An exploration of the factors that influence the implementation of evidence into practice

Implementation: the need for a contextual approach to the implementation of musculoskeletal guidelines

This chapter focuses on how strategies to reduce the burden of musculoskeletal disease might be used to inform the development of best clinical practice, public behaviour and health policy. We review what is known about how to modify clinical practice and public behaviour and the effectiveness of a range of interventions that seek to achieve change. From a health policy perspective we examine how those who produce evidence can be linked with decision-makers and how evidence can be used to answer key questions that are pertinent to policy-makers. We argue that implementation strategies need to be targeted to meet the particular contextual constraints and opportunities found within the specific clinical field, policy domain or public setting, but that research is needed to establish the cost and clinical effectiveness of more complex implementation strategies and the financial impact of changing public policy.

Understanding work contextual factors: a short-cut to evidence-based practice?

BACKGROUND

It has become increasingly clear that workplace contextual factors make an important contribution to provider and patient outcomes. The potential for health care professionals of using research in practice is also linked to such factors, although the exact factors or mechanisms for enhancing this potential are not understood. From a perspective of implementing evidence-based nursing practice, the authors of this article report on a study examining contextual factors.

AIM

The objective of this study was to identify predictors of organizational improvement by measuring staff perceptions of work contextual factors.

METHOD

The Quality Work Competence questionnaire was used in a repeated measurement survey with a 1-year break between the two periods of data collection. The sample consisted of 134 employees from four neonatal units in Sweden.

FINDINGS

Over the study period significant changes occurred among staff perceptions, both within and between units, on various factors. Changes in staff perceptions on skills development and participatory management were the major predictors of enhanced potential of overall organizational improvement. Perceived improvement in skills development and performance feedback predicted improvement in leadership. Change in commitment was predicted by perceived decreases in work tempo and work-related exhaustion.

CONCLUSIONS AND IMPLICATIONS

These findings indicate the potential for organizational improvement by developing a learning and supportive professional environment as well as by involving staff in decision-making at the unit level. Such initiatives are also likely to be of importance for enhanced use of research in practice and evidence-based nursing. On the other hand, high levels of work tempo and burnout appear to have negative consequences on staff commitment for improving care and the work environment. A better understanding of workplace contextual factors is necessary for improving the organizational potential of getting research into practice and should be considered in future implementation projects.

Breaking the silence: nurses' understandings of change in clinical practice

AIM

This paper reports a study exploring critical care nurses' understandings of change in their practice.

BACKGROUND

In contemporary nursing literature, change in clinical nursing practice is generally understood to be a rational process, synonymous with progress. It is seen as invariably contested, and hence difficult to achieve. It is represented as occurring infrequently. This literature effectively silences clinicians as this discourse of change does not recognize or incorporate their views or practices.

METHODS

This study was informed by a Foucauldian poststructuralist framework. The participants were 12 critical care nurses who engaged in three individual in-depth, focused interviews. The transcripts were deconstructed to reveal participants' discourses of change and the implications of these discourses for nursing work. The data were generated between 1996 and 1998 as part of a study whose in-depth analysis was completed in 2003.

FINDINGS

Change was revealed as a highly complex phenomenon, closely intertwined with understandings of clinical nursing work. Participants showed difficulty in identifying or recalling clinical changes. Several dichotomies shaped their understandings of change, including change/stasis, formal/informal and dramatic/subtle. Their experiences of change frequently conflicted with prevailing dominant understandings, but they did not openly challenge them. Rather, they employed dichotomies, such as abstract/concrete and other/self, to enable them to work with these conflicts. As a result, they engaged in practices such as naming other nurses as 'irrational'.

CONCLUSION

The data provide new understandings of change in clinical nursing practice, some of which challenge many widely held views (for example, that such change is a rare occurrence). It is argued that a lack of open challenge by clinical nurses contributes to their silencing, promotes disharmony amongst nurses and, hence, works against a collaborative approach to decisions about clinical practice.

Interventions to increase influenza vaccination rates in veterans with spinal cord injuries and disorders

OBJECTIVE

To increase the percentage of veterans with spinal cord injuries and disorders (SCI&D) who receive annual influenza vaccinations.

DESIGN

A repeated measures quality improvement project using several integrated evidence-based interventions.

SETTING

23 Veterans Affairs (VA) SCI Centers.

PATIENTS

Veterans with SCI&D average age = 57.3 years (range 21-102 y).

INTERVENTIONS

Patient reminder letters and education; provider reminders and posters; computerized clinical reminders for vaccination targeted to SCI & D; standing orders.

MAIN OUTCOME MEASURES

Patient self-reported vaccination status.

RESULTS

Baseline vaccination rate was 33% in fiscal year (FY) 2001. The percentage of veterans with SCI&D who reported receiving vaccinations increased from 62.5% in year 1 (FY2002) to 67.4% in FY2003 (P = 0.004); for individuals younger than 50 years of age, rates increased from 50% to 54%. Predictors of vaccination were age 65 years of age or older, VA health care visit in past year, nonsmoker, believing vaccination is important, having a health condition that may contribute to respiratory complications, and self-reported influenza in prior year.

CONCLUSIONS

Vaccination rates were higher than baseline and higher than reported for other high-risk groups. Interventions that incorporate system-wide approaches plus patient and provider education and reminders were moderately effective in increasing vaccination rates. Targeting younger persons, smokers, and those who do not use VA care may further improve rates.

Health professional and consumer views on involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan

BACKGROUND

The aim was to obtain the views of health professionals and patients about the concept of involving breast cancer patients in the multidisciplinary (MD) treatment planning meeting.

METHODS

Breast cancer surgeons, nurses, oncologists, and patient advocates completed a mailed questionnaire.

RESULTS

The majority of breast cancer health professionals and patient advocates support shared decision-making (58%-62%). However, less than a third of surgeons (32%), medical (25%), and radiation oncologists (24%) were supportive of involving women in the MD treatment planning meeting. In contrast, 93% of breast cancer advocates and 73% of breast cancer nurses were supportive of this approach. Patient advocates were significantly more in favor than all other groups (chi(2) = 148.8, df = 4, P < .001). The common reasons for supporting patient involvement included that it would lead to patients being more informed and empowered, provide them with an opportunity to ask questions, facilitate decision-making, and improve communication between the patient and the medical team. Health professionals stated that attendance would make patients anxious and that they would have to modify their medical language. Suggestions about how to manage patient involvement included the patient being supported by a breast nurse and pre-education before the meeting. Patient advocates were significantly more willing to participate in a randomized controlled trial of this process compared with all other groups. (chi(2) = 155.15, df = 4, P < .001).

CONCLUSIONS

Despite health professional's reservations, patient advocates were highly supportive of including women in the MD meeting. Such a high demand justifies consideration of this option.

The motivation of health professionals to explore research evidence in their practice: an intervention study

AIM

To assess the impact of multifaceted clinically focused educational strategies that concentrated on introducing dementia care research evidence on health professionals' awareness and inclination to use research findings in their future practice.

BACKGROUND

The promise of evidence-based practice is slow to materialize with the limitations of adopting research findings in practice readily identifiable.

METHOD

A pre- and post-test quasi experimental design. The study involved the administration of: a pretest (baseline), an intervention phase, and a post-test survey, the same research utilization survey. TOOL: The Edmonton Research Orientation Survey (EROS), a self-report tool that asks participants about their attitudes toward research and about their potential to use research findings, was used to determine health professionals' orientation to research.

INTERVENTION

The introduction of dementia care research evidence through multifaceted clinically focused educational strategies to improve practice. This was achieved through a resource team comprising a Clinical Nurse Consultant, as a leader and resource of localized evidence-based knowledge in aged care; an experienced Registered Nurse to support the introduction of strategies and a further experienced educator and clinician to reinforce the importance of evidence in change.

RESULTS

Across all the four subscales that are measured in the Edmonton Research Orientation Survey, statistical analysis by independent samples t-test identified that there was no significant change between the before and after measurements.

RELEVANCE TO CLINICAL PRACTICE

Successful integration of changes based on evidence does not necessarily mean that staff become more aware or are more inclined to use research findings in future to address problems.

Role of "external facilitation" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration

Background

Facilitation has been identified in the literature as a potentially key component of successful implementation. It has not, however, either been well-defined or well-studied. Significant questions remain about the operational definition of facilitation and about the relationship of facilitation to other interventions, especially to other change agent roles when used in multi-faceted implementation projects.

Researchers who are part of the Quality Enhancement Research Initiative (QUERI) are actively exploring various approaches and processes, including facilitation, to enable implementation of best practices in the Veterans Health Administration health care system – the largest integrated healthcare system in the United States. This paper describes a systematic, retrospective evaluation of implementation-related facilitation experiences within QUERI, a quality improvement program developed by the US Department of Veterans Affairs.

Methods

A post-hoc evaluation was conducted through a series of semi-structured interviews to examine the concept of facilitation across several multi-site QUERI implementation studies. The interview process is based on a technique developed in the field of education, which systematically enhances learning through experience by stimulating recall and reflection regarding past complex activities. An iterative content analysis approach relative to a set of conceptually-based interview questions was used for data analysis.

Findings

Findings suggest that facilitation, within an implementation study initiated by a central change agency, is a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. Facilitation was described primarily as a distinct role with a number of potentially crucial behaviors and activities. Data further suggest that external facilitators were likely to use or integrate other implementation interventions, while performing this problem-solving and supportive role.

Preliminary Conclusions

This evaluation provides evidence to suggest that facilitation could be considered a distinct implementation intervention, just as audit and feedback, educational outreach, or similar methods are considered to be discrete interventions. As such, facilitation should be well-defined and explicitly evaluated for its perceived usefulness within multi-intervention implementation projects. Additionally, researchers should better define the specific contribution of facilitation to the success of implementation in different types of projects, different types of sites, and with evidence and innovations of varying levels of strength and complexity.

Implications of translating research into practice: a medication management intervention

Through programs such as the Administration on Aging's Evidence-Based Prevention Initiative, researchers and practitioners are developing translational research studies seeking to implement rigorously tested, evidence-based interventions in new practice settings and evaluate the continuing effectiveness of these interventions. One such translational study is the Community-Based Medications Management Intervention (CBM Intervention), a collaborative effort to implement a medication management screening and intervention protocol in community-based waiver care management programs. The overall goals of the CBM Intervention are to implement an evidence-based medication management intervention in a California Medicaid waiver care management program, and to evaluate the effect of client-, intervention-, and organizational-level characteristics on resolving identified medication problems. This article presents the need for improved medication management in a frail, community-dwelling, older adult population and describes the CBM Intervention as an example of translating an evidence-based practice beyond its original efficacy trial in a home healthcare program into a care management program. It discusses critical factors involved in translating research into practice using a translational research framework, Promoting Action on Research Implementation in Health Services (PARIHS). Our experience suggests that although implementing research into practice can positively impact client care, professional skill enhancement and organizational effectiveness, this is very challenging work requiring signification facilitation for successful outcomes.

Clinical nurse specialists and the practice of community nurses

AIM

This paper presents the findings of a study of the roles of Clinical Nurse Specialists and community nurses working in primary care.

BACKGROUND

Clinical Nurse Specialists are recognized internationally as expert practitioners who could facilitate the implementation of evidence-based practice. However, others may misunderstand their role and greater support may be required if organizations are to capitalize on the skills of Clinical Nurse Specialists.

METHODS

Elements of 'Glaserian' grounded theory in a broadly ethnographic approach were used to gain an understanding of the perspectives of 22 Clinical Nurse Specialists working as tissue viability nurses or continence advisors and 19 district nurses in one health region in the United Kingdom. The data were collected in 2001-02.

FINDINGS

Clinical Nurse Specialists were keen to use their expertise to inform the practice of community nurses. However, they encountered difficulties when seeking to introduce changes in practice. Although Clinical Nurse Specialists were acknowledged as enabling rather than deskilling community nurses, receptivity to Clinical Nurse Specialists' ideas was dependent on what community nurses viewed as their own roles. As advisors, Clinical Nurse Specialists were dependent on the use of persuasion and vicarious power to bring about desired changes. These approaches are consistent with traditional approaches to change management as opposed to contemporary approaches to practice development.

CONCLUSION

If Clinical Nurse Specialists are to reach their full potential and use their expertise to inform the practice of others, organizations need to recognize these posts as central to practice development. In particular, a framework is required which enables practice developers to use more inclusive approaches when seeking to bring about changes in practice.

Eliciting Patient Treatment Preferences: A Strategy to Integrate Evidence-Based and Patient-Centered Care

BACKGROUND

The integrated patient-centered evidence-based approach to care is integral to guide practice and enhance the quality of care. In this paper, a strategy to operationalize the integrated approach is described.

DESCRIPTION OF STRATEGY

The strategy flows from the processes used to synthesize the best available evidence for interventions that address a clinical problem, and to elicit patient preferences for treatment options, which is an important step in patient-centered care. The strategy consists of three phases: (1) synthesis of evidence about the effectiveness and relevance of interventions derived from research and practice; (2) generation of written material describing the nature, dose, effectiveness, and risks associated with the evidence-based interventions; and (3) using the written descriptions to elicit patient preferences. Examples from an ongoing study are presented to illustrate the implementation of the strategy within the context of research.

IMPLICATIONS

Nurses are invited to apply the strategy in practice and to evaluate its feasibility and utility in enhancing the quality of care.

Analysis of the impact of a national initiative to promote evidence-based nursing practice

Best Practice Statements (BPS) are designed to facilitate evidence-based practice. This descriptive, exploratory study evaluated the impact of five of these statements in Scotland. A postal survey of 1,278 registered nurses was undertaken to determine use of these statements and their perceived benefits (response rate: 42%). Use of the BPS differed across clinical sites and some statements were more likely to be used than others. Identified barriers and drivers to their use were similar to factors known to encourage or hinder evidence-based practice generally. Although approximately 25% of clinical respondents reported using the BPS, most respondents reported perceived benefits to patients usually through quality improvement. Results highlight the importance of facilitation and supportive contexts in encouraging clinical use of these statements. Findings suggest that variation in clinical implementation of the BPS need to be addressed locally and nationally if their benefits are to be maximized.

An ethnographic study of tobacco control in hospital settings

BACKGROUND

Tobacco control in hospital settings is characterised by a focus on protection strategies and an increasing expectation that health practitioners provide cessation support to patients. While practitioners claim to have positive attitudes toward supporting patient cessation efforts, missed opportunities are the practice norm.

OBJECTIVE

To study hospital workplace culture relevant to tobacco use and control as part of a mixed-methods research project that investigated hospital-based registered nurses' integration of cessation interventions.

DESIGN

The study was conducted at two hospitals situated in British Columbia, Canada. Data collection included 135 hours of field work including observations of ward activities and designated smoking areas, 85 unstructured conversations with nurses, and the collection of patient-care documents on 16 adult in-patient wards.

RESULTS

The findings demonstrate that protection strategies (for example, smoking restrictions) were relatively well integrated into organisational culture and practice activities but the same was not true for cessation strategies. An analysis of resources and documentation relevant to tobacco revealed an absence of support for addressing tobacco use and cessation. Nurses framed patients' tobacco use as a relational issue, a risk to patient safety, and a burden. Furthermore, conversations revealed that nurses tended to possess only a vague awareness of nicotine dependence.

CONCLUSION

Overcoming challenges to extending tobacco control within hospitals could be enhanced by emphasising the value of addressing patients' tobacco use, raising awareness of nicotine dependence, and improving the availability of resources to address addiction issues.

Cluster Randomized Controlled Trial of the Effectiveness of Audit and Feedback and Educational Outreach on Improving Nursing Practice and Patient Outcomes

BACKGROUND

Current understanding of implementation methods is limited, and research has focused on changing doctors' behaviors.

AIM

Our aim was to evaluate the impact of audit and feedback and educational outreach in improving nursing practice and patient outcomes.

METHODS

Using a factorial design, cluster randomized controlled trial, we evaluated 194 community nurses in 157 family practices and 1078 patients with diagnosis of urinary incontinence (UI) for nurses compliance with evidence-linked review criteria for the assessment and management of UI and impact on psychologic and social well-being and symptoms. In the outreach arms, nurses' self-reported barriers informed development of tailored strategies.

RESULTS

In comparison with educational materials alone, the implementation methods tested did not improve care at 6 months follow-up. Moderate rates of improvement (10-17% of patients) in performance for the assessment of UI and greater rates of improvement (20-30% of patients) for the management of care were found but effects were similar across arms. Improvement in patient outcomes was more consistently positive for educational outreach than for audit and feedback but differences were not significant. Adjustment for caseload size, severity or duration of UI and patients' age did not alter results.

CONCLUSIONS

Printed educational materials alone may be as effective as audit and feedback and educational outreach in improving nurses' performance and outcomes of care for people with UI. Greater understanding of the underlying processes in improving performance within multidisciplinary teams through further, theory-driven studies with "no intervention" control groups and longer follow-up are needed.

The influence of patient complexity and nurses' experience on haemodynamic decision-making following cardiac surgery

Critical care nurses' haemodynamic decision-making in the immediate postoperative cardiac surgical context is complex. To optimise patient outcomes, nurses of varying levels of experience are required to make complex decisions rapidly and accurately. In a dynamic clinical context such as critical care, the quality of such decision-making is likely to vary considerably. The aim of this study was to describe variability of nurses' haemodynamic decision-making in the 2-hour period after cardiac surgery as a function of interplay between decision complexity, nurses' levels of experience, and the support provided. A descriptive study based on naturalistic decision-making was used. Data were collected using continuous non-participant observation of clinical practice for a 2-hour period and follow-up interview. Purposive sampling was used to recruit 38 nurses for inclusion in the study. The quality of nurses' decision-making was influenced by interplay between the complexity of patients' haemodynamic presentations, nurses' levels of cardiac surgical intensive care experience, and the form of decision support provided by nursing colleagues. Two factors specifically influenced decision-making quality: nurses' utilisation of evidence for practice and the experience levels of both nurses and their colleagues. The findings have implications for staff resourcing decisions and postoperative patient management, and may be used to inform nurses' professional development and education.

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Evaluating Psychiatric Nurses' Awareness of Evidence-Based Nursing Publications

BACKGROUND

Research has shown that nurses lack skills to find and appraise research literature, lack time and organisational support to utilise research, and need user-friendly research material to implement evidence-based health care in practice. In Sweden, the concept of evidence-based health care has been introduced by The Swedish Council on Technology Assessment in Health Care (SBU), a concept which the nursing profession quickly adopted. This study was initiated synchronously with the publication of two reports on evidence-based nursing (EBN) in psychiatric care.

AIM

To investigate the dissemination and awareness of literature on EBN among psychiatric nurses in Sweden, and more specifically whether nurses were aware of the EBN reports.

METHODS

A postal questionnaire was used with a prospective pre-post design. A questionnaire was constructed and distributed to the members in The National Association of Psychiatric Nurses at two occasions--before publication of the two reports and 1 year post-publication. The questionnaire was initially circulated to 2,294 nurses. The response rate for the first distribution was 82% and for the second 72%.

RESULTS

Although the results demonstrate an increase in awareness concerning the concept of EBN and access to literature between data collection, there were still many nurses who reported no access to the literature. The reported use of literature in practice was scarce; however, findings demonstrated an increase in opinion about the value of using literature in practice.

CONCLUSIONS

The findings of this study demonstrate that the dissemination of literature in EBN, as well as EBN literature in psychiatric care, still requires considerable development to assure its use in practice.

IMPLICATIONS

The diffusion and dissemination of evidence-based literature within nursing must be guided by a structured plan followed by concrete examples of its implication(s) for practice.

Nursing best practice statements: an exploration of their implementation in clinical practice

AIMS AND OBJECTIVES

To explore implementation of the first five Best Practice Statements from the perspective of nurses involved in their development.

BACKGROUND

Best Practice Statements were introduced in Scotland to encourage consistent evidence-based nursing practice. As a new initiative, research was required to investigate their clinical implementation.

DESIGN AND METHODS

In this descriptive study, semi-structured interviews of a purposive sample of nurses (n = 15) were undertaken. Content analysis was used to identify themes emerging from the interview data.

FINDINGS

Four main themes emerged from analysis of transcripts: variations in use of the Best Practice Statements; benefits to patients; benefits to practitioners; and, barriers and drivers to use. Amongst participants, personal users adopted the statements in their own practice but enablers also actively encouraged others to use the statements. Whether participants acted as enablers depended on individual, team and organizational factors. The ability of participants to act as leaders was influential in determining their ability both to facilitate local implementation and to encourage others to regard the Best Practice Statements as a priority for implementation.

CONCLUSIONS

This exploratory study highlighted examples of patients and practitioners benefiting from the Best Practice Statements. Such findings suggest these statements could become a useful tool in promoting evidence-based nursing practice. However, implementation of the Best Practice Statements varied between participants and their organizations. Nurses who were most effective in promoting local implementation of the Best Practice Statements adopted facilitator and leadership roles within their organizations.

RELEVANCE TO PRACTICE

By relating research findings to the literature on guideline and research utilization, this study gives further insight into the implementation of evidence-based practice by nurses. In particular, it supports the conclusion that to be truly effective, initiatives to promote evidence-based practice require nurses to act as local facilitators and leaders.