcomes of the Swedish Salut Programme

Background

To improve health in the population, public health interventions must be successfully implemented within organisations, requiring behaviour change in health service providers as well as in the target population group. Such behavioural change is seldom easily achieved. The purpose of this study was to examine the outcomes of a child health promotion programme (The Salut Programme) on professionals’ self-reported health promotion practices, and to investigate perceived facilitators and barriers for programme implementation.

Methods

A before-and-after design was used to measure programme outcomes, and qualitative data on implementation facilitators and barriers were collected on two occasions during the implementation process. The sample included professionals in antenatal care, child health care, dental services and open pre-schools (n=144 pre-implementation) in 13 out of 15 municipalities in a Swedish county. Response rates ranged between 81% and 96% at the four measurement points.

Results

Self-reported health promotion practices and collaboration were improved in all sectors at follow up. Significant changes included: 1) an increase in the extent to which midwives in antenatal care raised issues related to men’s violence against women, 2) an increase in the extent to which several lifestyle topics were raised with parents/clients in child health care and dental services, 3) an increased use of motivational interviewing (MI) and separate ‘fathers visits’ in child health care 4) improvements in the supply of healthy snacks and beverages in open pre-schools and 5) increased collaboration between sectors. Main facilitators for programme implementation included cross-sectoral collaboration and sector-specific work manuals/questionnaires for use as support in everyday practice. Main barriers included high workload, and shortage of time and staff.

Conclusion

This multisectoral programme for health promotion, based on sector-specific intervention packages developed and tested by end users, and introduced via interactive multisectoral seminars, shows potential for improving health promotion practices and collaboration across sectors. Consideration of the key facilitators and barriers for programme implementation as highlighted in this study can inform future improvement efforts.

Using the NHS sustainability framework to understand the activities and resource implications of Canadian nursing guideline early adopters

AIMS AND OBJECTIVES

To examine the activities and resource implications for the initial cohort of healthcare organisations involved in the introduction of multiple nursing guidelines.

BACKGROUND

The Best Practice Spotlight Organization initiative was launched in 2003 as part of the Registered Nurses' Association of Ontario's Best Practice Guidelines programme. While previous research has evaluated improvements in patient care and outcomes, there has been limited research from an organisational perspective on the activities conducted to introduce nursing guidelines.

DESIGN

Secondary analysis of retrospective narrative data.

METHODS

We conducted a content analysis of the 2004-2006 annual reports from the seven participating sites. We used both deductive and inductive approaches to categorise the guideline implementation activities and their resource implications.

RESULTS

All sites reported implementing multiple guidelines (four to nine guidelines per site) and used a wide range of implementation activities that clearly addressed nine of the 10 NHS Sustainability dimensions. The dimension not reported was benefits beyond helping patients. All sites established steering committees that involved staff and senior leaders, reviewed selected guidelines and recommendations, reviewed existing policies and procedures and developed new policies and procedures, recruited champions or peer mentors, applied for additional external funding to support activities, developed relationships with external clinical partners, included guideline implementation in orientation, developed intra-agency web-based and print communications for the project, and evaluated practice changes. For each of these activities, the sites reported expenditures and resource usage.

CONCLUSIONS

The organisational processes used for the introduction of new nursing guidelines in Canada are remarkably consistent with factors identified by leaders and change agents in the UK who developed the NHS Sustainability Model.

RELEVANCE TO CLINICAL PRACTICE

A multidimensional framework for sustainability is useful for planning successful guideline implementation across an organisation. Examples of specific activities and resource implications for organisational change are provided.

The quality of care provided to patients with chronic non-communicable diseases: a retrospective multi-setup study in jimma zone, southwest ethiopia

Background

Chronic Non-Communicable Diseases are among the major causes of morbidity and mortality worldwide. However, access to and quality of health care for patients is very low in developing countries including Ethiopia. Hospitals and Health Centers are the main sources of health care for such patients in Ethiopia. In this study we assessed the quality of care patients with Chronic Non-Communicable Diseases received in hospital and health center setups.

Methods

A retrospective multi-setup study was conducted in Jimma University Specialized Hospital and four Health Centers in Jimma Zone from February to March 2010. A total of 52 process indicators of quality covering three disease conditions: Diabetes, Hypertension and Epilepsy were measured by reviewing randomly selected medical records. Quality of care was measured as a proportion of recommended components of care actually provided to patients. And also outcome and structural measures were assessed to supplement process measures of quality.

Results

Six hundred seventy four medical records were reviewed. Recommended care components were actually provided to patients in 35.1% (95% CI:34.1%, 36.0%), 38.5% (95% CI:37.5%, 39.5%) and 60.1% (95% CI:59.3%, 61.0%) of times on which patients were eligible, among patients with Diabetes, Hypertension and Epilepsy, respectively. After case mix adjustment, it was found that 45.9% (95% CI:45.4%, 46.5%) of recommended components of care was actually provided to patients. This was 45.1% (95% CI:44.4%, 45.8%) in the hospital and 30.5% (95% CI:29.7%, 31.3%) in the health centers. Among patients for whom outcome data was available, optimal level of disease control was achieved only for 47 (30.5%), 40 (38.5%) and 193 (52.9%) of patients with Diabetes, Hypertension and Epilepsy, respectively.

Conclusion

The quality of care provided to patients with Chronic Non-Communicable Diseases is very low in both settings though it is relatively better in Jimma University Specialized Hospital. Therefore, a continuous process of quality improvement is recommended in both settings.

Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System

Objectives

The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care.

Methods

This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system.

Results

We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation.

Conclusions

The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.